Community Care

Each clinical determination and indication contains the following terms and associated definitions:

• Effective date: Date the community care medical policy is effective.
• Exclusion criteria: Characteristics that disqualify prospective Veterans from care pathways or prescriptions.
• Experimental or Investigational: A treatment, procedure, equipment, drug, or service that has not been determined to be medically effective for the condition being treated but may be part of a research study to evaluate if the condition improves with use.
• Facility: The service is performed in a facility setting (i.e., hospital, ambulatory or surgical center).
• Facility type: Hospital or other institution where outpatient and inpatient services are performed.
• FDA approval: To receive U.S. Food and Drug Administration (FDA) approval, drug manufacturers must conduct testing and submit their data to FDA. FDA may approve the drug if the agency determines the benefits of the drug outweigh the risks for intended use.
• Locality description: Place of service locality (e.g., city, county).
• Medical necessity: Health care services that can be justified as reasonable, necessary and appropriate based on evidence-based clinical standards of care.
• Medicare carrier: Identification number assigned by Centers of Medicare and Medicaid Services (CMS) to a carrier (Medicare Administrative Contractor) authorized to process claims from a physician or supplier.
• Medicare locality: Identification number assigned by the CMS for a locality where care is received.
• Non-facility: The service is performed in a non-facility setting (i.e., physician’s office or outpatient clinic).
• Policy number: A unique ID code that combines an abbreviation of the name and version number.
• Procedure: Current Procedural Terminology (CPT) / Healthcare Common Procedure Coding System (HCPCS) codes are industry standard codes used to identify specific surgical, medical, or diagnostic interventions.
• Procedure code modifier: Supplemental information or “adjust care” descriptions to provide extra detail concerning a procedure or service.