Provider Pulse

December 2020

Welcome to December

December signals the end of the infamous 2020 calendar year, but not the end of information TriWest Healthcare Alliance (TriWest) provides to help you serve our Veterans. The Department of Veterans Affairs (VA) launched a new website to support the Emergency Care 72-hour notification process. In addition, VA Patient-Centered Community Care (PC3) authorization letters now have an end date of March 31, 2021 since that is the date PC3 ends. This month, we also cover Home Health agency compliance, timely filing extensions, an update to the VA fee schedule, and more. Keep reading for these updates below.

In This Edition:

VA Creates Emergency Care Reporting Portal

To help support the Emergency Care 72-hour notification process when treating Veterans within the Department of Veterans Affairs (VA) Community Care Network (CCN), the Office of Community Care (OCC) launched a new online Emergency Care Reporting (ECR) portal.

This ECR portal is designed for CCN providers, VA medical center (VAMC) staff, Veterans, and Veteran representatives to provide secure, patient-related information to help with getting authorizations generated, claims paid and facilitating coordination of care. Veteran-specific details are used to quickly coordinate care and make eligibility determinations.

CCN Emergency Care Must Be Reported to VA Within 72 Hours

A CCN Emergency Room (ER) doesn’t need an approved referral/prior authorization before treating an eligible Veteran in an emergency. However, the CCN ER is required to notify the Community Care Centralized Notification Center within 72 hours of the Veteran self-presenting for treatment.

Notify the Community Care Centralized Notification Center via:

To minimize the risk of inappropriate disclosures of Veterans’ personal protected information, VA will discontinue communication of emergency treatment authorization information to the submitting provider outside of a secure portal. Use Availity for secure access to view claims, eligibility, and authorization notifications.

Check Eligibility Before Treating for Urgent Care
As a reminder, a CCN urgent care clinic/retail walk-in location can provide care to a Veteran who self-presents after verifying eligibility. Call 833-4VETNOW (833-483-8669) to verify Veteran eligibility. No approved referral/prior authorization is required prior to treating eligible Veterans under CCN. For more details regarding the Urgent/Emergent Care process, please refer to the CCN Urgent Care & Emergency Care Quick Reference Guide.

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PC3 Contract and Authorization Validity Ends March 31, 2021

The Department of Veterans Affairs (VA) Patient-Centered Community Care (PC3) will officially end on March 31, 2021. Earlier this year, TriWest sent updated PC3 authorization letters with an adjusted end date of March 31, 2021, to correct any authorization that had an end date beyond March 31, 2021.

As a reminder, TriWest will continue paying for authorized care that occurred prior to the expiration date of the VA authorization or March 31, 2021, whichever comes first.

Providers should not submit a Request for Services (RFS) to extend any of these authorizations for their Veteran patients under PC3. However, CCN contracted providers may send an RFS to VA to obtain a new approved referral/authorization under the Community Care Network (CCN).

Only CCN-contracted providers will be allowed to deliver care to Veterans with an approved referral after March 31, 2021. Learn more about CCN at http://www.triwest.com/provider.

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Patient-Driven Groupings Model Compliance for Home Health Agencies

Starting Jan. 1, 2020, home health agencies were required to implement the Centers for Medicare/Medicaid Services (CMS) new Patient-Driven Groupings Model (PDGM) reimbursement. The new PDGM payment model examines the following five main variables:

  1. Admission source (how the patient was referred to the agency)
  2. Timing of care
  3. Clinical grouping (i.e., type of care: neurological, wounds, behavioral health, etc.)
  4. Veteran’s functional impairment level
  5. Adjustment for consideration of Veteran’s co-morbid conditions

These variables contribute to a focus on clinical characteristics to more accurately reflect an individual Veteran’s condition and needs. The result of the variables reveals a Home Health Resource Group (HHRG) that drives reimbursement.

Upon reviewing a sampling of PDGM documentation in the first two quarters of 2020, TriWest identified two opportunities – admission source and timing variables – where home health agencies, providing services under the Home Health Skilled (bundled) SEOC, can improve documentation and billing practices.

As a reminder, below are the types of admission sources and timing that home health agencies need to follow under PDGM:

Admission Source Types:

InstitutionalCommunity
Acute (inpatient acute care hospitals) No acute care in the 14 days prior to the home health admission.
Post-acute Veteran received care in the 14 days prior to the home health admission at a skilled nursing facility, inpatient rehab facility, long term care hospital, or inpatient psychiatric facility. No post-acute care in the 14 days prior to the admission.

Timing:

  1. Early periods: First 30-day period in a sequence of home health periods
  2. Late periods: Second and later 30-day periods in a sequence of home health periods

We appreciate your attention to these documentation details that demonstrate individualized Veteran-centric care.

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Reminder: Leeway Regarding Timely Filing

Starting Oct. 1, 2020, providers who initially submitted a claim to the wrong Department of Veterans Affairs (VA) payer (e.g., VA or OptumServe instead of TriWest) were given more leeway with VA’s 180-day timely filing limit. The deadline to resubmit those claims for reconsideration is fast approaching.

After Dec. 31, 2020, requests for reconsideration of claims that were denied because they were sent to the wrong payer must be submitted within 180 days of the denial.

Follow these instructions to successfully correct your claim submission:

  1. Keep a copy of the remittance advice from the original submission to the wrong entity. This serves as documentation of timely filing and should be kept to ensure that the original submission date can be confirmed in the event of an audit.
  2. If submitting a paper claim: Print out and complete the Provider Timely Filing Form on TriWest’s Payer Space on Availity, and submit the Provider Timely Filing Form with your paper claim to WPS MVH.
  3. If submitting an electronic claim via EDI: Use an indicator “9”on the 837 in the data field CLM20 to indicate resubmission for timely filing. The “9” indicator definition means the original claim was rejected or denied for reasons unrelated to the billing limitation rules. Claims with the “9” resubmission indicator will bypass automatic timely filing denials.
  4. Submit the claim to WPS MVH (TriWest) within 180 days from the date of the denial by the incorrect VA payer.

Claims that do not meet the above requirements will be denied if submitted after 180 days. TriWest can no longer accept remittance advice documentation from non-VA payers, like TRICARE, Medicare, or other health insurers.

Remember, providers are not allowed to balance bill Veterans or TriWest for services provided under the Community Care Network (CCN) contract, including any remaining balances after a timely filing denial.

For more information, visit VA’s “File a Claim for Veteran Care” webpage https://www.va.gov/COMMUNITYCARE/revenue_ops/Veteran_Care_Claims.asp or call the Community Care Contact Center at 877-881-7618.

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VA Fee Schedule Application Update

TriWest removed the Department of Veterans Affairs (VA) Fee Schedule application from its websites in November. The links are now redirected to a VA web page that VA will update regularly. Please bookmark the new page if needed as a reference.

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PC3 Information Available on Availity

Patient-Centered Community Care (PC3) providers still have access to claims, authorizations, forms, PC3 quick reference guides, and the PC3 Provider Handbook via TriWest’s Payer Space on Availity.

Availity is a multi-payer online resource where providers will find claims information and other community care resources, including the Provider Handbooks, Quick Reference Guides, live webinar trainings, MicroLearning videos, and news and announcements for both PC3 and VA’s Community Care Network (CCN).

Please register now to maintain access to the most up-to-date resources and tools needed to work with TriWest.

For technical assistance with the Availity Portal, please call Availity at 800-282-4548. For all other questions, please email ProviderServices@TriWest.com. For more information on Availity, please refer to the Availity Quick Reference Guide.

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Provider Handbook Updates

The only change to the CCN Handbook in January 2021 is on page 13:

To help support the Emergency Care 72-hour notification process, the Office of Community Care (OCC) has launched a new online Emergency Care Reporting (ECR) portal.

PThe contact information is as follows:

Based upon TriWest being awarded the contract to administer CCN in Alaska, also known as Region 5, TriWest is creating a dedicated Alaska Appendix to the CCN Handbook. Alaska Providers, stay tuned to TriWest’s CCN Page for more information!

There are no planned changes to the PC3 handbook for January 2021.

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Updated: 1/14/2021 1:51:36 PM