Billing and Claims Submission
PGBA is TriWest’s claims processor in Regions 4 and 5.
Providers should submit claims within 30 days after rendering services. There is a 180-day timely filing limit.
TriWest cannot pay claims for out-of-network providers. Additionally, all care requires an approved referral/authorization (except where the authorization is generated after the 72 hour notification for emergency care or at the time of verification of eligibility for urgent care); otherwise claims will be denied.
- Providers should not collect copays, cost-shares or deductibles. CCN reimburses up to 100% of the allowed amount, including any patient obligation.
- Payments made by TriWest or VA shall be considered payment in full under CCN. Providers may not impose additional charges to TriWest or the Veteran for covered services.
- All claims submitted without a VA referral/authorization number will be denied. The only exception is urgent care.
- Providers are required to share the VA referral/authorization number with the ancillary providers included in a Veteran’s episode of care. The ancillary provider is also required to use this same VA referral/authorization number when submitting their claim for the specific episode of care.
- It is extremely important that you do not use any extra characters, spaces, or words with the referral/ authorization number or the claim will deny. For example, if the correct referral/authorization number is VA0012345, referral numbers included in the following format would be denied:
- Auth VA0012345
- Auth # VA0012345
- Ref VA0012345
- Ref # VA0012345
- VA 0012345
- VA012345
- For CCN, TriWest follows Medicare Fee-for-Service billing guidelines, fee schedules and payment methodology when applicable.
- Avoid these top 3 most common errors when filing your claims.
Timely Filing Requirements
Make every effort to submit claims within 30 days of rendering services. Adhering to this recommendation will help increase provider offices’ cash flow. VA CCN Prime Contract limits timely filing of initial claims to 180 days after rendering services. Providers have 90 days to appeal or re-submit a claim.
PGBA Claims Submission Options
All CCN claims process electronically, regardless of the method of submission. This is a program requirement and, therefore, filing claims electronically is preferred and encouraged. If you choose to submit paper claims, they must scan to an electronic format, creating a potential issue for handwritten or manually typed claims. Claims that cannot be scanned cleanly may reject.
TriWest, on behalf of VA, is the payer for in-network authorized claims associated with an approved referral/ authorization filed under the CCN. PGBA processes these claims.
If you submit electronically through a clearinghouse, please use the PGBA Payer ID of TWVACCN.
Benefits of Filing Claims Electronically
Improve your claim submission accuracy and payment timing with electronic submission and funds transfer. You can do this by enrolling in Electronic Funds Transfer (EFT)/Electronic Remittance Advice (ERA) and Electronic Data Interchange (EDI) through PGBA.
Just login to Availity.com, navigate to the TriWest Payer Space, and click on the Resources tab. Find the “PGBA EFT/ERA Enrollment Package”, complete the forms and submit them to PGBA.
For details on electronic funds transfer, remittance advice and data interchange through PGBA, refer to the PGBA Frequently Asked Questions.
Providers can submit electronic claims without a clearinghouse account through Availity’s Basic Clearinghouse option. The Basic Clearinghouse option is FREE to CCN providers.
If electronic submission is not an option, providers may mail paper claims to:
TriWest VA CCN Claims
PO Box 108851
Florence, SC 29502-8851
For best image scan results, complete the form using 10-point and 10-pitch Courier or Courier New 10 mono-space fonts.
Additionally, VA benefits do not coordinate with other Federal programs (TRICARE, Medicare, Medicaid, etc.). If a provider has an approved referral/authorization on file from TriWest, the provider should bill TriWest, as TriWest pays primary on behalf of VA.
Clean Claim Requirements
In order for a claim to process and pay, TriWest must have visibility to the appointment in its systems.
Once the provider receives an authorization letter from either TriWest or VA, the referral/authorization number is the unique identifier assigned for each approved referral/authorization’s episode of care. TriWest requires that the provider include this number on the claim or the claim will be denied.
It is important that providers properly submit claims to PGBA with the following documentation, and in the correct format:
- VA referral number AND one of the following:
- 10-digit Electronic Data Interchange Personal Identifier (EDIPI)
- 17-digit Master Veteran Index (MVI) ICN
- Social Security number (SSN)
- Last 4 digits for SSN with preceding 5 zeros i.e., 000-00-XXXX
Consider the Following:
- Do not use any extra characters, spaces, or words with the referral number or the claim will deny. Include a Type 2 (organization) NPI on all claims. Solo practitioners without an organizational NPI should use an individual NPI.
- Ensure all coding aligns with Medicare criteria, if applicable. When Medicare policy does not apply, please follow language in the authorization information, VA consult notes, the Provider Handbook, or other training materials provided by TriWest and VA.
Claim Status and Appeals
Providers can check the status of claims through Availity. The tool gives providers a more intuitive and robust workflow to check the claim status of Veteran patients. Login to Availity and then click on the Claims & Payments option located on the top-left corner of the main screen. Under Claims & Payments, select the Claim Status option. The Claim Status tool allows providers to check the status of a submitted claim and view remittances.
Providers can also search claims by:
- Member ID
- Tax ID
- Service date
- Claim number
If you have problems checking your claims status, visit Availity to use the secure “Chat with TriWest” feature, or call TriWest Claims Customer Service at 877-CCN-TRIW (877-226-8749) from 8 a.m. to 6 p.m. in your time zone.
VA Requires Signature on File for CCN Claims
As a requirement of participation in CCN, network providers need to have a Signature on File for any Veteran who will receive care. Similar to standard insurance policies, the Signature on File will indicate that the provider is authorized to submit a claim on behalf of the Veteran, and authorizes payment of medical benefits to the provider.
If a claim was denied because it was sent to another VA payer, requests for reconsideration of claims must be submitted within 180 days of VA’s or VA payer’s denial. Follow these instructions to successfully correct the claims submission:
- Retain a copy of the remittance advice from original submission to wrong entity. This serves as documentation of timely filing and should be retained to ensure that the original submission date can be confirmed in the event of an audit.
- 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 the paper claim to PGBA.
- If submitting an Electronic Claim via EDI: Use an indicator “9”on the 837 in the data element field CLM20 to indicate resubmission for timely filing. The “9” indicator definition is Original Claim rejected or denied for reason unrelated to the billing limitation rules. Claims with the “9” resubmission indicator will bypass automatic timely filing denials.
Claims that do not meet the above requirements will be denied. TriWest can no longer accept remittance advice documentation from non-VA payers, such as 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 contract, including any remaining balances or after a timely filing denial.
If providers cannot find a claim, there may have been errors with the submission. If providers can see a claim, it is in process. Please do not resubmit for in-process claims.
For missing claims please verify that:
- It has been at least 10 business days since you uploaded the claim or 15 business days since the provider mailed the claim.
- A paper claim was not handwritten and all information was typed correctly.
TriWest strives to pay all clean claims within 30 days.
- Due to its contract status, TriWest is exempt from penalties associated with Medicare’s prompt payment requirements.
- If claims show as paid, but the provider has not received a remittance, please contact TriWest CCN Customer Service at 877-CCN-TRIW (877-226-8749) so that TriWest can verify the accuracy of the remit address in our system.
- Notification of denial is provided within 45 days of receipt of the claim in TriWest systems.
To submit an appeal, download TriWest’s Claims Reconsideration Form, available under the “Resources” tab on the TriWest Payer Space on Availity.
- Providers must submit separate appeals for each disputed item.
- Reconsiderations must be submitted within 90 days of claim processed date as indicated on the Provider Remittance Advice (PRA) as an “unsolicited” claims attachment within Availity. Be sure to include all supporting documentation.
Returns and Recoupments of Claims
When TriWest or PGBA identifies an overpayment, a recoupment is initiated. A letter is sent to the provider’s office with information regarding the reason for recoupment.
- If a provider promptly returns funds, the recoupment case is closed.
- For an overpayment balance, PGBA offsets against current and future claims. The Provider Remittance Advice (PRA) will detail these amounts.
- For overpayments owed to TriWest, send monies to:
TriWest VA CCN Finance
Attention: Refunds
PO Box 108852
Florence, SC 29502-8852
Please include the refund control number (RCN) on the check or money order and the enclosed payment stub with the remittance to ensure proper credit to your account.
To ensure refund credit to the correct claim, include a copy of the remittance advice. If the remittance advice is not available, include the claim number and the Veteran’s EDIPI number or the last four digits of the SSN and the Veteran’s date of birth.
Claims for Out-of-Network Providers
TriWest can reimburse certain out-of-network providers under CCN for services provided under a CCN-approved referral. The only out-of-network providers who are eligible for this type of reimbursement are:
- Ancillary providers when services are provided as an adjunct to medical or surgical services provided by in-network providers; and
- Out-of-network facilities, at which the services provided, are performed by an in-network physician performing scheduled, non-emergent care.
Ancillary providers are defined as those providers who perform diagnostic or therapeutic services as an adjunct to basic medical or surgical services such as facility-based physicians, assistant surgeons, anesthesiologists, specialty physicians, radiologists, pathologists, and emergency care physicians.
Out-Of-Network Billing
An approved referral/authorization from VA supports a specific plan of care as it relates to a specified number of visits and/or services related to a SEOC, as long as the services are provided by a CCN provider. Providers should always include the original VA referral number from the approved referral/authorization when billing TriWest. If out-of-network providers do not know the original referral number, they should contact the CCN provider who received the approved referral/authorization to acquire it.
Out-of-network providers must submit health care claims directly to TriWest by billing PGBA, TriWest’s claims processor. Medical documentation related to care should be submitted to VA, preferably through HSRM. Under CCN regulations, payment from TriWest is considered payment in full from VA, and out-of-network providers are never allowed to balance bill a Veteran. The scope of care provided to a Veteran by an out-of-network provider must be included on an approved CCN referral/authorization.