Billing and Claims

TriWest Healthcare Alliance, on behalf of the U.S. Department of Veterans Affairs (VA), is the third party administrator (TPA) and payer for the following networks:

• Community Care Network (CCN) Region 4
• Community Care Network (CCN) Region 5

TriWest partners with PGBA to process and pay out claims to CCN providers who have rendered services to Veterans in accordance with an authorized VA referral.

It is a contract requirement that all CCN claims process electronically, regardless of the method of submission. As a result, 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.

PGBA only reviews claims that have an approved VA referral/authorization number. An approved referral/authorization from VA:

• supports the service rendered by a CCN provider;
• has a specific plan of care; and
• details a specified number of visits and/or services related to a Standard Episode of Care (SEOC).

Billing for Services Rendered to Veterans

• All care requires an approved referral/authorization with the exception of urgent care. A claim submitted without a VA referral/authorization number will be denied/rejected.
• 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.
• 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.
• For CCN, TriWest follows Medicare billing guidelines, fee schedules and payment methodology when applicable.
• Remember, providers are not allowed to balance bill Veterans or TriWest for services provided under the CCN contract, including any remaining balances or after a timely filing denial.

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, not VA, as TriWest pays primary on behalf of VA.

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PGBA Claims Submission Options

TriWest has designated PGBA as the claims payer for all authorized claims. Providers will submit all claims to PGBA either through the electronic claims submission process, or via a paper claim form.

All CCN claims process electronically, regardless of the method of submission. This is a requirement and, therefore, filing claims electronically is preferred and encouraged. If you choose to submit paper claims, they must scan to an electronic format. Claims that cannot be scanned cleanly may reject.

Filing Electronic Claims

Claims submitted electronically are less likely to be rejected compared to paper claims. Improve your claim submission accuracy and get your payments faster by signing up for electronic claim submission and funds transfer. You can do this by enrolling in Electronic Data Interchange (EDI) through PGBA.

Download the form and FAQs on www.TriWest.com/ClaimsInformation.

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 you submit electronically through a clearinghouse, please use the PGBA Payer ID of TWVACCN.

Electronic Fund Transfers and Electronic Remittance Advice

TriWest network providers can enroll online for ERA and/or EFT through the Availity Essentials Transaction Enrollment application. Your organization’s Availity administrator can set up user account access and assign roles and permissions to help you get paid faster and avoid paper checks.

Providers can also find the EFT/ERA Enrollment Package forms and FAQs at www.TriWest.com/ClaimsInformation.

Filing Paper Claims

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. As stated earlier, all paper forms are converted to electronic format per contract requirements with VA.

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Corrected/Void Claims

A corrected claim should be submitted when you need to replace or correct information on a claim that was previously submitted and/or processed by PGBA. Submitting a corrected claim will have the effect of completely replacing your previously filed claim with the information on the corrected claim.

Examples of a corrected claim include (but are not limited to):

• Providing a referral number or rendering NPI originally omitted
• Changing procedure or diagnosis codes, or the patient’s name or demographic information, or any other information that would change the way the claim was originally processed.

Submit a void claim when you need to cancel a claim already submitted and/or processed by PGBA. See VA's Veteran Care Claim page for more information under "Corrections and Voids".

How to File a Corrected/Void Claim

Corrected claims can be submitted electronically as an EDI 837 transaction with the appropriate frequency code. For more details, go to VA's Corrections and Voids claim page.

When correcting information on 837 institutional claims, use bill type xx7, Replacement of Prior Claim or bill type xx8 to void a previous claim.

When correcting a paper CMS 1500 professional claim, use the following frequency codes in Box 22 and use left justified to enter the code. Include the 12-digit original claim number under the Original Reference Number in this box.

• Frequency code 7: Replacement of Prior Claim: Corrects a previously submitted claim.
• Frequency code 8: Void/Cancel of Prior Claim: Indicates this bill is an exact duplicate of an incorrect bill previously submitted. This code will void the original submitted claims.

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Claim Status Check

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 a claim cannot be found, there may have been errors with the submission. If a claim is visible, 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.

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.

Automatically Receive Claims Status Reports

TriWest offers the option to self-subscribe and receive claims status reports emailed directly to your inbox. Reports can be automatically generated monthly, weekly or on an ad hoc date range based on your preference.

To subscribe, log in to your Availity account. Then:

• Select the Payer Spaces tab.
• Choose TriWest Healthcare Alliance.
• Select Provider Claims Reporting Tool.
• Select your Tax ID number.
• Click Add New Subscription.
• Select the frequency you prefer and enter the email address(es) where the reports should be delivered. (Note: Reports can be sent to up to five email addresses at a time.)
• Submit.

For a more detailed look at the Provider Claims Reporting Tool, refer to the Provider Claims Reporting Tool User Guide that displays screenshots on how to subscribe.

Claims Processing Time

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 a claim shows 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.

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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.

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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

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/authorization 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, VA’s secure, web-based system used to generate and submit referrals and authorizations to community providers.

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.

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