VA created a High Performing Provider (HPP) designation under CCN for those providers who excel in a set of standard health care evaluation metrics. Providers are scored on a set of standard quality metrics approved by VA to determine whether they are deemed to be an HPP. The HPP designation may be used by VA or TriWest when selecting a provider to see a Veteran.
The HPP designation describes CCN providers based on standard quality metrics approved by VA.
For more information on the HPP designation, please review the HPP Quick Reference Guide. Inquiries regarding the HPP process can be submitted to CQHPP@TriWest.com. A summary of specific provider metrics is available on request by completing the HPP Inquiry Form on the TriWest Payer Space on Availity under the “Resources” tab. Providers should send the completed HPP Inquiry Form to CQHPP@TriWest.com.
The following provisions are applicable to services rendered pursuant to authorizations for care under CCN as administered by TriWest and will be incorporated by reference into the Provider’s Network Agreement as if fully set forth therein. The Spanish version of the Provider Handbook is provided for convenience only; the English version of all contractual documents between TriWest and the provider, including but not limited to the Provider Handbook, shall be exclusively used for legal interpretation. For avoidance of doubt, in the event of any ambiguity or disagreement between the terms of the Spanish version of the Provider Handbook and the original English version, the English version shall take precedence and control.
All defined terms herein have the same meaning as they have in the Provider Network Agreement or Program Terms & Conditions unless otherwise defined below.
- Beneficiary – Any individual enrolled and authorized to receive care through the TriWest Provider network by any Program incorporated into the Provider Agreement.
- CCN Covered Services – Services, items and supplies for which benefits are available to VA Beneficiaries in accordance with the rules, regulations, polices and instructions of Veterans Administration and the Veterans Health Administration.
- DME – Durable Medical Equipment to include any equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in a the absence of an illness or injury, and is appropriate for use in the home.
- Emergency Care – Medical care required within twenty-four hours or less that is essential to evaluate and stabilize conditions of an Emergency/Emergent Need that if not provided may result in unacceptable morbidity/ pain if there is significant delay in evaluation or treatment.
- Emergency/Emergent Need – Conditions of one’s health that may result in the loss of life, limb, vision, or result in unacceptable morbidly/pain when there is significant delay in evaluation or treatment.
- Network Subcontractor – An entity that is a party to a Provider Network Agreement and operates as a subcontractor to TriWest to manage provider data, credentialing, and certain other functions as may be designated by TriWest. Some Provider Network Agreements may not have a Network Subcontractor as a party to the agreement, in such cases, references to Network Subcontractor in this Provider Handbook should be interpreted as a reference to TriWest.
- Party – Any individual or entity that is a party or a third-party beneficiary to the Provider Network Agreement.
- Prior Authorization – A required process through which VA reviews and approves certain medical services to ensure the medical necessity and appropriateness of care prior to services being rendered within a specified timeframe from a non-VA provider or additional resources in the community. This type of process requires a Prior Authorization be obtained “prior to” the specified service.
- Provider – Any individual or entity providing healthcare services pursuant to an authorization for care issued by TriWest, or who is otherwise subject to the terms and conditions of a Program or this Handbook.
- Urgent Care – The medical services defined in 38 C.F.R. § 17.4600(b)(5) provided in an outpatient setting to treat acute or chronic illness or injury.
- VA Beneficiary – Any person eligible to receive CCN Covered Services under the rules, regulations, policies and instructions of the VA.
- Veterans Health Administration (VA) – The division of the Department of Veterans Affairs that provides health care services and administers health care benefits for eligible Beneficiaries.
TriWest and Network Subcontractor shall have the right to immediately terminate Provider Agreements upon written notice to provider upon the occurrence of any of the events listed below:
- Provider’s state or federal license or authorization to do business is reduced, restricted, suspended, or terminated (either voluntarily or involuntarily), or Provider’s other applicable license or accreditation necessary to perform any services contemplated by the Provider’s Agreement is reduced, restricted, suspended, or terminated (either voluntarily or involuntarily); or
- Provider’s professional liability coverage as required under Provider’s Agreement is reduced below required amounts or is no longer in effect; or
- Provider fails to meet TriWest’s or Network Subcontractor’s credentialing, re-credentialing, quality management or utilization management criteria, or fails to comply with quality management or utilization management processes; or
- Provider fails to provide material information or provides erroneous information on Provider’s credentialing application or re-credentialing application; or
- Provider is no longer Medicare-eligible, Medicaid-eligible, or is not eligible to participate in another government program; or
- Provider or any one of its officers is arrested or indicted on felony charges that directly or indirectly relate to provisions of services under Provider’s Agreement, and TriWest and Network Subcontractor makes a reasonable and good faith determination that the nature of the charges are such that termination or necessary to avoid unnecessary risk or harm to Beneficiaries that could occur during the pendency of the criminal proceedings.
- All notices and other communications to a Party must be in writing, hand delivered, delivered by prepaid commercial courier services with tracking capabilities, faxed, or delivered by the U.S. mail to the address listed on the signature page of the Provider’s Agreement. The Parties may change the address of record by notifying the other Party of the new address. Notice shall be complete upon the earlier of actual receipt or five (5) days after being deposited into the U.S. mail. Notices and other communications in writing need not be mailed either by registered or certified mail, although a signed return receipt received through the U.S. Post Office shall be conclusive proof between the Parties of delivery of any notice or communication and of the date of such delivery.
- Provider shall notify TriWest or Network Subcontractor in writing immediately upon learning of any action, policies, determinations or internal or external developments that may have a direct impact on Provider’s ability to perform its obligations under the Provider’s Agreement. Such matters shall include, but are not limited to:
- Any change in ownership, specialty services provided, Medicare designation (including but not limited to sole community, critical access, etc.) or location of facility(ies);
- Action against or lapse of Provider’s license, certification, accreditation or certificate of authority;
- Loss of hospital privileges;
- Arrest or indictment;
- Reduction in insurance coverage below the required limits set forth for the applicable Program, or termination of insurance coverage;
- Any activity that compromises the confidentiality and security of the medical records of Beneficiaries;
- Exclusion or any other penalty from Medicare, Medicaid, or any other federal health care program.
- Provider shall complete VA required training that will be determined at a later date and reflected in the next version of the TriWest Provider Handbook.
TriWest may periodically include provider’s name, gender, work address, work fax number, work telephone number, whether the provider is accepting new patients, specialty and sub-specialty and willingness to accept Beneficiaries in a directory of Network Providers. Provider is responsible for notifying TriWest or Network Subcontractor of any changes of address, phone or fax number, or specialty services rendered within 10 business days.
Provider shall comply with all applicable state and federal laws as well as regulations and all rules, policies and procedures of the applicable program including without limitation to credentialing, peer review, referrals, utilization review/management, clinical practice guidelines, case management and quality assurance programs and procedures established by TriWest or the applicable health care program including submission of information concerning provider and compliance with Preauthorization requirements, care approvals, pharmacy, dental and DME utilization requirements, care approvals, concurrent reviews, retrospective reviews, discharge planning for inpatient admissions, critical event notifications, quality of care audits, return of medical records and Prior Authorization of referrals.
When provider utilizes any ancillary providers to render services for the same episode of care for which provider has accepted an authorization, the referring provider must ensure that the ancillary provider is provided with the authorization number and billing information for the applicable episode of care. Provider should make reasonable efforts to utilize ancillary providers that are CCN contracted providers. Ancillary providers that are not CCN contracted providers must agree to be reimbursed at the Medicare allowable rate for the services billed and in no event can TriWest pay an ancillary provider more than VA’s allowable rate. Ancillary providers may not bill Veterans, including any balance billing; the referring provider is responsible for ensuring that ancillary providers are aware of CCN payment rates and the restrictions against billing the Veteran beneficiary.
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.
Medical Records and Documents
- Provider shall submit medical documentation to VA in an EDI 278 transaction format, where available. Providers, who do not have the capability to submit EDI 278 transactions, shall submit via secure e-mail or fax.
- Initial outpatient medical documentation is medical documentation associated with the first appointment of an episode of care. Initial medical documentation for outpatient care shall be returned within 30 days of the initial appointment.
- Final outpatient medical documentation is medical documentation that summarizes the result of any medical care provided. Final medical documentation of outpatient care shall be returned within 30 days of the completion of the episode of care.
- Medical documentation associated with inpatient care shall be returned within 30 days of discharge and shall consist of a Discharge Summary.
- Medical documentation requested on an urgent basis must be returned to the requesting party within one (1) business day of the request.
- Ancillary providers who are unable to return medical documentation to VA must send medical documentation to the referring provider for proper care coordination. Please refer to VA’s Facility Contact Information for Care Coordination for assistance.
- Provider must meet the requirements of state and local laws and if applicable must have a full, current, non-probationary and unrestricted license in the state where services are delivered.
- Provider must remain in compliance with the seven (7) elements of the OIG’s Compliance Program Guidance.
- Implementing written policies, procedures and standards of conduct.
- Designating a compliance officer and compliance committee.
- Conducting effective training and education.
- Developing effective lines of communication.
- Conducting internal monitoring and auditing.
- Enforcing standards through well-publicized disciplinary guidelines.
- Responding promptly to detected offenses and undertaking corrective action.
- If applicable, provider cannot have had any state license termed for cause or have relinquished any state license after being notified in writing by that state of potential termination for cause.
- If applicable, providers shall meet all Medicare Conditions of Participation (CoP) and Conditions for Coverage (CfC), where such conditions exist, subject to CMS modifications, as required by the U.S. Department of Health and Human Services (HHS). These conditions may be met through CMS certification or accreditation by organizations deemed by CMS to meet or exceed the CMS Medicare standards set forth in the CoP/CfC. For additional details regarding these requirements see https://www.cms.gov.
Professional Liability Coverage
Provider shall provide and maintain professional liability insurance in an amount in accordance with the laws of the state in which the care is provided.
OHI Billing and Claim Submission Requirements
When VA determines it is secondary payer as indicated by the authorization for services, the provider must first invoice VA Beneficiary’s other health insurance (OHI), and invoice TriWest second as described herein. When the VA is secondary payer, TriWest will reimburse provider only up to the difference between the amount paid by Beneficiary’s OHI and the rate(s) that provider has negotiated with TriWest for the services. When claims are denied by VA Beneficiary’s OHI, provider must submit the Explanation of Benefits (EOB) or remittance advice (RA) statement indicating the dates of service, amounts of the claim, and reason(s) for denial to TriWest. Provider will be permitted up to 90 days after the other insurer’s adjudication to file claims with TriWest when, (i) provider first submitted the claim to the VA Beneficiary’s OHI, in accordance with this section, and (ii) the adjudication occurred past the CCN claims submission deadline. Any claims submitted to TriWest past this ninety (90) day period will be denied.
Claims Submission Policies and Procedures
The following guidelines are necessary in order to submit claims electronically to TriWest via PGBA:
- You can submit claims directly to PGBA. New direct submitters must file a Trading Partner agreement to be assigned a submitter ID. The EDI Gateway User manual provides the information you will need to determine if direct submissions are the right option for you. Contact the PGBA EDI Help Desk at 800-259-0264, option 1 or email EDI@pgba.com to request a copy of the EDI Gateway User manual. Use these EDI resources posted on Availity in the TriWest Payer Space:
- PGBA EDI Provider Trading Partner Agreement
- PGBA 837I Companion Guide
- PGBA 837P Companion Guide
- PGBA EDI FAQs
- Provider agrees that all claims submitted via EDI, for all legal and other purpose, will be considered signed by the provider or provider’s authorized representative.
- Provider agrees to maintain a patient signature file. Provider understands PGBA may validate through file audits, those claims submitted via EDI which are included in any quality control or sampling method required by PGBA. Provider understands if no signed authorization is on file, an authorization must be obtained by the provider from the patient prior to EDI submission to PGBA.
- Provider acknowledges that PGBA and Network Subcontractor shall have no obligation with respect to the content of the information in claims either to verify, check, or otherwise inspect the information supplied by the health care provider, except to reformat the claim data to the specification required by TriWest. Provider further acknowledges that TriWest will determine whether provider has submitted enough information in the EDI claims in order to determine the completeness, accuracy, and validity of the information and claims, and that source documents for claims data are the responsibility of the provider.
- The following guidelines are necessary in order for providers to receive Approved Referral/Authorization or Prior Authorization electronically from the VA via the EDI 278 Electronic submission process. The VA shall submit Approved Referral/Authorization or Prior Authorization to provider in an EDI 278 transaction format, where available. Those providers, who do not have the capability to receive EDI 278 transactions, may receive Approved Referral/Authorization or Prior Authorization via secure e-mail or fax.
This Alaska Appendix to the TriWest Provider Contract Provisions (“Alaska Appendix”) are applicable to services rendered pursuant to authorizations for care under the Department of Veterans Affairs (“VA”) Community Care Network Program (“CCN”), as administered by TriWest Healthcare Alliance Corp. (“TriWest”) in Alaska, and will be incorporated by reference into the Alaska Provider’s Network Agreement as if fully set forth therein. The TriWest Provider Contract Provisions, and the TriWest CCN Provider Handbook shall remain in full force and effect. In the event of a conflict between the TriWest Provider Contract Provisions, or TriWest CCN Provider Handbook, and the Alaska Appendix, the Alaska Appendix shall control.
- Extended Care – Extended care services mean geriatric evaluation; nursing home care; domiciliary services; adult day health care; non-institutional palliative care, non-institutional hospice care, and home health care when they are non-institutional alternatives to nursing home care; and respite care.
- Mental Healthcare – Services include psychological and social interventions, rehabilitation, and support services, per 38 C.F.R. 17.98.
Credentialing for Tribal Health Services
Alaska Tribal Health Programs (THP) have established accreditation and credentialing standards established by the Indian Health Service (IHS) which are acceptable within the scope of this contract for CCN participation and Veteran care.
CCN providers shall be accredited by a nationally recognized accrediting organization for the healthcare services and providers that are within scope of an accreditation. All services, facilities, and CCN providers are in compliance with the accrediting organizations’ standards or applicable Federal and State laws, where accreditation is not required, and VA approves, for a service provider prior to serving Veterans under this contract. National certification, in lieu of accreditation, is sufficient for THPs to meet this requirement.
THPs participating in CCN shall satisfy only those generally applicable State or other requirements for participation as a provider of healthcare services, provided THP, and its providers, may not be subject to licensure by the State of Alaska as provided for in 25 U.S.C. 1621d(a)(1)(A), 162 It, and 1647a(2) or other applicable State or Federal law. THP satisfies the Centers for Medicare and Medicaid Services (“CMS”) conditions of participation/conditions of coverage. THP providing inpatient services shall be accredited by The Joint Commission or another equivalent accrediting body.
Professional Liability Coverage
Provider shall provide and maintain professional liability insurance with a responsible insurance carrier of not less than the following amount(s) per specialty per occurrence: $1,000,000 per occurrence; $3,000,000 aggregate. However, if the provider is an entity or a subdivision of a State that either provides for self-insurance or limits the liability or the amount of insurance purchased by State entities, then the insurance requirement of this contract shall be fulfilled by incorporating the provisions of the applicable State law.
Alaska providers need to follow the medical documentation provisions stated earlier in this handbook and are encouraged to use VA’s e-Prescribing and mail order pharmacy options for Veterans. Physicians will need to contact their Electronic Health Records (EHR) vendor for information on their e-prescribing capabilities.
In addition to the online formulary, an online formulary search tool is available. This application provides formulary alternatives to non-formulary drugs in the same VA drug class.
Medical Documentation – What to Submit
Alaska providers should follow the medical documentation provisions stated earlier in this handbook along with the following two that are unique to Alaska:
- Provider/Practitioner Authentication (signature either electronic or on paper) – Alaska only
- Include typed name and provider phone number
- THP Facility name (where applicable) – Alaska only
Please refer to VA’s Facility Contact Information for Care Coordination for assistance in returning medical documentation.
Your Provider Agreement specifies the contractual rates for services provided to CCN beneficiaries by incorporating references to the Alaska VA Professional Fee Schedule, the Alaska VA Fee Schedule and VA Maximum Allowable (Allowed) Charges. These VA fee schedules may be found below:
Drive-Time and Appointing for Veterans in Alaska
The following are VA standards for drive-time and appointing for Veterans in Alaska:
Average Drive-Time Standards
|Primary Care||30 minutes|
|Mental Health Care||30 minutes|
|Extended Care||30 minutes|
|Specialty Care||60 minutes|
* Note: The following services are EXCLUDED from the drive-time standards: telehealth, non-urgent neurosurgery and cardiothoracic surgery, rheumatology, and dermatology.
Maximum Appointment Availability Times
|Type||Actual Wait Time|
|Primary Care||20 days|
|Mental Health Care||20 days|
|Extended Care||20 days|
|Specialty Care||28 days|
For questions regarding this information, please email us at firstname.lastname@example.org or call 877-226-8749.