Urgent Care and Emergency Care
Urgent Care/Retail Walk-In Process
TriWest network urgent care/retail location providers may treat Veterans who self-present without an approved referral/authorization. However, the urgent care/retail location staff must confirm the Veteran’s eligibility before providing care by calling 833-4VETNOW (833-483-8669). This step also activates the prescription (Rx) benefit for the Veteran for the urgent care visit.
Providers must ensure they are part of the TriWest network before treating the Veteran through this benefit. Providers may request to join the TriWest network at https://joinournetwork.triwest.com.
The Veteran will be billed separately by VA for any applicable copayment. If a Veteran has general questions about copayments, direct them to https://www.va.gov/health-care/copay-rates.
To follow the Urgent Care process:
- The Veteran will self-present to the TriWest network urgent care/retail location clinic. The urgent care/retail location clinic will ask the Veteran for his or her:
- Date of birth
- Last four digits of the Social Security number (SSN)
- Overseeing VAMC
- Home address
- The urgent care/retail location staff calls TriWest at 833-4VETNOW (833-483-8669) to confirm the Veteran’s eligibility. Staff will input the Veteran’s date of birth and last four Social Security digits into the phone system.
- This eligibility check is imperative because it’s directly linked to approval for urgent medications the Veteran may need. Without the eligibility check, the system may deny the Veteran medication that the urgent care clinic prescribed.
- If eligibility is confirmed, the urgent care/retail location clinic may treat the Veteran for his or her medical condition.
- The urgent care/retail location provider may write a medically necessary prescription for up to a 14-day supply. The medicine must be listed on VA’s Urgent Care Formulary.
- The Veteran may fulfill the prescription at any in-network pharmacy with ExpressScripts. No voucher is required when fulfilling an urgent medication prescription. However, it will not process if a check of the Veteran’s eligibility was not done in advance.
- After the Veteran leaves, the urgent care/retail clinic must submit medical documentation from the visit to the Veteran’s associated VA facility based on the Veteran’s residential ZIP code within 30 days from the date of service. Providers may submit medical documentation via fax, email or Industry Standards Electronic Means to the Veteran’s VAMC.
- If the Veteran doesn’t know his or her home VAMC, the clinic can look up the VAMC closest to the Veteran’s home address using this VA lookup tool.
- The urgent care/retail location clinic will then submit its claim to PGBA, TriWest’s claims processor. TriWest is responsible for paying claims.
If the Veteran needs additional or follow-up care, the urgent care/retail location provider should refer the Veteran back to his/her authorizing VAMC.
Covered and Excluded Urgent Care Codes
VA defines urgent care as the treatment of non-emergent symptoms needing immediate attention, such as flu-like symptoms, strep throat, minor burns, pink-eye, or ear and skin infections. The Urgent Care/Retail Location benefit is not intended to cover routine primary care or preventive screening services.
To help providers better understand what’s excluded, VA has provided a list of excluded codes, available here: https://www.triwest.com/UC-excluded-codes.
VA allows providers to administer the flu shot to Veterans during an urgent care/walk-in visit. VA will cover flu shots as a standalone service under the CCN Urgent Care/Walk-in benefit or at any network retail pharmacy.
Critical Findings During Urgent Care
Providers must report any Critical Findings discovered during an urgent care/retail location treatment to the Veteran’s home VAMC within 24 hours by phone.
VA defines a Critical Finding as one of the following:
- A test result value or interpretation that, if left untreated, could be life-threatening or place the Veteran at serious risk
- A newly identified suicide risk in a Veteran
- A new diagnosis of cancer
Urgent Care that Turns into an Emergency Situation
If a Veteran’s urgent care situation escalates to a true emergency, the urgent care or retail location clinic should take whatever action is necessary to protect the health and safety of the Veteran. For example: Call 9-1-1, call the Veteran’s family to transport the Veteran to the emergency room, or order an ambulance to take the Veteran to the emergency room.
Emergency Care Requirements
Community hospitals and providers treating Veterans who self-present to an emergency department are required to notify VA within (72) hours of Veterans presenting to the emergency room via the Emergency Care Reporting (ECR) portal, or by calling 844-72HRVHA (844-724-7842).
Providers also are required to include a valid email address for decision correspondence when reporting emergency treatment.
Providers need the notification identification number, assigned upon submission of reporting, to correlate authorization decisions to reported emergency events.
VA will only accept emergency treatment information by the following:
- Website: Emergency Care Reporting (ECR) portal
- Phone: 844-72HRVHA (844-724-7842)
Questions? Contact the Emergency Treatment team at VHAOCCEmergencyCareTeam@va.gov.
VA will need to know:
- Veteran’s full name
- Last four digits of the Veteran’s Social Security number (SSN)
- The condition for which the Veteran is being seen
- The mode of transportation by which the Veteran arrived. If arriving by ambulance, a copy of the trip report should be provided, if possible.
- TriWest strongly recommends that providers indicate in the Veteran’s record who at the VA took the notification information or what number it was called into or faxed to, as this is a critical requirement for payment.
- Providers also should provide inpatient information in case the visit resulted in an admission.
VA health care staff will determine the Veteran’s eligibility and, if appropriate, retroactively authorize care.
If the Veteran is being seen for authorized care and, during treatment, it is determined the Veteran is experiencing an emergency, the treating provider/facility must render emergency treatment immediately and notify VA. Additionally, the local ER that receives the Veteran must follow the steps above.
If a Veteran is receiving authorized services and the treating facility determines the Veteran needs a higher level of care than its facility is capable of providing, it must obtain authorization from VA prior to transferring the Veteran to another facility by submitting an RFS.
In the event that care is not authorized by VA to be paid by TriWest, the provider must submit claims within 90 days of the encounter directly to VA for reconsideration. No separate payment will be made for ER facility charges for inpatient services authorized by VA that are subject to reimbursement under the VA Inpatient Acute Care Prospective Payment System.