Provider Pulse – March 2024
Qualifications for the High Performing Provider Designation
The Department of Veterans Affairs (VA) created a High Performing Provider (HPP) designation under the Community Care Network (CCN) for providers who excel in a set of standard health care evaluation metrics. It is one, but not the only, measure of provider practice quality.
Providers are scored on a set of standard quality metrics approved by VA to determine whether they are deemed to be an HPP. Additionally, the HPP designation may be used by VA or TriWest when selecting a community provider to see a Veteran.
CCN providers include providers practicing at the individual level, practitioners in a group setting, and institutional providers (such as hospitals). The three types of providers are scored differently.
- Individual providers are evaluated based on a combination of VA priority measures and standard measures from Blue Health Intelligence.
- Provider practice groups are scored as a single entity, and providers in those groups are assigned the score of the overall group.
- Hospitals are scored on a selection of CMS measures from the Hospital Compare system.
A summary of your specific provider metric results is available on request by completing the HPP Inquiry Form on the TriWest Payer Space on Availity.
For more information on the HPP designation, please review the HPP Quick Reference Guide. Providers should send the completed HPP Inquiry Form to CQHPP@TriWest.com.
Download RFS Forms Before Submitting
When filling out a digital Request For Services (RFS) form, it is recommended that you first save it to your desktop before submitting. This will help avoid the information being received in an unreadable format.
You can find the RFS form on the Veterans Health Administration web page, or on the VA Provider Storefront web page. For more information contact the RFS team at RequestForServiceSupport@va.gov, or reference the RFS Quick Reference Guide.
Last Day to Submit PC3 Claims with a Retroactive Referral is June 30
This is a notice to all providers that claims containing a retroactive referral filed under the Patient-Centered Community Care (PC3) program must be submitted on or before June 30, 2024.
TriWest Healthcare Alliance (TriWest) administers claims for the current Department of Veterans Affairs (VA) Community Care Network (CCN) in Regions 4 and 5. TriWest has also continued to support the prior version of the PC3 program that concluded in Region 4 on March 31, 2021 and in Region 5 on March 31, 2022.
For Current PC3 Claims:
- Services that fall under a Retroactive Referral must be submitted by June 30, 2024 to be considered.
- All other PC3 claims requests, unrelated to Retroactive Referrals (adjustments, reconsiderations, recoupments, etc.) are no longer accepted due to program close-out.
Timely Filing Requirements Reminders:
- All community care claims must be submitted within 180 calendar days from the Date of Service. Claims that do not meet timely filing requirements will be rejected/denied accordingly. For detailed information on timely filing requirements please visit the Timely Filing Requirements section of the CCN Provider Handbook.
Community care claims reconsideration requests must be submitted within 90 days from the original claim decision date. Please reference the Claims Reconsideration Request Form and its instructions.
VA CCN Pharmacies to Begin Prescribing Adalimumab-bwwd (Hadlima®)
Beginning in March 2024, all Department of Veterans Affairs (VA) pharmacies are required under the Community Care Network (CCN) to automatically convert patients from Adalimumab (HUMIRA®) to the nationally contracted product, Adalimumab-bwwd (Hadlima®).
This includes any Veteran prescription filled at a VA pharmacy that is written by a CCN or VA provider.
Changes to the National VA Formulary:
- Adalimumab (HUMIRA®) will become non-formulary (NF).
- Adalimumab-bwwd (Hadlima®) will be added to the National Formulary as Prior Authorization-Facility (PA-F).
- All other adalimumab biosimilars are considered NF.
Only patients who are approved through local formulary appeal processes on an individual basis with solid clinical justification (e.g., allergies to excipients) via a non-formulary request will be allowed to convert to a non-contracted product.
For more information please reference the VA National Formulary – Pharmacy Benefits Management Services.
Submit an Online Reconsideration Request for Timely Filing
Under the Department of Veterans Affairs (VA) Community Care Network (CCN), if you have received a denial for timely filing, you may qualify for reconsideration of payment if you answer “yes” to both of the following questions:
- Do you have proof of claim submission within 180 days from the date of service or date of discharge?
- Did you originally submit to a VA payer (TriWest, Optum, VA)?
If you meet the criteria above, please submit an Online Claims Reconsideration Request and be sure to attach your valid proof of timely filing for review. Timely Filing reconsiderations will be worked in the order they are received.
VA CCN Provider Handbook Updates
The following subsection will be added to the Credentialing and Contract Provisions page of the CCN Provider Handbook:
Marketing and Advertising
Provider shall not (1) advertise the award of the Provider Network Agreement or the Program Terms and Conditions in such a manner as to state or imply that the VA endorses a product, project, commercial line of endeavor, provider’s practice or services, or (2) solicit, either directly or indirectly, the VA, VA Medical Centers (VAMC) or Veterans through either provider’s commercial advertising or direct outreach. A TriWest network provider may only utilize the approved website badges on provider’s website as well as the approved print-ready signs found on TriWest’s Proudly Caring for Veterans web page to indicate their participating status in the TriWest network supporting VA.