March

Provider Pulse

March 2017

Welcome to the New Provider Pulse!

We are very excited to announce the launch of Provider Pulse, a monthly newsletter to help providers better understand the Department of Veterans Affairs (VA) community care programs.

Provider Pulse will be written and published every month by the Provider Education team at TriWest Healthcare Alliance. TriWest is the contractor responsible for administering VA's Patient-Centered Community Care Program (PC3) and Veterans Choice Program (VCP) in 28 states and the pacific islands of American Samoa, Guam and Northern Marianas.

What can you expect to read in Provider Pulse?

  • Updates or changes to the PC3 and VCP programs
  • Tips and tricks on navigating VA's community care programs
  • Reminders on medical documentation and claims requirements
  • Educational articles on different aspects of PC3 and VCP
  • News bulletins related to VA community care in the TriWest region

Ensuring access, quality and continuity of care is vital to you as a health care provider. As a VA contractor, we're here to make sure you have the tools, resources and information you need to care for our nation's Veterans.

So stay educated, stay informed, and enjoy the inaugural edition of Provider Pulse!

In This Edition:

Who to Bill: TRICARE or TriWest?

TriWest, TRICARE, Department of Veterans Affairs (VA): aren't they all the same thing?

At first glance, it might seem that way. However, TRICARE, TriWest and VA are very different entities. If you don't understand the differences, you might bill the wrong entity and have trouble receiving payment.

Here's the breakdown to help:

TRICARE

TRICARE is the nation's health care benefit for active duty Service members, National Guard/Reserve members, military retirees, and their families. TRICARE is a program under the U.S. Department of Defense and receives its funding through the defense budget. The key to remember for TRICARE is it covers those who are currently serving in, or have retired from, our Armed Forces.

VA

VA benefits cover those who once served in the military, but have now either separated or retired from the military and become Veterans. This means they are no longer serving in the Armed Forces. VA benefits fall under the Department of Veterans Affairs, which is separate from the Department of Defense. When it comes to VA, think "Veterans and no longer serving in the military."

TriWest

TriWest Healthcare Alliance (that's us) is a private company that VA contracts with to administer its Patient-Centered Community Care and Veterans Choice programs. TriWest has a substantial network of dedicated providers in its 28-state region and Pacific islands who accept the VA programs. TriWest also ensures Veterans are appointed for health care, sends authorizations to providers, collects medical documentation, and pays clean claims.

In the past, TriWest administered the TRICARE program for many years across the western U.S. However, in 2013, TriWest stopped administering TRICARE and partnered with VA to serve Veterans.

Still need help understanding who to bill? Visit our new billing section on the Provider Portal at www.triwest.com/provider-billing.

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How Other Health Insurance (OHI) Works

For Veterans you treat under the Veterans Choice Program (VCP), you may have been told to bill "Other Health Insurance (OHI)," even if you have an authorization from TriWest Healthcare Alliance.

To help clarify, TriWest always pays for pre-authorized services. If your staff is told to bill OHI, it means to bill the other health plan first as primary, and TriWest will pay secondary.

VA has developed a set of rules under the VCP that apply to OHI. The information below highlights those rules and will provide direction when billing TriWest.

OHI Billing Process

TriWest will always pay PRIMARY on service-related or service-connected treatments, regardless of a Veteran's OHI. VA has a dedicated team to determine service-connection status.

Additionally, VA determines if a Veteran's OHI should be billed as primary. TriWest will notify the provider through a secondary notification. This notification is separate from the authorization letter.

If the Veteran has Medicare (including Advantage), Medicaid, or TRICARE:

  • TriWest pays primary. TriWest cannot pay secondary.
  • Always bill TriWest if you have a TriWest authorization, even if the Veteran also has Medicare, Medicaid, or TRICARE.

If the Veteran has commercial health insurance:

  • Bill the commercial plan first. TriWest will pay secondary (unless service-connected).
  • Always follow the billing rules of the primary OHI, including collection of copays, cost-shares and deductibles.
  • The Veteran does not choose which plan is primary.
  • When you bill TriWest, include the OHI's Explanation of Benefits (EOB) with your claim, even if it is a zero-balance EOB.

If you have an authorization from TriWest but are not in-network with the Veteran's OHI, or the TriWest-authorized services are not covered under the Veteran's OHI:

  1. Bill the OHI.
  2. Receive the denial.
  3. Bill TriWest with a copy of the OHI claim denial.
  4. TriWest will process the claim for authorized services according to your agreement or contract.

OHI Notification Process

When a Veteran calls the number on the back of his or her Choice Card, a TriWest Patient Service Representative collects OHI information and schedules an appointment. From there, TriWest will fax the provider an authorization letter. If TriWest determines the Veteran has commercial OHI:

  • TriWest reaches out to VA after sending the authorization letter.
  • VA confirms if the episode-of-care is service-connected or not.
  • TriWest faxes an OHI notification to the provider—separate from the authorization—explaining who to bill as the primary payor, and whether the visit is service-connected.

If the provider does not receive a secondary notification within three to four weeks after the authorization arrives, it is safe to assume the Veteran does not have commercial OHI. Proceed with billing TriWest as the primary payor.

Additional Information

Refer to the TriWest OHI Quick Reference Guide, available at www.triwest.com/provider-ohi.

The TriWest Provider Portal at www.triwest.com/provider is your one-stop shop for information on filing claims and navigating the Veterans Choice Program. If you have any further questions after reviewing the information on the portal, contact TriWest Provider Services:

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The New Address for Your Claims

As of Aug. 1, 2016, the address where providers send their paper claims changed. To ensure you receive payment, send all future paper claims to:

WPS-VAPC3
PO Box 7926
Madison, WI 53707-7926

The old address was for a location in El Paso, TX, whereas the new address goes to Madison, WI. Please keep in mind you may encounter an overlap of addresses on the Veterans Choice Card during this transition. The old cards still list the former Texas address, while the new cards will list the updated Wisconsin address.

Don't Delay, Cut Paper Today

If you want to avoid dealing with the claims submission address change, then don't delay, and cut paper today! It's as easy as E3:

EDI – submit claims electronically
EFT – receive payment electronically
ERA – receive remittance electronically

To sign up for all three—or E3—visit http://www.wpsic.com/edi/edi-forms.shtml.

Claims Submission Process

Now that you've updated your records and know about your electronic options, do you know the correct claims submission process? When submitting claims to TriWest, make sure you're following the two-step process below:

  1. Upload Medical Documentation to TriWest Provider Portal
    • Register for a secure account on TriWest's Provider Portal at www.triwest.com/provider and upload medical documentation directly to the system.
      • Documents up to 5 MB can be uploaded in PDF or TIF format
      • If unable to access the Provider Portal, fax medical documentation to TriWest at 1-866-259-0311.
  2. Submit Claims to Wisconsin Physicians Service (WPS)

    TriWest uses WPS for all claims processing. After submitting medical documentation to TriWest, send claims either:

    • Electronically. Enroll for EDI to submit electronic claims by calling WPS at 1-800-782-2680 and selecting Option 1.
    • Via mail. Mail paper claims to the following address:

      WPS-VAPC3
      PO Box 7926
      Madison, WI 53707-7926

    To reiterate, send your medical documentation to TriWest, and your claims to WPS. For more information on claims, you can read and download our Provider Claims Quick Reference Guide available on our Provider Portal at www.triwest.com/provider.

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Need Help? Where to Turn

Whether you can't log into the TriWest Provider Portal, or you need help filing a secondary authorization request (SAR), TriWest has a slew of ways to support you. Below are the different places you can call, email or visit online for help:

TriWest Provider Portal

The TriWest Provider Portal at www.triwest.com/provider is always available as your one-stop shop for information on filing claims and navigating the Department of Veterans Affairs (VA) community care programs. You can find many resources on the Provider Portal, including:

Provider Services Phone and Email Support

The Provider Services Department at TriWest exists solely to support you—the provider. Whether you have questions on the SAR process, where to send claims, or how the Veterans Choice Program works, Provider Services is the authority on almost anything provider-related.

You can reach Provider Services' support staff in one of two ways:

Provider Portal Technical Support

Having trouble logging into your account on the Provider Portal? Not sure why that error message keeps popping up? Call our Provider Portal Assistance Line! Provider Portal Assistance is a tech support team that will troubleshoot technical issues with the Provider Portal.

You can call Provider Portal Assistance at 1-855-722-2838, Option 3, Option 2.

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Updated: 8/2/2022 10:10:53 PM