Provider Pulse

June 2018

Welcome to June

Who's ready for the first day of summer? Here at TriWest, we are! And we have lots going on to tell you about. The biggest news is VA temporarily waived its 180-day timely filing requirement for claims submission. Read more about this below, and don't miss the other articles too!

VA Temporarily Waives Claims Submission Timeline

Effective immediately, the Department of Veterans Affairs (VA) is temporarily waiving its 180-day timely filing requirement for claims submission.

Providers who received claim denials due to this requirement must re-submit their claims within 90 days of this notice for payment reconsideration; if claims are re-submitted after this period, they may be denied as untimely. TriWest will not automatically reprocess claims that were previously denied. This waiver is temporary, so please continue using your best efforts to submit clean claims within 30 days.

As a Reminder, Here is the TriWest Claims Submission Process:

1. Upload Medical Documentation to TriWest’s 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 WPS Military and Veterans Health (WPS MVH)
   • TriWest uses WPS MVH for all claims processing. After submitting medical documentation to TriWest, send claims either:
     • Electronically. Set up an Electronic Data Interchange (EDI) to submit electronic claims by calling WPS Health Solutions (the parent company to WPS MVH) at 1-800-782-2680 and selecting Option 1.
     • Via mail. Mail paper claims to the following:
       WPS MVH-VAPC3
       PO Box 7926
       Madison, WI 53707-7926

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Have Questions? Join a Webinar!

Did you know that TriWest Provider Education conducts several live and interactive webinars each month, at no cost to you?

Attending one of our webinars is a fantastic way to get your questions answered about the VA community care programs!

What Webinars Do We Offer?

• Introduction to the Patient-Centered Community Care (PC3) and Veterans Choice Programs – covers every process from authorizations and referrals, to medical documentation and ER care
• Billing Processes and Procedures – concentrates on claims submission and the difference between Medicare, Medicaid, TriWest, and TRICARE
• SEOC Training – our newest webinar explaining how to read and understand our new authorization letter formats called Standardized Episodes of Care, or SEOCs
• Behavioral Health – an introduction to the processes and procedures of VA's community care programs with an emphasis on behavioral health providers

Why wait when there's so much good information available to you?

Register now!

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REMEMBER: Never Bill a Veteran

If you end up providing care for a Veteran through one of the VA community care programs, it's no different than if the Veteran went to a VA Medical Center.

VA always pays. This means you, as the provider (including ancillary providers), may never bill a Veteran.

You should never collect co-pays, cost-shares, or deductibles from a Veteran who has a TriWest authorization to see you. You should also never balance-bill a Veteran. If a claim is denied, you may submit a claim appeal to TriWest via our claims processor, WPS MVH.

If the Veteran owes any money for his or her visit, VA will bill the Veteran directly. This is not something you—as the provider—need to worry about.

How to Submit a Claim Appeal

As we said before, you may not balance-bill Veterans if they have a TriWest authorization to see you. If you believe you were paid incorrectly, or that your claim was denied unfairly, you have the right to submit an appeal to TriWest. Here is the claim appeal process:

• Submit claim appeals within 90 days of receipt of the Explanation of Benefits or Remittance Advice.
• Mail the appeal to: WPS MVH-VAPCCC, PO Box 14491, Madison, WI 53708-0491.
• You will receive a response within 60 days of our receipt of your appeal.

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Is Your SAR Routine, Urgent, or Emergent?

Not all SARs are created equal. When we say SARs, we're talking about "Secondary Authorization Requests".

You will fill out certain SARs differently than others, depending if the care you're requesting is routine, urgent, or emergent. So, how do you know which status your SAR qualifies for?

ROUTINE

Any care that is not urgent or emergent is considered routine. NEVER mark your SAR as urgent or emergent if it is for routine care. Please see below to determine if your SAR may be considered urgent or emergent.

URGENT

Only mark a SAR as urgent if at least one of the following is true:

• Processing time that lasts more than two days could jeopardize the life or health of the Veteran, or his/her ability to retain or regain maximum function.
• Processing time that lasts more than two days will subject the Veteran to severe pain that cannot be managed without the treatment being requested.

Do NOT mark urgent for administrative urgency.

EMERGENT

Indicate "emergent" only when a new issue/diagnosis has developed for a Veteran who was already authorized to see you, or a Veteran self-presents for emergent reasons without a prior-authorization (for emergency room visits, please see our Quick Reference Guide on Emergency Care).

• VA determination of emergent care includes loss of limb, loss of life, loss of eyesight and other urgency at this level.
• If the care is emergent, please proceed with the care and submit the SAR immediately, indicating that the care is being rendered emergently.
• Emergent SARs can come in after care is rendered; providers will still get paid. This is an exception to the pre-authorization requirement.

Still need help on the SAR process? Review our SAR Quick Reference Guide!

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