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January 2021

Welcome to January

Happy New Year as we welcome in 2021. January always signals a new beginning to a new year and new opportunities. TriWest Healthcare Alliance (TriWest) will continue to offer you information to help you better serve our Veterans. In this issue of Provider Pulse, you’ll find a notice about the 2021 CMS and U.S. Department of Veterans Affairs (VA) fee schedules, along with information on VA’s rollout of the COVID-19 vaccination. This month, we also cover VA formulary requirements, eSeminars learning paths, and more. Keep reading for more details.

In This Edition:

Annual Updates to CMS Physician Fee, VA Fee Schedules

VA’s Community Care Network (CCN) is funded by federal dollars and closely follows Medicare Fee-For-Service guidelines for payments. This includes moving to the most current Centers for Medicare & Medicaid Services (CMS) Fee Schedules, implemented every January.

Additionally, the VA Fee Schedule is updated in January and includes rates for physician, clinical laboratory, ambulance, and drug services. When there is no Medicare rate and there is a VA Fee Schedule amount available, VA reimburses at the lesser of billed charges, or the local VA Fee Schedule amount for the period when the service was performed.

CMS changes to an assigned remittance rate, or payment, will vary by specialty and location. Look up the value of specific Current Procedural Terminology (CPT) codes on the CMS.gov website via the Physician Fee Schedule Look-Up Tool. You can also obtain rates for your region from the Medicare Administrative Contractor (MAC) that manages your jurisdiction. Rates are specific to the geographic area where the care is rendered.

Remember, TriWest follows Medicare reimbursement guidelines, but cannot coordinate benefits with Medicare. TriWest and Veteran benefits cannot pay secondary or as a Medicare supplemental plan. If care was pre-authorized as a VA benefit, please submit the claim to our claims processor, WPS Military and Veterans Health (WPS MVH). Do not submit these claims to Medicare or TRICARE.

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COVID-19 Vaccines at VA

VA is working closely with the Centers for Disease Control and Prevention (CDC) and other federal partners to directly provide COVID-19 vaccines to Veterans and VA health care personnel.

VA has developed a phased plan for these vaccines based on criteria from CDC. This plan will do the most good for the most people during this time. Under this plan, VA is initially offering vaccines to two groups:

  • Veterans living in its long-term care facilities,
  • VA health care personnel to help continue providing care for Veterans.

After these first two groups, VA will begin to offer vaccines to more Veterans who are at high risk of severe illness from COVID-19.

For more detailed information, refer to the VA's webpage regarding COVID vaccines.

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Help a Veteran by Discussing Vaccinations

As the nation’s annual influenza season is underway and vaccines for COVID-19 have begun to be distributed, it is important for providers to inform Veterans of the importance of keeping up with their vaccinations.

This reminder follows a recent assessment of Veterans engaged in TriWest’s Case Management program. The initial assessment revealed that only 17 percent of oncology patients reported that they had a conversation with their provider regarding immunizations. Subsequent follow up revealed that this number increased to only 45 percent in the following month.

Quality care for Veterans includes raising awareness around important health topics. By discussing the various immunizations and vaccines available, Veterans can get information and resources that can help them. By keeping up-to-date with their vaccinations, Veterans are not only protecting themselves and their loved ones, but the community around them as well.

Take a look at some VA information regarding vaccinations and Veterans:

  • VA reaches over 80 percent of Veterans over the age of 65 with the flu vaccine.
  • Vaccines are one of the safest medical interventions we have.
  • VA provides the pneumococcal vaccine to almost 95 percent of Veteran patients who should receive it.
  • People aged 65 or older need a one-time shot to help prevent pneumonia.
  • Once you get a vaccine, it also protects others around you from getting that disease.
  • All adults need a tetanus and diphtheria booster shot every 10 years.

Resources for more information

Educating Veterans so they take proper precautions can help them, and their loved ones, stay healthy and avoid these common illnesses.

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When to Expect Your 1099 Form in 2021

A 1099 Form reports income from self-employment earnings, interest and dividends, government payments, and more. It is a tax form similar to a Form W-2 that you use to file taxes.

TriWest is responsible for sending you a new Form 1099 by Jan. 31, 2021. If you haven’t received your Form 1099 by then, please wait until Feb. 1 to contact TriWest’s claims processor WPS MVH or TriWest. If you call before Feb. 1, you will automatically be directed to check back after that date.

Need a new Form 1099 or are you disputing the amount on your 1099?

  • If you never received a Form 1099 or you need a new 1099 with corrected information, fax a W-9 with the information listed below. Also include the 1099 if applicable:
    • Fax Number: (866) 589-7693
    • Attention: New 1099 Needed
  • The W-9 needs to include the following:
    • Line 1 – Name as being registered with the IRS for the Tax Identification Number (TIN) listed in Part 1
    • Line 2 – Group Name (DBA name) or Disregarded Entity name/TIN; when applicable (if same as Line 1, can be blank)
    • Line 3 – Appropriate federal tax classification
    • Line 4 – Exemption Codes; when applicable
    • Lines 5 and 6 – Address where annual tax 1099 statement should be sent
    • Part I – TIN. Either a Social Security Number (SSN) or an Employer Identification Number (EIN) can be used, but cannot use both.
      • The TIN provided must match the name given on Line 1 to avoid backup withholding.
    • Part II – Must be signed and dated including day, month and year (format does not matter)

TriWest will update the information needed and resend a corrected Form 1099 to you.

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Reminder: Follow the VA National Formulary Requirements

As a reminder, you must follow the VA National Formulary requirements when prescribing routine medication to Veterans. If a preferred medication is not on the VA drug formulary, you must contact the authorizing VA Medical Center (VAMC) and request a Formulary Review Request form, fill out the form, and return it to the authorizing VAMC for approval or denial. This process can take up to 96 hours for review.

Providers prescribing urgent or emergent medication must adhere to VA’s Urgent/Emergent Formulary.

Don’t Provide Drug Samples to Veterans

Providing drug samples to Veterans could have adverse consequences. Samples often require other criteria for use, do not contain important instructions on the package, or may have interactions with other prescribed medications that are tracked through VA’s pharmacy system.

If a Veteran has an immediate prescription need and cannot wait or travel to a VA pharmacy, VA requests that you follow these guidelines:

  • Immediate need prescriptions may be sent to the referring VA medical facility’s pharmacy, or to a retail pharmacy participating in the network. Immediate need prescriptions are contained on the VA Urgent/Emergent Formulary.
    • Up to a 14-day supply with no refills of the immediate need medication may be authorized.
    • Only a seven-day supply for opioids or up to the opioid prescribing limit allowed by state – whichever is less – may be authorized.
    • If the medication is needed past 14 days, the provider will need to send another prescription to the referring VA medical facility’s pharmacy for prescription fulfillment services.
  • Routine/maintenance prescriptions must be sent to the referring VA medical facility’s pharmacy. If you do not have the ability to electronically submit prescriptions to pharmacies, please contact the Community Care representative at the referring VA medical facility for their pharmacy fax number.
  • The use of drug samples or drug coupons is prohibited.

If you believe providing a drug sample to a Veteran is absolutely necessary, please contact your referring VAMC for guidance first.

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VA Changes Reimbursement Policy: Spinal Decompression

VA has reviewed its policy relating to chiropractic care and will no longer reimburse spinal decompression Healthcare Common Procedure Coding System (HCPCS) code S9090 on VA standardized episodes of care (SEOC) with dates of service effective Jan. 1, 2021, and later.

As part of its efforts to continually review the services provided to Veterans, VA determined that there was insufficient evidence regarding unique benefits of this service to justify continued reimbursement for this code. Other types of lumbar traction can be used for care provided to Veterans and will be reimbursed by VA.

As with any non-emergent Veteran community care, the services must be authorized in advance.

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ESeminar Learning Paths for Busy CCN Providers

Can’t attend an in-depth, live, training webinar? TriWest created on-demand eSeminar Learning Paths for providers who need quick, detailed information about CCN. These on-demand Learning Paths range from six to 17 minutes in length, and can be accessed via the TriWest Learning Center on Availity.com.

What are the Three Learning Paths?

The Introduction to Community Care Network (CCN) defines CCN and the provider’s role and responsibilities, highlights the additional services Veterans may receive under CCN, and outlines the role and resources TriWest maintains and provides in administering the network on behalf of VA.

The second Learning Path, CCN Approved Referrals/Authorizations and the Appointing Process, demonstrates how to trigger an approved referral/authorization, what the pharmacy process is, what to expect in the appointing process, when to submit medical documents to the VA, and whether a Request for Services (RFS) is considered urgent, emergent, or routine under CCN.

Finally, the CCN Claims Guidelines Learning Path describes the CCN claim submission requirements including where to submit claims, what to include, and who is eligible to file claims.

Register for these CCN eSeminar Learning Paths:

  1. Log in to your account on Availity at www.availity.com (If you don’t have an account, register for a free account.)
  2. Navigate to the TriWest Payer Space
  3. Enter the TriWest Learning Center
  4. Click on “Learning Paths” at the top of the webpage
  5. Select “Enroll” and “Yes” to verify the selected CCN eSeminar Learning Pathway

Once you have enrolled, you can view each module in the Learning Path, stop and start if needed, and print a completion certificate.

For additional assistance and information, please use the TriWest Learning Center Quick Reference Guide.

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VA Offering Free Community Care Training

VA is sponsoring free webinar training that gives community providers an overview of Community Care details and the corresponding VA regulations. The webinar offers an in-depth discussion/presentation on Community Care, VA policies, claims, referrals, and Community Care Modernization and Improvements. Points of contact and resources will be provided for those participants who have additional questions or who want to learn more.

Register for the course on VA’s training website. Prior to the webinar, please email any questions you have to VHA10DCommunityProviderCommunications@va.gov.

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You’ll receive important Veteran-related information on a monthly basis, or more often if there are urgent updates we need to communicate. This is an opt-in service, so if you find our information no longer applies to you, you can opt-out at any time. Thank you for caring for our nation’s Veterans.

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Provider Handbook Updates

An appendix regarding services rendered pursuant to authorizations for care under CCN, as administered by TriWest in Alaska was added to Page 23 of the CCN handbook. There are no planned changes to the PC3 handbook for February 2021.

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Updated: 11/16/2023 3:55:22 PM