To help improve claims payment accuracy for Adult Day Health Care (ADHC), the Department of Veterans Affairs (VA) and TriWest Healthcare Alliance (TriWest) have re-evaluated the current billing requirements.
As a reminder, ADHC services for Veterans should be billed on a daily basis.
Please make note of the following requirements when billing for ADHC:
- Claims must be on a UB04 claim form.
- The type of bill should be 891, which is the bill used for a specialty facility.
- The Medical Rehabilitation Day program revenue code of 93X must be billed, providers may use codes 931 or 932.
- All codes must include a Healthcare Common Procedure Code (HCPC). All revenue codes are Per Diem codes and should only be billed with 1 unit per day.
- S5101 (half day),
- S5102 (full day), or
- S5105 (extended).
- T2003 is for transportation and can be billed per encounter/trip.
The Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022, also known as the PACT Act, allows VA to provide much-needed benefits and care to generations of Veterans who were exposed to burn pits and other toxic substances during military service.
The PACT Act:
- Offers every enrolled Veteran an initial toxic exposure screening and a follow-up screening at least every five years.
- Solidifies VA’s process for establishing presumptions of service connection of toxic exposure-related conditions.
- Makes generations of Veterans eligible for VA health care, while increasing access to care.
- Increases funding for VA research on Veteran toxic exposure.
- Gives VA tools to hire and retain employees and modernize over 30 facilities.
To assist Veterans who feel they may have been exposed:
- Ask the Veteran if they are aware of VA’s new toxic exposure screening.
- If a Veteran feels they may have been exposed, refer them to Toxic Exposure Screening Information - War Related Illness and Injury Study Center.
Learn more about the PACT Act: The PACT Act and Your VA Benefits.
Please be advised of the following updates to observation hours and urgent care claims codes.
Changes to Observation Hour Claims
Facility claims may be denied if they are submitted with observation hours greater than 72 hours, as observation can no longer be greater than 72 hours.
If observation hours exceed 72 hours, facilities can submit a new claim adding the extra hours in the non-covered field for them to be considered.
Changes to Urgent Care Claims
Please be advised that the following COVID-19 diagnosis and immunization codes were removed from the exclusion list for urgent care claims:
Urgent Care Billing Tips
- Box 23 should be left blank for all urgent care claims. Billing with a ‘dummy’ authorization number or reference number in box 23 will result in the claim being denied.
- Only the clinic is currently loaded for urgent care, therefore individual practitioners cannot be loaded.
- Veteran eligibility should be verified prior to being seen at an urgent care clinic.
- To verify eligibility, call the IVR number 833-4VETNOW (833-483-8669).
- Urgent care prescription benefits will be activated at the time the eligibility verification call is made through the IVR.
- Prescriptions must be filled by a TriWest network pharmacy.
- Copays should not be collected by the urgent care at the time of service. Copays will be determined and billed by VA if applicable.
For more information please review the CCN Urgent Care and Emergency Care Quick Reference Guide.
TriWest now offers you the ability to self-subscribe and receive claims status reports emailed directly to your inbox. Reports can be automatically generated monthly, weekly or on an ad hoc date range based on your preference. This tool puts claims status reports at your fingertips, saving you time by automating the reporting functionality and giving you an improved workflow to review the claims status of your Veteran patients.
With claim status reports delivered securely to your email inbox as an Excel file, you can quickly review the status of submitted claims without being logged into Availity.com or calling a TriWest contact center agent for the information.
Subscribe Now to Receive Claim Status Reports Emailed to You
To subscribe, log in to your Availity account. Then:
- Select the Payer Spaces tab.
- Choose TriWest Healthcare Alliance.
- Select Provider Claims Reporting Tool.
- Select your Tax ID number.
- Click Add New Subscription.
- Select the frequency you prefer and enter the email address(es) where the reports should be delivered. (Note: Reports can be sent to up to five email addresses at a time.)
For a more detailed look at the Provider Claims Reporting Tool, refer to the Provider Claims Reporting Tool User Guide that displays screenshots on how to subscribe.
If you’re not signed up for Availity, register for a free account to use your single user ID and password to check claims status and access all TriWest information, webinar sessions, quick reference guides, and the CCN Provider Handbook.