Provider Pulse – April 2023
Follow the Buy and Bill Process
The Buy and Bill process allows providers to obtain medications that they may administer in the office and bill directly to TriWest.
Providers who administer medications to patients in their office are required by TriWest to follow the Buy and Bill process. While most prescriptions are available from a specialty pharmacy, they are not all available as a pharmacy benefit at this time. Therefore, providers must obtain their prescription medications from a specialty distributor and not a specialty pharmacy.
Providers can submit claims to TriWest for medication reimbursement and the office medication administration when this process is used.
What is Buy and Bill?
Buy and Bill is a process for providers to obtain specialty medications that require administration to patients in office.
Providers should purchase the medication from a specialty distributor (specialty pharmacies are one type of distributor, but not all are available as a pharmacy benefit at this time). Depending on the medication or product, the provider may order one, or buy in bulk to keep on hand in the office. Any medications purchased using the Buy and Bill process are administered in the provider’s office or alternate site of administration (depending on requirements for administration of the specific treatment).
Buy and Bill Process Steps:
- Ensure the medication is covered for a condition referred under the issued Standard Episode of Care (SEOC).
- Write a prescription for the medication.
- Order and receive medication from a specialty distributor.
- Administer the medication to a Veteran and document in medical record.
- Submit medical claim for procurement and administration to TriWest.
- Receive reimbursement from TriWest.
For more information, visit the Buy and Bill Quick Reference Guide (QRG).
VA Medical Policies Help Guide Care
The Department of Veterans Affairs (VA) has begun to publish medical policies for community care providers to help ensure that recommended care meets VA clinical criteria. The policies help guide providers but are not intended to replace clinical judgment. These policies also do not affect provider reimbursement for care.
To view VA’s most current medical policies, visit the Community Care Medical Policy page on VA’s website. For more detailed information, take the Medical Policy webinar on VHA TRAIN.
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Provider Handbook Updates