Provider Pulse – December 2023

Turn Your Valuable Time into Fast Pay with the EFT/ERA Availity Enrollment App

Spend more time caring for our nation’s Veterans and less on claims paperwork and waiting on snail mail, with the new Availity EFT/ERA online enrollment tool!

This easy online tool enables secure and efficient EFT/ERA enrollment, and ensures you will save time by receiving automated and direct pay.

Consider the benefits of enrolling in EFT/ERA:

No enrollment fee.
No more time-consuming paper checks.
Receive payment in as little as 10 days.
Safe and secure funds transfer to your bank account.

To sign up or learn more about the app, visit Availity.com, select My Providers | Enrollment Center | Transaction Enrollment.

HIT Medication to be Based on ASP Pricing Starting January 1

To better align with the Department of Veterans Affairs (VA) Community Care Network (CCN), reimbursement provisions for home infusion therapy (HIT) drugs will now be based on ASP pricing instead of AWP pricing, which was the previous payment methodology. Any home infusion therapy drugs billed with place of service 12 will now be based on ASP pricing instead of AWP.

This change will go into effect for claims processed with a Date of Service (DOS) Jan. 1, 2024 and after.

Reimbursement for services rendered cannot exceed the number of units authorized by the approved Standard Episode if Care (SEOC). If a provider requires additional units, they must request a new referral from VA. Infusion therapy services covered under CCN continue to include Ambulatory Infusion Suite (AIS) and IV therapy outpatient infusion, in addition to HIT.

For more information please reference the Infusion Therapy Services QRG.

PC3 Claims Must be Filed by March 31, 2024

This is a notice to all providers that claims filed under the Patient-Centered Community Care (PC3) program cannot be processed after March 31, 2024. TriWest will no longer accept PC3 claim submissions starting April 1, 2024.

TriWest Healthcare Alliance (TriWest) administers claims for the current Department of Veterans Affairs (VA) Community Care Network (CCN) in Regions 4 and 5. Until now, TriWest has also continued to support the prior version of the PC3 program that concluded in Region 4 on March 31, 2021, and in Region 5 on March 31, 2022.

For Current PC3 Claims:

Services that fall under a Retroactive Referral, including reconsideration requests, must be submitted by March 1, 2024, to be considered.
All PC3 claims requests (adjustments, reconsiderations, recoupments, etc.) will be processed no later than March 31, 2024.
Effective April 1, 2024, PC3 claims cannot be processed or adjusted. TriWest will not be able to accept PC3 claims or related inquiries and requests in any format.

Timely Filing Requirements Reminders:

All CCN claims must be submitted within 180 calendar days from the Date of Service. Claims that do not meet timely filing requirements will be rejected/denied accordingly. For detailed information on timely filing requirements please visit the Timely Filing Requirements web page.
Community care claims reconsideration requests must be submitted within 90 days from the original claim decision date. Effective January 1, 2024, reconsideration requests that are not submitted timely will be rejected upfront. Please reference the Claims Reconsideration Request Form and its instructions.

Avoid Denied Claims: Look Up VA Referral Numbers Online

A new tool is available on TriWest.com and Availity for providers to look up a Department of Veterans Affairs (VA) referral number for any claim online. These new self-service features were added to assist providers and billing teams with including the proper VA referral number on claims.

A VA referral number is required on all claim forms (except for urgent care), and is often the missing component to having a claim processed and paid successfully.

To lookup a referral number, go to Availity.com and use the Chat with TriWest tool. For providers who do not have an Availity account, visit www.triwest.com/claimsinformation to launch the referral look-up tool.

It is very important to exclude any extra characters, spaces, or words with the referral number, or the claim will deny. For example, if the correct referral number is VA0001234567, referral numbers included in the following format would be denied:

Auth VA001234567
Auth # VA001234567
Ref VA001234567
Ref # VA001234567
VA 001234567
VA01234567

For more information, please refer to the Claims Submission Quick Reference Guide.

VA Medical Policies Help Guide Care

VA publishes 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.

Provider Handbook Updates

Two updates are planned for the CCN Provider Handbook.

New Content for Online EFT/ERA Enrollment

There will be an update to the Provider Handbook to encourage online enrollment for EFT/ERA as follows.

TriWest network providers can enroll online for ERA and/or EFT through the Availity Essentials Transaction Enrollment application. Your organization’s Availity administrator can set up user account access and assign roles and permissions to ensure you receive payments more quickly and avoid the hassle of paper checks and/or remits.

Instructions on how to enroll:

Log in to Availity.com and navigate to Availity Essentials.
Select My Providers | Enrollment Center | Transaction Enrollment.
- With the Transaction Enrollment permission, the user can enroll a single provider or providers in bulk (up to 500 at a time).

Please see the Electronic Enrollment Option for TriWest ERA/EFT for online enrollment instructions.

New Home and Other Infusion Therapy Services Section

A new section will be added under the Home Health Care Services section:

Home and Other Infusion Therapy Services

Under the Department of Veterans Affairs (VA) Community Care Network (CCN), infusion therapy services includes: home infusion therapy (HIT), Ambulatory Infusion Suite (AIS), and IV Therapy Outpatient Infusion.

Reimbursement provisions for home infusion therapy (HIT) drugs are based on ASP pricing.
Reimbursement for services rendered cannot exceed the number of units authorized by the approved SEOC. If a provider requires additional units, they must request a new referral from VA.
Compounding fees are not separately payable.
Unlisted codes will follow the pricing hierarchy of:
- Medicare pricing methodology
- VA fee schedule
- Paid at billed (inclusive of any agreed contractual discount) not to exceed billed charges