Provider Pulse – October 2023
Reminder: Only Bill CPT Codes in Approved SEOC
The Department of Veterans Affairs (VA) put into effect a different model of ordering health care called Standardized Episodes of Care (SEOC), and TriWest Healthcare Alliance (TriWest) has implemented them.
The creation of SEOCs was driven by VA’s desire to improve consistency across all VA Medical Centers (VAMC), to clearly request and deliver bundled health care services, decrease the administrative burden for providers, reduce the amount of paperwork, and improve the continuity of care for Veterans. Each specialty has its own SEOC template authorizing a standardized, minimum amount of care that can be rendered when medically necessary.
The VA has indicated a list of the most likely CPT/HCPCS codes expected based upon the type of care being requested. The narrative section of the SEOC identifies what services are covered. The codes VA has included can be found on the VA website. However, a SEOC may not necessarily contain every code that could be used in treating a condition.
Codes that are not on the SEOC, but are either Medicare-payable or there is a value on the VA Fee Schedule, can be covered under CCN. These codes must be appropriate to the type of care being rendered, meet medical necessity and other possible clinical requirements for coverage, and be billed correctly.
The "Code Range"
The “Code Range” section of the SEOC clarifies what services are covered. The Code Range lists the ranges of authorized Current Procedural Terminology (CPT) codes. A SEOC may not necessarily contain every CPT code that could be used in treating a condition. When a code is not included in the SEOC code range, but is listed on the Medicare or VA Fee Schedule, and is medically necessary and appropriate for the type of care, that code will be allowed if billed correctly.
When determining what is covered under a SEOC, please refer to both the Narrative and the Code Range as they work together.
Updates Coming to CCN Region 5 Payment Hierarchy
VA is updating its Community Care Network (CCN) Region 5 (Alaska) contract to include a percentage of billed charges into the payment hierarchy. The existing payment hierarchy doesn’t allow reimbursement of all procedure codes. This change will occur on October 31, 2023.
As of October 31, VA is adding a fourth payment option that will be based on a percentage of billed charges. Procedure codes not on a VA fee schedule had no reimbursement and were therefore denied. These codes will now be paid using the percentage of billed charges. TriWest will automatically adjust claims for dates of service on April 1, 2021 and after, that had previously denied for this reason. Providers are not required to contact TriWest to make the adjustment request.
The new CCN Region 5 payment hierarchy will be:
Professional Services:
- Alaska VA Professional Fee Schedule
- Alaska VA Fee Schedule
- VA Max Allowable Charges
- Up to 100% of Billed Charges
Outpatient Facilities:
- CMS – 100% Medicare Fee Schedule
- Alaska VA Fee Schedule
- Maximum Allowable Charges Schedule
- Up to 100% of Billed Charges
Inpatient Facilities:
- 100% Medicare MS-DRG Payment
- Inpatient Behavioral Health Negotiated per Diem rate (i.e., daily all-inclusive rate)
Please reference your provider contract amendment which has been updated to include this reimbursement language.
New Enhancements Available on Availity Claims Submission Forms
Availity has announced its new enterprise claims entry for Availity Essentials which provides a more efficient and automated claims management workflow, and less claims denials with online forms.
Availity's enterprise claims entry screens include the following enhancements:
- Pre-submission claim forms that flag potential errors or information gaps that could lead to denials.
- Improved workflows through multi-payer direct data entry.
- Template claims form that supports repeatable data to be used for later submissions.
- A summary screen that provides a high-level view of submitted claims.
Any providers who do not have a clearinghouse and are not currently using Availity can sign up on Availity.com.
Request for Service Form Update: What You Need to Know
The Request for Service (RFS) Form that is submitted to your local VAMC to request new or additional Veteran care has been updated.
Please continue to submit an RFS Form (10-10172) to your local VAMC for the following:
- Additional visits or time beyond what is authorized in an active referral (for example, the current authorization is expiring).
- A new specialty service referral.
- An additional procedure or service not included in the original SEOC.
Exemptions
Dental and IVF/ART (In Vitro Fertilization Treatment/Assisted Reproductive Technology) services are exempt from mandatory use of form 10-10172.
Reminder: Your signature (wet or electronic) is required. To avoid potential future care delays, please sign and date the RFS Form on the initial submission. Forms received by VA without your signature will not be processed, and will be returned to you. If that happens, you must then sign the form and resubmit it to VA.
You can find the RFS form on the Veterans Health Administration web page and on the VA Provider Storefront web page. For more information contact the RFS team by emailing RequestForServiceSupport@va.gov.
Help Veterans Beat the Flu This Year
Flu vaccines are now available to Veterans at all VAMCs, and at more than 65,000 in-network community retail pharmacies and urgent care walk-in locations through April 30, 2024, at no cost.
Veterans are eligible for vaccination if:
- Enrolled in the VA health care system, AND,
- Received care from a VA provider or an in-network community care provider within the past 24 months.
Encourage your Veteran patients to visit VA's flu web page to learn more.
Reminder: No Medical Record Processing Fees under CCN
As a reminder, there are no processing fees allowed for Veterans or for VAMCs who request medical records from a provider’s office.
As noted in the provider’s contract language, providers agree to waive any costs associated with the submission of medical documentation, including but not limited to any copying or handling fees when participating in the VA CCN.
Thank you for helping ensure Veterans receive a copy of their medical records at no charge if requested. If you have questions regarding your contract and this requirement, contact TriWest Provider Services at providerservices@triwest.com.
New Update: 100 Day Benefit Period for Skilled Nursing Facilities
To align with Medicare guidelines, TriWest will now only allow up to a 100 day benefit period for Skilled Nursing Facilities (SNF) under VA CCN.
The benefit period begins the day the Veteran is admitted for an inpatient stay in a hospital or SNF, and ends when the Veteran has not been admitted for inpatient hospital care or in a SNF for at least 60 consecutive days. The benefit can also end if the Veteran is still admitted to the SNF, but hasn’t received any skilled care for at least 60 days. Once the full 100 days is used, the current benefit period must end before renewing the SNF benefits.
There is no limit to the number of benefit periods Veterans can have, but each benefit period starts again with a qualifying hospital stay that meets all the Medicare requirements.
Provider Handbook Updates