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Provider Pulse: April

Provider Pulse

April 2017

Welcome to April!

It’s officially the month of spring, and we have a great Provider Pulse edition for you. From new changes coming your way, to reminders on non-VA Formulary prescriptions, April’s Provider Pulse is chock full of helpful information. We hope you find the articles useful, and the warming weather refreshing!

In This Edition:

VA Medical Documentation: What to Send, Exclude?

When it comes time to bill TriWest Healthcare Alliance for treating a Veteran, do you know what to include in your medical documentation?

The Department of Veterans Affairs (VA) requires providers to send their medical documentation to TriWest to ensure coordination of care for Veterans. However, some providers may send too much information, while others may send too little.

Review the guidelines below to make sure you’re on par with VA’s requirements.

What to Send

For authorizations under the Veterans Choice Program (VCP), VA requires providers to send only the notes from the initial appointment and the end-of-episode-of-care summary. For example, this means if you have an authorization from Jan. 1 – May 1, you would submit your medical records from the initial appointment. For all appointments between those dates, don’t send anything. Then, on or around May 1, submit your end-of-episode-of-care summary records.

However, if you received an authorization for the Patient-Centered Community Care Program (PC3), you still need to send your medical documents after every visit to allow TriWest to process claims for these visits.

What to Exclude

It is possible to send too much information as well. When submitting your medical documentation to TriWest, don’t send:

Where to Send Medical Documentation

All medical documentation must be submitted to TriWest Healthcare Alliance. After you send your medical documents, submit your claims to Wisconsin Physicians Service (WPS), the TriWest claims processor. Instructions for submitting medical documents and claims are listed below:

  1. Upload Medical Documentation to TriWest Provider Portal
    • Register for a secure account on TriWest’s Provider Portal at www.triwest.com/provider and upload medical documentation directly to the system.
      • Documents up to 5 MB can be uploaded in PDF or TIF format
    • If unable to access the Provider Portal, fax medical documentation to TriWest at 1-866-259-0311.
  2. Submit Claims to WPS
    After submitting medical documentation to TriWest, send claims either:
    • Electronically. Enroll for EDI to submit electronic claims by calling WPS at 1-800-782-2680 and selecting Option 1.
    • Via mail. Mail paper claims to the following address:
      WPS-VAPC3
      PO Box 7926
      Madison, WI 53707-7926

For more information on medical documentation, please review our Medical Documentation Quick Reference Guide, available on our Provider Portal at www.triwest.com/provider under the "Quick Reference Guides" menu item.

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Get Ready for These SAR Changes, Coming Up!

TriWest is partnering with the Department of Veterans Affairs (VA) to make some changes and standardize referrals to the community. Our collective goal is to minimize the number of secondary authorization requests (SAR) submitted to reduce provider office administrative burden and expedite Veteran care.

These changes, while still in development, may launch as early as mid-April, or as late as May or June. We will let you know, whether via email or fax blast, after the changes have taken place.

In the meantime, if you are not sure whether you need to submit a SAR, visit our new SAR decision tool at www.triwest.com/provider-SAR.

How will the future changes affect you?

As we said, these changes are in the process of development. Because we appreciate your partnership with TriWest to care for Veterans, we wanted to give you a heads up now. Stay tuned for more information as it becomes available!

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Don’t Forget This One Step to Order Labs, X-Rays, Anesthesiology

If you need to order routine labs, x-rays, or anesthesiology services for a Veteran patient, you can choose whichever “ancillary provider” you want. Just don’t forget this vital step:

Write your authorization number on the order form for the labs, x-rays, or anesthesiologist ... and tell them to include that number on their claim when billing TriWest.

TriWest includes routine labs and x-rays on its authorizations, as well as anesthesiology services for surgical procedures. However, as the originating provider, you must tell your ancillary providers to bill TriWest and provide them with the authorization number.

You should also provide the ancillary provider with a copy of the Veterans Choice Program Terms and Conditions. Remind them they cannot directly bill the Veterans for any amount, under any circumstances, related to the authorization.

What Happens If You Forget the Authorization Number?

If you forget to write your TriWest authorization number on the order form for the labs, x-rays, or anesthesiologist, the ancillary provider won’t know who to bill. This may result in the ancillary provider billing the Veteran for services that should be covered.

What if You’re the Ancillary Provider?

If you’re the ancillary provider and receive an order for a Veteran that doesn’t include an authorization number, pick up the phone, and call the ordering provider’s office. Ask the provider for an authorization number. Then, bill TriWest for your services and include the authorization number on your claim – never bill the Veteran.

How do You Bill TriWest?

It’s simple! Follow this two-step process:

  1. Upload Medical Documentation to TriWest Provider Portal
    • Register for a secure account on TriWest's Provider Portal at www.triwest.com/provider and upload medical documentation directly to the system.
      • Documents up to 5 MB can be uploaded in PDF or TIF format
      • If unable to access the Provider Portal, fax medical documentation to TriWest at 1-866-259-0311.
  2. Submit Claims to Wisconsin Physicians Service (WPS)

    WPS is TriWest's claims processor. After submitting medical documentation to TriWest, send claims either:

    • Electronically. Enroll for EDI to submit electronic claims by calling WPS at 1-800-782-2680 and selecting Option 1.
    • Via mail. Mail paper claims to the following address:

      WPS-VAPC3
      PO Box 7926
      Madison, WI 53707-7926

Need more information on labs and x-rays? Review our Laboratory Services Quick Reference Guide!

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3 Steps to Request a Non-VA Formulary Medication

What happens if you need to prescribe a medicine for a Veteran, but the drug isn’t covered under the Department of Veterans Affairs (VA) National Formulary?

In short, you have to ask VA for permission to prescribe the non-formulary medicine. Follow these three steps to request a non-VA formulary drug:

  1. Fill out a Formulary Request Review Form and send it to your local VA medical center.
    Before you can prescribe a non-formulary medicine, contact your local VA medical center. Ask them for their Formulary Request Review Form. Fill it out and send it back to the VA pharmacy.
  2. Wait for VA’s response on approval or denial.
    The VA medical center will review your request and respond with an approval or denial. Turnaround time is usually about 96 hours.
  3. If approved, prescribe the medicine for the Veteran.
    If the VA medical center approves your request, you may proceed with prescribing the medication for the Veteran. Follow the process outlined in our Pharmacy Section of the TriWest Provider Portal at www.triwest.com/provider-pharmacy.

Remember: always fax both the prescription AND a copy of your original care authorization to the appropriate VA medical center! The medicine may be filled at either a VA pharmacy or a Consolidated Mail Outpatient Pharmacy.

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