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Provider Pulse – January 2022

Don’t Include Medical Documentation with Claims Submissions

Providers, please consider the following reminder: Do not include any medical documentation when you submit Department of Veterans Affairs (VA) Community Care Network (CCN) claims or reconsideration requests. Doing so will hinder the process and cause delays in claims processing.

All medical documentation, except for emergency care, must be sent directly to the authorizing VA Medical Center (VAMC), preferably via VA’s HealthShare Referral Manager (HSRM). For more information on where and how to submit medical documentation, please refer to the Medical Documentation Quick Reference Guide or the CCN Provider Handbook.

Claims are required to be submitted with the following:

  • VA-approved referral/authorization number as the Treatment Authorization Number or Prior Authorization Number.
  • Plus, one of the following as the insured’s ID:
    • 10-digit Electronic Data Interchange Personal Identifier (EDIPI)
    • 17-digit Master Veteran Index (MVI) ICN
    • Social Security Number (SSN)
    • Last 4 digits for SSN with preceding 5 zeros

For faster claims processing, be sure to avoid these common errors we see in claims processing. To get paid faster without returns, send these tips to your billing team. For more information on submitting claims and what should be included, refer to the Claims Submission Quick Reference Guide.

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CMS Claims Processing Changes: VA Will Not Require RAPs or NOAs

The Centers for Medicare & Medicaid Services (CMS) recently announced changes to claim processing requirements that affect the use of Requests for Anticipated Payments (RAP) for skilled home health care claims, including changes to submission timelines and late penalties.

Specifically, for care with dates of service beginning Jan. 1, 2022, CMS no longer requires RAPs to be submitted with claims. Instead, a Notice of Admission (NOA) must be submitted with home health care claims. The change is intended to simplify the claims process.

However, VA will not require a RAP or NOA to be included with home health care claims submitted to VA. In addition, VA will not implement any of the late penalties, since neither a RAP nor NOA is required. VA will pay claims based on the Health Insurance Prospective Payment System (HIPPS) code submitted on the claim and will look to providers to bill appropriately.

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Annual Updates to CMS Physician Fee, VA Fee Schedules

VA’s CCN is funded by federal dollars and closely follows Medicare Fee-For-Service guidelines for payments. This includes moving to the most current CMS Fee Schedules, implemented every January.

Additionally, the VA Fee Schedule is updated in January and includes rates for physician, clinical laboratory, and drug services. When there is no Medicare rate and there is a VA Fee Schedule amount available, VA reimburses at the lesser of billed charges, or the local VA Fee Schedule amount for the period when the service was performed.

CMS changes to an assigned remittance rate, or payment, will vary by specialty and location. Look up the value of specific Current Procedural Terminology (CPT) codes on the CMS.gov website via the Physician Fee Schedule Look-Up Tool. You can also obtain rates for your region from the Medicare Administrative Contractor (MAC) that manages your jurisdiction. Rates are specific to the geographic area where the care is rendered.

Remember, TriWest Healthcare Alliance (TriWest) follows Medicare reimbursement guidelines, but cannot coordinate benefits with Medicare. Veteran’s CCN benefits administered by TriWest cannot pay secondary or as a Medicare supplemental plan. If care was pre-authorized as a VA benefit, please submit the claim to our claims processor, PGBA. Do not submit these claims to Medicare or TRICARE.

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When to Expect Your 1099 Form in 2022

A 1099 Form reports income from non-employment earnings, interest and dividends, government payments, and more. It is a tax form similar to a Form W-2 that reports information on employment income and is used to file personal taxes.

TriWest is responsible for sending you a new Form 1099 by Jan. 31, 2022. If you haven’t received your Form 1099 by then, please wait until Feb. 1 to contact TriWest’s claims processor, PGBA, or TriWest. If you call before Feb. 1, you will automatically be directed to check back after that date.

Need a new Form 1099 or are you disputing the amount on your 1099?

  • If you never received a Form 1099 or you need a new 1099 with corrected information, fax a W-9 with the information listed below. Also include the 1099 if applicable.
  • The W-9 needs to include the following:
    • Line 1 – Name as being registered with the IRS for the Tax Identification Number (TIN) listed in Part 1.
    • Line 2 – Group Name (DBA name) or Disregarded Entity name/TIN; when applicable (if same as Line 1, can be blank).
    • Line 3 – Appropriate federal tax classification.
    • Line 4 – Exemption Codes; when applicable.
    • Lines 5 and 6 – Address where annual tax 1099 statement should be sent.
    • Part I – TIN. Either a Social Security Number (SSN) or an Employer Identification Number (EIN) can be used, but you cannot use both.
      • The TIN provided must match the name provided on Line 1 to avoid backup withholding.
    • Part II – Must be signed and dated including day, month and year (format does not matter).

Fax to: 866-589-7693; Attention: New 1099 Needed

TriWest will update the information needed and resend a corrected Form 1099 to you.

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Provider Handbook Updates

There are no updates planned for the CCN Provider Handbook or the PC3 Provider Handbook.

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Updated: 9/15/2022 11:13:22 PM