Provider Pulse – July 2024
Additional IVF Benefits Available for Covered Veterans
Under the Department of Veterans Affairs (VA) Community Care Network (CCN), additional in vitro fertilization (IVF) and assisted reproductive technologies (ART) benefits are now available for covered Veterans and their legal spouse* who is determined to have a service-connected (SC) condition resulting in their inability to procreate without the use of fertility treatment.
Covered Veterans and their legal spouse may utilize donor embryos obtained at their own expense when receiving IVF counseling and services. The Veteran pays for the procedures or associated fees for the extraction, storage, or transportation of donor gametes.
For more information, reference the Assisted Reproductive Technology/In-Vitro Fertilization Services for Veterans packet.
*VA will determine which Veterans are eligible for IVF/ART services; only a limited and specific group of Veterans are approved for this benefit through VA. The VAMC can assist Veterans who are interested in services, but are unsure if they are eligible and/or authorized. CCN rules apply to IVF/ART services.
Clean Claims Equal Timely Payments
Properly submitting your claims to PGBA in a clean, efficient manner helps the claim to process and pay in a timely manner while reducing the chances of it being denied and/or rejected.
The claims process begins once the provider receives an authorization letter from either TriWest or VA. The letter is assigned a referral/authorization number which is the unique identifier for each approved referral/authorization’s episode of care. An approved referral/authorization from VA:
- supports the service rendered by a CCN provider;
- has a specific plan of care; and
- details a specified number of visits and/or services related to a Standard Episode of Care (SEOC).
TriWest must have visibility to the appointment via the assigned referral/authorization number in its systems. If the referral/authorization number is not included on the claim, the claims will be denied and/or rejected.
TriWest partners with PGBA to process and pay out claims to CCN providers who have rendered services to Veterans in accordance with an authorized VA referral. PGBA only reviews claims that have an approved VA referral/authorization number.
For more information regarding clean claims as well as the proper documentation on submitting claims to PGBA, refer to the Billing and Claims section of the CCN Provider Handbook as well as the Claims Submission quick reference guide.
Make Sure Your Durable Medical Equipment Meets VA Requirements
The Department of Veterans Affairs (VA) is the primary resource for all routine durable medical equipment (DME). Make sure your DME meets the requirements presented by VA for prosthetics, orthodontics, and sensory aid fulfillment services.
For urgent and emergent care, providers may directly supply Veterans with DME, and TriWest will reimburse providers. Examples of urgent and emergent DME include splints, crutches, canes, slings, and soft collars.
Here are some additional reminders:
- DME is covered under CCN for urgent and emergent care only.
- Under the Community Care Network (CCN), TriWest pays Centers for Medicare and Medicaid Services (CMS) pricing on all DME.
- All other routine DME is coordinated with VA and VA Medical Centers (VAMC).
For non-urgent non-emergent DME, TriWest follows VA reimbursement guidelines for Ambulatory Surgery Center (ASC) claims. Here are some helpful reminders:
- To have routine DME (including eyeglasses) authorized and provided to the Veteran, first complete the Community Care Provider–Request for Service form (VA Form 10-10172).
- Once you download the RFS form, fully complete the DME section. Include the measurements for frames if ordering eyeglasses.
- After completing the DME form, fax it to the authorizing VAMC within 24 hours. VA will then directly coordinate the DME between you and the Veteran.
For more information, look through the DME quick reference guide.
Understanding the Approved Referral/Authorization Process
Under CCN, the approved referral/authorization is the process starting point for Veterans to receive care. The Veteran must have an approved referral/authorization from VA before scheduling an appointment. Then, CCN providers must have an approved referral/authorization on file before rendering care, unless the Veteran needs urgent or emergent care.
An approved referral/authorization can be triggered in one of three ways:
- The provider determines a Veteran patient needs additional care beyond what was originally authorized.
- The Veteran contacts his or her local VAMC to confirm CCN eligibility.
- VA assesses the Veteran’s need and makes the determination to refer the Veteran for care in the community, therefore generating an approved referral/authorization. VA will then send the authorization information to TriWest for administrative purposes.
Once VA generates an approved referral/authorization, the appointing process can begin and the authorization letter will follow. Providers may check the status of an approved referral/authorization using HSRM.
Appointing Process
Providers must have an approved referral/authorization before an appointment can be made. Except for urgent or emergent care, providers should not administer care that does not have an approved referral/authorization from either VA or TriWest; otherwise, claims may be denied.
Under CCN, appointments can be made in the following ways:
- VAMC direct appointing
- TriWest appointing
- Veteran self-appointing
Veterans must have an approved referral/authorization in order to self-appoint; otherwise, the provider risks not being reimbursed.
Regardless of the appointing pathway, providers may NEVER charge a Veteran for not keeping a scheduled appointment under CCN.
For more specific information regarding the referral/authorization process, including CCN requirements for appointing and drive-time, refer to the CCN Processes and Procedures section of the CCN Provider Handbook and the Appointing Processes quick reference guide.
VA CCN Provider Handbook Updates
Updates are planned for the Pharmacy Services and Durable Medical Equipment section of the CCN Provider Handbook. This section will be adjusted to include the updated guidelines for submitting urgent and emergent DME requests as outlined by VA, as well as instructions for accessing the Community Care Provider – Request for Service form 10-10172 to submit for authorized DME.
There will also be upcoming changes to the Veteran Eligibility and covered services section of the CCN Provider Handbook to include abortion counseling and select procedures for covered Veterans.