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Provider Pulse – March 2022

PC3 Closing Out in Region 5, Pacific Territories

The Department of Veterans Affairs (VA) Patient-Centered Community Care (PC3) ends on March 31, 2022, in the areas designated as Community Care Network (CCN) Region 5 and the Pacific Territories.

Continued provider participation is a priority but will require providers to be contracted under CCN. VA requires all providers to be fully contracted, credentialed, and in-network with TriWest to participate in CCN and to continue to receive referrals for Veterans. If you have not signed a CCN contract to continue to care for Veterans, contact TriWest at 866-286-4174. Best efforts will be made to transition the Veteran to a new provider in situations where a Veteran must change providers.

Effective April 1, 2022, new authorizations for care must be issued under CCN. Please do not submit a Request for Services (RFS) to continue care under PC3. Only CCN contracted providers may send an RFS to VA to obtain a new approved referral/authorization under CCN.

Providers with existing PC3 referrals can complete the associated episode of care, but any extensions of the episode of care must be done as a CCN network provider. Once a region transitions to CCN, TriWest CCN contracted providers may send an RFS to VA to obtain a new approved referral/authorization under CCN.

For instructions on where to submit a claim, providers should refer to the authorization letter received for each episode of care. For questions about claims submission, contact TriWest at 877-CCN-TRIW (877-226-8749).

Additionally, if ongoing Veteran care has not yet been transitioned to CCN, please direct the Veteran to contact their local VA Medical Center (VAMC) to request an extension of care under CCN if ongoing care is needed.

TriWest will continue to pay PC3 claims on approved referrals for dates of service through the authorization expiration date or March 31, 2022, whichever comes first. Providers should submit PC3 claims within 30 days for timely reimbursement. Check your authorization for specific instructions on where to send claims.

If you need to check a PC3 claim reimbursement status, log in to your Availity account or contact a TriWest representative via the Availity chat function.

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Save Time, Avoid Delays: File Claims Electronically

Improve your claim submission accuracy and payment timing by filing your claims electronically. Submitting electronic and clean claims will help turn around payment to you within 30 days!

Did you know you can also check your claims online, chat securely with TriWest staff, check multiple claims, and view remittances? Online options make claims filing and status check easier than ever.

Filing claims electronically is easy, and it’s also required by VA for CCN. Enrolling in electronic submissions and funds transfers means you’ll work within the preferred claims processing method.

To start submitting claims electronically and getting faster claims payments today, log in to Availity.com. Navigate to the TriWest Payer Space. Click on the Resources tab. Find the “PGBA EFT/ERA Enrollment Package” and/or the “PGBA EDI Provider Trading Agreement.” Complete the forms and submit them to PGBA.

Resources to help you get started:

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Oral Appliance Therapy Claims are Medical, Not Dental

When filing a claim for an Oral Appliance Therapy (OAT) Standardized Episode of Care (SEOC), there are a few things you should know. Most importantly, an OAT claim is considered medical in nature, not dental care. Delta Dental is not involved in contracting, appointing, and/or paying for OAT.

Diagnoses for OAT include, but are not limited to, sleep apnea and temporomandibular joint disorder (TMJ). No dental care is approved on this SEOC.

If you are submitting claims to TriWest for the first time, sign up for electronic submissions. All claims are processed electronically, regardless of the method of submission, but it’s fast and easy to file electronically. Not only that, but it allows you to check the status of your claim on Availity.com. If you haven’t already, sign up today! Use the payer ID TWVACCN.

For claims filed manually, send to PGBA:

  • TriWest VA CCN Claims
    P.O. Box 108851
    Florence, SC 29502-8851

For more information about filing an OAT claim, refer to the Provider Handbook available on Availity.com.

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RFS Not Necessary for Surgical Facility’s NPI

Providers do not need to submit a Request for Services (RFS) to an authorization to validate a surgical facility’s NPI to guarantee payment, even if the facility is non-network.

TriWest will pay the facility claim as long as it’s billed using the authorization issued to the surgeon who performs the procedure. The facility and the surgeon are responsible to work together to ensure both parties have the documentation necessary for a successful claim.

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Provider Handbook Updates

There was some clarification language about provider responsibilities added on Page 9 of the CCN Provider Handbook.

As a Community Care Network (CCN) provider, you have certain responsibilities when caring for Veterans, as designated by the Department of Veterans Affairs (VA).

  • Always ensure appointments for authorized services are honored.
  • Honor all appointments with Veterans for covered services with an approved referral authorization. If you cancel a Veteran’s appointment, the appointment must be rescheduled in a timely manner based on the Veteran’s medical necessity and the required CCN appointment availability standards, from the time of initial appointment request:
    • Within 24 hours for emergent health care need
    • Within 48 hours for urgent health care need
    • Within 30 days for routine care need
  • Submit a Request for Services (RFS) directly to VA, preferably through VA’s online HealthShare Referral Manager (HSRM) portal, if you determine the Veteran needs additional care beyond what’s authorized.
  • NEVER charge a Veteran for not keeping a scheduled appointment.
  • Do not balance bill Veterans, TriWest, or any other payer for services provided under the CCN contract. A payment for authorized services under this contract is always deemed payment in full.
  • Do not collect copays, cost-shares, or deductibles. CCN reimburses up to 100% of the allowed amount, including any patient obligation.
  • Consider payments under CCN as payment in full.
  • Providers may not impose additional charges to TriWest, the Veteran, or any other payer for covered services. For CCN, TriWest follows Medicare Fee-for-Service billing guidelines, fee schedules, and payment methodology when applicable.
  • Never solicit Veterans or Veterans Affairs medical centers (VAMC) for services.

On Page 19 under Provider Claims Submission, the following language was clarified:

TriWest will pay claims for out-of-network providers, as long as there is a valid referral to support the care.

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