To ensure network providers are paid timely and at the correct rates, TriWest Healthcare Alliance (TriWest) recommends following all appropriate coding requirements. This is especially true for Ambulatory Surgery Centers (ASC) claims.
TriWest follows the U.S. Department of Veterans Affairs (VA) reimbursement guidelines for ASC claims. ASC facilities are required to bill services on a UB-04 (CMS-1450) claim form. All routine lab, radiology, anesthesiology and associated ASC services are considered covered under the primary provider’s authorization if they are medically necessary. A separate authorization letter is not required.
Additionally, the VA referral/authorization number is required on the claim. It should be inserted in the following claim forms in specific locations:
- CMS UB-04: Box 63 Treatment Authorization Codes field; or
- EDI – two options:
- 2300 – REF (G1) Prior Authorization
- 2300 – REF (9F) Referral Number
Include VA Referral/Authorization Number with Claim
TriWest provides an authorization letter to the primary provider that states the range of covered care, before any services are rendered. The primary provider may be a surgeon or other provider who is responsible for the episode of care.
Please note that the ASC is responsible for receiving the VA referral number or a copy of the authorization letter from the primary provider. To avoid a denied claim, include the VA referral number with the claim.
All routine lab testing and/or X-ray services, when medically necessary, are included in the authorization. A servicing provider, such as an anesthesiologist, and the ASC that performs the approved services, are also considered covered under the initial authorization letter.
For more information on how to submit ASC claims, please refer to the ASC Facility Claims Quick Reference Guide.
Providers are reminded that under VA Community Care Network (CCN) guidelines, skilled bundled home health services are reimbursed via the Medicare Patient-Driven Groupings Model (PDGM).
These types of claims should be billed on a CMS UB-04 claim form using Type of Bill (TOB) 32X. The claim submission must include the VA referral number associated to a skilled bundled home health Standardized Episode of Care (SEOC).
Additionally, skilled unbundled (or non-bundled) services are reimbursed on a fee-for-services basis and can be billed on a CMS-1500 claim form using Place of Service 12, or a CMS UB04 claim form, using TOB 34X. The claim submission must include the VA referral number associated with a skilled unbundled SEOC.
Effective for dates of service Sept. 1, 2023 and after, skilled bundled home health services are rejected if the claim is not submitted with TOB 32X and if it is not submitted with a VA referral associated with a skilled bundled home health SEOC and includes TOB 32X.
Also, effective for dates of service Sept.1, 2023 and after, skilled unbundled home health services are rejected if not submitted with TOB 34X (CMS UB04) or Place of Service 12 (CMS 1500) and if not submitted with a VA referral associated with a skilled unbundled home health SEOC.
National Suicide Prevention Month is observed each year in September to raise awareness and to spread hope to those affected by this public health concern. Suicide is preventable.
Lethal Means Safety helps prevent suicide, and is essential to helping Veterans who may be in crisis. Reducing access to firearms and other household risks can help ensure our nation’s bravest are safe. The Department of Veterans Affairs (VA) encourages all providers to complete the Lethal Means Safety course found on VHA TRAIN.
To access the Lethal Means Safety course:
- Log in to or create a VHA TRAIN account.
- Take Course 1075258: Preventing Suicide Through Lethal Means Safety & Safety Planning
TriWest also recently produced a video you can share with your Veteran patients about what they can do at home to prevent access to lethal means.
For more information or behavioral health resources, see TriWest’s Tools for Coping section of its Behavioral Health website.
To ensure Veterans are scheduled for care quickly, providers are reminded to use specific diagnosis codes so care can be rendered in a timely manner and providers can be reimbursed properly. This includes the proper use of Z diagnosis codes by radiology providers.
For example, the Department of Veterans Affairs Medical Center (VAMC) software system determines if a referral/consult can be completed in a timely manner at a VAMC or if it needs to go to a VA CCN provider. If the referral goes to a CCN provider through this automated process, the VAMC provider ordering a radiology study does not know where the order will go and does not have the ability to put a proper diagnosis code on the order.
The VAMC software system assigns a Z code (a diagnosis code that indicates factors influencing health status and contact with health services) that is generic and non-specific to that Veteran’s referral. However, a Z code is not allowed in the primary diagnosis position for Medicare billing. Since CCN follows Medicare billing requirements, CCN claims will deny when submitted this way.
Because VA software cannot be programmed without the Z code, VA and TriWest ask that when a radiology center or any other provider bills for the study, they use a code that is more specific to the study’s findings. Please accept these referrals for scheduling despite this Z code so Veteran care is not delayed.
If you have a successful workaround or ideas of how this could be improved for your radiology group, please contact Lori B. Highberger, M.D., TriWest’s Deputy Chief Medical Officer at firstname.lastname@example.org. We appreciate your feedback!
There will be an update to the Provider Handbook concerning changes to the Region 5 Payment Hierarchy that references a percent of billed charges for certain services.
Updates Coming to Region 5 Alaska Payment Hierarchy
The Department of Veterans Affairs (VA) is updating its CCN Region 5 (Alaska) contract to include the percentage of billed charges into the payment hierarchy as of October 31, 2023.
As of October 31, VA is adding a fourth payment option that will be added as a percentage of billed charges for certain services. Applicablecodes that were previously denied for not including a fee schedule to price against will now be paid using the percentage of billed charges. Adjustments will be conducted for previously denied claims in a bulk project.
Impacted claims previously denied for the CCN Region 5 (Alaska) for dates of service April 1, 2021 and after will be adjusted to pay the services.
For codes that do not pay through the Alaska VA Professional Fee Schedule, Alaska VA Fee, or VA Max Allowed charges, the percentage of billed charges will now be applied for applicable codes.
Please reference your provider contract amendment, which is being updated to include this reimbursement language. These changes will be added to the Alaska Appendix to the TriWest Provider Contract Provisions in the CCN Provider Handbook.