TriWest's top priority is to provide Veterans the health care they deserve through the best health care providers. We appreciate your interest in learning more about how you can provide medical care to those who have sacrificed so much for our nation. If you have any questions, please feel free to call us directly: 1-855-722-2838.
Q: How do I report an actual or potential Health Care Quality Concern?
A:TriWest encourages providers and other concerned individuals to notify our Clinical Quality Management (CQM) department of any actual or suspected quality of care concerns involving any provider or facility rendering care to our Veterans. This includes unsafe conditions that have the potential to cause harm to our Veterans.
TriWest has implemented a one page downloadable form, the Health Care Quality Concern Form, to make reporting as easy as possible. Upon completion, please fax this form directly to CQM at 1-866-299-4235. CQM RNs and physician reviewers will investigate and take appropriate action. The source of referrals is held in the strictest confidence.
Q: What is the Patient-Centered Community Care Program (PC3)?
A:In September 2013, the Department of Veterans Affairs (VA) launched the Patient-Centered Community Care (PC3) program. The program includes a private network of primary care and specialty care physicians from across the country who have signed a contract with TriWest to see Veterans when VA is unable to provide care directly.
Q: What is the Veterans Choice Program (VCP)?
A:In August 2014, President Obama signed into law the Veterans Access, Choice and Accountability Act (VACAA) of 2014, which established the Veterans Choice Program (VCP). Through the VCP, all eligible Veterans have an option to seek health care with private care providers in the community. In order to confirm eligibility, Veterans must call the number on the back of their Veterans Choice Card to set an appointment. The VCP is Veteran-driven, meaning Veterans choose whether to opt-in, rather than VA making the choice for them. As a physician, you may be contacted by TriWest or a Veteran regarding the VCP.
Q: As a doctor, am I obligated to accept the VCP?
A:We hope you will choose to care for those who have served our country by accepting patients who schedule appointments with the VCP and a valid authorization for care. However, there is no legal requirement for any doctor or hospital to honor the VCP. We want to help you understand all you need to know in order to provide services to VCP-eligible Veterans. Please call us at 1-866-606-8198 for assistance with authorizations, questions about the program or to learn more about the submission of claims for services.
Q: How does it benefit me to join the TriWest network?
A:Currently, there are several VA programs that provide opportunities for Veterans to seek care with private physicians when VA cannot meet Veterans' needs. This is a unique opportunity for health care providers to step up and answer an urgent call. By enlisting in the TriWest provider network, you can ensure our nation's Veterans have access to the medical care they need and deserve. If you join the network, you will be joining close to 180,000 providers who have answered the call to improve health care for our nation's Veterans. When you open your practice to even a few Veterans, you'll be doing a service for your country that goes far beyond clearing up health care backlogs. In joining our network, we will:
• Manage all Veteran appointments on your behalf.
• Pay you directly and timely.
• Provide you with Veterans' health care information from VA before appointments to help you render care.
• Ensure medical records are returned to VA for comprehensive care.
To join the TriWest Provider Network, visit https://joinournetwork.triwest.com/.
Q: How do I submit medical documentation?
A:Medical documentation must be submitted to TriWest.
Do NOT attach medical documents to your claims sent to Wisconsin Physicians Service (WPS). Unless otherwise instructed, do NOT send medical documents directly to VA.
Upload medical documentation to the TriWest Provider Portal at www.triwest.com/provider after registering for a secure account. If the Provider Portal is not available to you, fax medical documents to TriWest at 1-866-259-0311. For more information on medical documentation, review the Medical Documentation Quick Reference Guide.
Q: How long does it take for TriWest to review my medical documentation after it is has been uploaded?
A:The information is uploaded immediately into our system and is usually reviewed within two business days.
Q: I need to refer a Veteran to another doctor or facility outside my office, or request a second opinion. How do I ensure this additional care is authorized through VA?
A:Visit our Secondary Authorization Request (SAR) Decision Tool at www.triwest.com/provider-SAR to see if you need to submit a SAR. If so, fill out a SAR form (the tool will direct you to it) and include your notes, discharge plans (if applicable), and justification for the additional services. Then, fax everything to TriWest at 1-866-259-0311. The status of your SAR will be available on the Secure Provider Portal.
Q: How do I extend the date range that TriWest authorized for care?
A:Fill out a Secondary Authorization Request (SAR) form and fax it to TriWest at 1-866-259-0311. The status of your SAR will be available on the Secure Provider Portal.
Q: Once my Secondary Authorization Request (SAR) has been uploaded, how long does it take for TriWest to review it?
A:TriWest will submit your SAR to the appropriate VA medical center, if needed. Turnaround time is usually about 14 business days.
Q: How long does it take for TriWest to respond to a SAR?
A:TriWest forwards the SAR to the appropriate VA medical facility if needed and looks to respond within 14 business days.
Q: How do I submit my TriWest claims for reimbursement?
A:Follow the steps below to submit claims properly:
(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.
o 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) TriWest uses WPS for all claims processing. After submitting medical documentation to TriWest, send claims either:
• Electronically. Set up an EDI to submit electronic claims by calling WPS at 1-800-782-2680 and selecting Option 2.
• Via mail. Mail paper claims to the following: WPS-VAPC3 PO Box 7926 Madison, WI 53707-7926
Q: How long does it take to process claims payments?
A:TriWest shall make its best effort to pay claims within 30 days.
Q: If the Veteran has another health federal health care plan in addition to TriWest, such as Medicare (including Advantage plans), Medicaid, or TRICARE, who should I bill?
A:TriWest always pays primary for services provided to Veterans under VA community care programs. Therefore, if you have a TriWest authorization on file, bill TriWest. Do not bill any other health plan, including Medicare, Medicaid, or TRICARE
Q: Who can I speak with if I have a question regarding my reimbursement?
A:For detailed reimbursement or claims questions, please contact 1-855-PCCCVET (722-2838). Choose Option 3 and then follow the prompts.
Q: Are there any co-pays or cost shares under PC3 or VCP?
A:Providers do not collect co-pays, cost shares or deductibles under these VA programs. If any are associated with the Veteran’s appointment, VA will bill the Veteran directly.
Q: Can I get electronic checks and remittance advices?
A:To apply for an EFT or ERA, you can contact Wisconsin Physicians Services (WPS) at 1-800-782-2680.
Q: How do I register for the Secure Provider Portal?
A:Please click here to register for the Secure Provider Portal.
Q: What are the benefits of using the Secure Provider Portal?
A:The Provider Portal is your one-stop shop for information on filing claims and navigating the PC3 and VCP programs. If you register for secure access, you can view authorizations, submit medical documentation, check a claim's status and download required forms, among other benefits.
Q: What types of documents can be uploaded to the Secure Provider Portal?
A:PDF or TIF documents with a maximum size limit of 5MB may be uploaded to the Secure Provider Portal.
Q: How do I reset my password in the Secure Provider Portal?
A:Passwords can be reset by using the dropdown button under your name. Passwords can be changed once every 24 hours.
Q: How do I get my password unlocked?
A:To unlock your password, you have three options: (1) contact your administrator, (2) send an email to VAPortalAssistance@TriWest.com or (3) contact TriWest at 1-855-722-2838, option 3, and then option 2 for Portal Assistance.
Q: Who do I contact if I forgot my login credentials?
A:If you are unable to remember your login credentials, please send an email to VAPortalAssistance@TriWest.com or contact TriWest at 1-855-722-2838, option 3, and then option 2 for Portal Assistance.
Q: How do I receive assistance with the website?
A:Contact TriWest by sending an email to VAPortalAssistance@TriWest.com or by calling 1-855-722-2838, option 3, and then option 2 for Portal Assistance.
Q: Is there training or information I can obtain regarding these VA programs?
A:Yes! We offer live webinars, review-at-your-own-pace eSeminars, Quick Reference Guides and the Provider Handbook. The Provider Portal at www.triwest.com/provider is always available as your one-stop shop for information on filing claims and navigating the VA programs.
Q: I need more help understanding how the entire process works, from appointing, to authorizations, to billing, to TriWest’s role in these VA programs. Do you have a single document that explains EVERYTHING?
A:If you need more help understanding the PC3 and VCP, we strongly recommend signing up for one of our complimentary webinars, conducted by our Provider Education Team. The webinars are presented live and last about two hours. They cover everything listed above and offer interactive question-and-answer sessions. View our webinar schedule and register for one by clicking here.
Q: What happens if the Veteran is a "no show" for his or her appointment? Do I have to notify TriWest?
A:You are not required to notify TriWest, but we will contact you for medical documentation for that visit until you confirm the Veteran did not show. If a Veteran is a “no show” for an appointment, you can update the authorization on the Secure Provider Portal or respond to the medical documentation request fax. Veterans cannot be billed for "no shows."
Q: How do I determine if a Veteran is eligible for VCP or PC3?
A:If you have an authorization on file to see a Veteran, that authorization serves as the eligibility confirmation. Determining eligibility is NOT the provider’s job. Under the VCP, TriWest determines a Veteran’s eligibility based on two criteria: (1) Will the Veteran need to wait 30 days or more to receive care at the local VA medical center, or (2) Does the Veteran live more than 40 miles away from a VA medical clinic with primary care?
The Veteran must call TriWest at the number on the back of his or her Veterans Choice Card to confirm eligibility, set an appointment and receive authorization for care from a provider’s office. Under PC3, VA will send TriWest a referral for a Veteran to seek care within the community if VA cannot provide it. TriWest will then send an authorization to the provider.
Q: How do I notify Veterans that I participate in PC3 or VCP?
A:If you join the TriWest provider network by signing a contract under PC3, you will receive a welcome letter which explains how to register for TriWest’s secure provider portal, as well as other pertinent information for the VA programs TriWest administers. If you participate in the VCP, we recommend calling us at 1-866-606-8198, so when an eligible Veteran requests an appointment within his or her community, we can refer that Veteran to you and your services. Feel free to share your commitment to Veterans online, in your facility or with other doctors who can also help to support our nation's heroes.
Q: VA doctors have special protections against malpractice lawsuits when they treat Veterans. Do those apply to me if I treat Veterans using the VCP?
A:No. Physicians employed directly by VA are covered by the Federal Government's medical liability policies. Those policies would not apply if you treat Veterans in your practice.
Q: How will I obtain access to the Veteran's medical records?
A:If medical records are necessary, TriWest will coordinate with VA to make sure the provider has what is needed.
Q: How do PC3 and the VCP work together?
A:Both PC3 and the VCP work together as a supplement to VA to help reduce wait times and ensure Veterans are receiving timely and reliable access to health care. If a provider decides to accept the VCP, he or she is making a commitment to see Veterans as-needed.
Q: How many providers participate in the TriWest network?
A:TriWest has close to 180,000 providers, hospitals and other medical facilities in our network across 28 states. If you are interested in joining our network, please click here and provide some basic information.