Veterans Choice Program Changes to Medical Documentation Requirements Frequently Asked Questions
The Department of Veterans Affairs (VA) made an important modification to the Veterans Choice Program (VCP) as of March 1, 2016 affecting requirements for medical documentation. Among the most important changes:
- TriWest may now reimburse providers’ claims before receiving medical documentation.
- However, VA still requires medical documentation to ensure coordination of care for Veterans. Therefore, you must still submit all medical documents.
- Providers will have more time to submit medical documentation to TriWest:
Outpatient care – 75 calendar days
Inpatient care – 30 calendar days
Urgent care – 2 business days
- These changes affect the VCP only. They do NOT affect the Patient-Centered Community Care Program (PC3).
Q: What does this mean for my VCP claims payments?
A: We can now reimburse your claims before receiving medical documentation—which means faster payment.
However, claims paid PRIOR to receipt of medical documents are subject to retrospective review and potential recoupment if required documentation is not submitted within mandatory timelines.
If you’re a VCP provider waiting on claims previously held back because of medical documentation, TriWest is in the process of releasing payment due to this program modification. TriWest will send further communications when we have defined this process and have a concrete timeline. It is TriWest’s goal to have approved claims be paid in approximately 60 days.
Q: What is the new timeframe for submitting medical documents under the VCP?
A: You now have:
- 75 calendar days to submit medical documentation for initial and final outpatient visit;
- 30 calendar days to submit medical documentation for inpatient care;
- 2 business days to submit medical documentation for urgent care.
For more details on timeframes, please refer to our Medical Documentation Quick Reference Guide.
Q: Where should I send my medical documentation?
A: All medical documents need to be sent to TriWest Healthcare Alliance separate from claims. Do NOT send medical documents to Wisconsin Physicians Service (WPS), TriWest’s claims processor, and unless otherwise instructed on your authorization letter, do NOT send medical documents directly to VA.
Submit medical documents to TriWest by following these steps:
- Register for a secure account on TriWest’s Provider Portal at www.TriWest.com/provider and upload medical documentation directly to the system.
- 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.
Q: What information should my medical documents include?
A: Documentation needs to include the initial appointment and end-of-episode-of-care (EoC) records. Minimum requirements for content of medical documentation, as applicable to the care, include:
- An executive summary of the encounter to include any procedures performed and recommendations for further testing or follow-up (i.e. discharge summary for inpatient);
- Results of community testing or imaging such as MRI, CT scan;
- Actual results of any ancillary studies/procedures which would impact recommended follow-up such as biopsy results ( i.e. positive biopsy results from EoC GI provider who recommends a follow up such as surgery); and
- Any recommended prescriptions and treatment plans.
Additionally, all notes should include the Veteran’s:
- Full name
- Date of birth
- Last four digits of social security number.
For more details on medical documentation requirements, please review our Medical Documentation Quick Reference Guide.
Q: Which providers are affected by these changes?
A: These changes affect the Veterans Choice Program (VCP) only. They do not affect the Patient-Centered Community Care Program (PC3) at this time.
Q: I am a contracted TriWest network provider under PC3, but I also see Veterans under the Veterans Choice Program (VCP). How do I know which rules to follow?
A: Contracted TriWest network providers who also see Choice Veterans will receive an authorization under the VCP. When this happens, adhere to these program modifications.
If you’re unclear whether the authorization is for the VCP or PC3, you may log into your secure account on the TriWest Provider Portal at www.triwest.com/provider. Here, you can look up the authorization and the Portal will clarify which program the Veteran falls under.