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: 

Outpatient care – 75 calendar days

Inpatient care – 30 calendar days

Urgent care – 2 business days

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:

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:

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:

Additionally, all notes should include the Veteran’s:

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.

If you’re still unclear, please call TriWest at 1-855-722-2838, Option #3.