Provider Pulse – March 2024

Qualifications for the High Performing Provider Designation

The Department of Veterans Affairs (VA) created a High Performing Provider (HPP) designation under the Community Care Network (CCN) for providers who excel in a set of standard health care evaluation metrics. It is one, but not the only, measure of provider practice quality.

Providers are scored on a set of standard quality metrics approved by VA to determine whether they are deemed to be an HPP. Additionally, the HPP designation may be used by VA or TriWest when selecting a community provider to see a Veteran.

CCN providers include providers practicing at the individual level, practitioners in a group setting, and institutional providers (such as hospitals). The three types of providers are scored differently.

  • Individual providers are evaluated based on a combination of VA priority measures and standard measures from Blue Health Intelligence.
  • Provider practice groups are scored as a single entity, and providers in those groups are assigned the score of the overall group.
  • Hospitals are scored on a selection of CMS measures from the Hospital Compare system.

A summary of your specific provider metric results is available on request by completing the HPP Inquiry Form on the TriWest Payer Space on Availity.

For more information on the HPP designation, please review the HPP Quick Reference Guide. Providers should send the completed HPP Inquiry Form to CQHPP@TriWest.com.

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Save RFS Forms Before Submitting

When filling out a digital Request For Services (RFS) form, it is recommended that you first save it to your desktop before submitting. This will help avoid the information being received in an unreadable format.

You can find the RFS form on the Veterans Health Administration web page, or on the VA Provider Storefront web page. For more information contact the RFS team at RequestForServiceSupport@va.gov, or reference the RFS Quick Reference Guide.

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VA PC3 Claims to Cease Processing March 31

This is a notice to all providers that any claims filed under the Department of Veterans Affairs (VA) Patient-Centered Community Care (PC3) will no longer be processed after March 31, 2024.

TriWest Healthcare Alliance (TriWest) administers claims for VA’s current Community Care Network (CCN) in Regions 4 and 5. TriWest also continued to support the prior version of PC3 that concluded in Region 4 on March 31, 2021 and in Region 5 on March 31, 2022.

For Current PC3 Claims:

  • Services that fall under a Retroactive Referral, including reconsideration requests, had to be submitted by March 1, 2024 to be considered.
  • All PC3 claims requests (adjustments, reconsiderations, recoupments, etc.) will be processed no later than March 31, 2024.
  • Effective April 1, 2024, PC3 claims will no longer be adjusted, and TriWest will not be able to accept PC3 claims or related inquiries and requests in any format.

Timely Filing Requirements Reminders:

  • All community care claims must be submitted within 180 calendar days from the Date of Service. Claims that do not meet timely filing requirements will be rejected/denied accordingly. For detailed information on timely filing requirements please visit the Timely Filing Requirements web page.
  • Community care claims reconsideration requests must be submitted within 90 days from the original claim decision date. Effective January 1, 2024, reconsideration requests that are not submitted timely will be rejected upfront. Please reference the Claims Reconsideration Request Form and its instructions.

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VA CCN Pharmacies to Begin Prescribing Adalimumab-bwwd (Hadlima®)

Beginning in March 2024, all Department of Veterans Affairs (VA) pharmacies are required under the Community Care Network (CCN) to automatically convert patients from Adalimumab (HUMIRA®) to the nationally contracted product, Adalimumab-bwwd (Hadlima®).

This includes any Veteran prescription filled at a VA pharmacy that is written by a CCN or VA provider.

Changes to the National VA Formulary:

  • Adalimumab (HUMIRA®) will become non-formulary (NF).
  • Adalimumab-bwwd (Hadlima®) will be added to the National Formulary as Prior Authorization-Facility (PA-F).
  • All other adalimumab biosimilars are considered NF.

Only patients who are approved through local formulary appeal processes on an individual basis with solid clinical justification (e.g., allergies to excipients) via a non-formulary request will be allowed to convert to a non-contracted product.

For more information please reference the VA National Formulary – Pharmacy Benefits Management Services.

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Submit an Online Reconsideration Request for Timely Filing

Under the Department of Veterans Affairs (VA) Community Care Network (CCN), if you have received a denial for timely filing, you may qualify for reconsideration of payment if you answer “yes” to both of the following questions:

  1. Do you have proof of claim submission within 180 days from the date of service or date of discharge?
  2. Did you originally submit to a VA payer (TriWest, Optum, VA)?

If you meet the criteria above, please submit an Online Claims Reconsideration Request and be sure to attach your valid proof of timely filing for review. Timely Filing reconsiderations will be worked in the order they are received.

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VA CCN Provider Handbook Updates

The following subsection will be added to the Credentialing and Contract Provisions page of the CCN Provider Handbook:

Marketing and Advertising

Provider shall not (1) advertise the award of the Provider Network Agreement or the Program Terms and Conditions in such a manner as to state or imply that the VA endorses a product, project, commercial line of endeavor, provider’s practice or services, or (2) solicit, either directly or indirectly, the VA, VA Medical Centers (VAMC) or Veterans through either provider’s commercial advertising or direct outreach. A TriWest network provider may only utilize the approved website badges on provider’s website as well as the approved print-ready signs found on TriWest’s Proudly Caring for Veterans web page to indicate their participating status in the TriWest network supporting VA.

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Updated: 3/28/2024 4:03:21 PM