Updated Guidance for Janssen (Johnson & Johnson) COVID-19 Vaccine
Effective April 23, CDC and FDA recommend resuming use of the Janssen COVID-19 vaccine with certain guidance. Read the CDC guidance for providers.
Community Providers COVID-19 Resource Page
COVID-19 Response from TriWest Healthcare Alliance
In the wake of the COVID-19 (Coronavirus) pandemic, TriWest Healthcare Alliance continues to monitor the situation in cooperation with the Department of Veterans Affairs (VA). TriWest will use this web page to update providers on the latest information regarding the pandemic.
Eligible Veterans can Get a COVID-19 Vaccine in the Community Under Certain Guidelines
VA’s COVID-19 Guidance for Community Providers
Check VA's COVID-19 Guidance for Community Providers page for additional guidance and support.
We are grateful to the work you do in support of both VA and our nation’s Veterans. We are proud to have you as part of our care network.
Thank you for being on the frontlines to care for our Veterans, and all those in the community, particularly during the COVID-19 pandemic.
COVID-19: General Questions
Q: What resources is VA making available for Veterans during the pandemic?
- If a veteran has flu-like symptoms such as fever, cough, shortness of breath, please direct the Veteran to call their local VA medical center or MyVA311 (844-698-2311, option 3) before sending a Veteran to their local VA Medical Center (VAMC) or clinic.
- In addition to calling first, Veterans may contact their VA health care team to learn about VA’s telephone and video care options, as well as My HealtheVet Secure Messaging.
- Eligible Veterans who meet criteria provided by the Centers for Disease Control and Prevention (CDC) and local public health department guidelines can receive COVID-19 antigen testing and services from community providers, paid for by VA.
- For more information about COVID-19 vaccines, a Veteran should visit VA's vaccine page for the latest information.
Q: Will VA cover the cost of COVID-19 testing?
- Consistent with guidance VA released on July 10, 2020, VA reimburses community providers for COVID-19 antigen testing and services provided to eligible Veterans at one of the following outlets:
- In-network Urgent Care/Retail locations, if it is in conjunction with a clinical visit for care.
- In-network Community Care Network providers, if a referral or authorization exists.
- Emergency Departments, if the visit otherwise meets criteria for VA coverage of emergency care services (either through PC3 or CCN networks or care that is paid for directly by VA).
- Eligible Veterans do not pay a VA copayment for COVID-19 testing or services.
Q: What are the VA reimbursement guidelines?
- To expedite COVID-19 testing and services for Veterans early in the pandemic, when coverage in VA was limited, VA decided in 2020 to temporarily reimburse all COVID-19 testing, urgent and emergent care claims for eligible Veterans, including claims made without a VA referral. This means that COVID-19 testing and services with dates of service prior to January 1, 2021 that were not authorized (do not have a VA referral) can be submitted to VA for payment.
- However, now that coverage is more widely available, claims for reimbursement for COVID-19 testing or services on or after January 1, 2021 must be approved via VA referral or meet urgent or emergent care eligibility requirements in order to receive payment.
- If you are filing a claim for authorized COVID-19 testing or services, please ensure the claim meets all requirements, including timely filing, and is submitted to the appropriate payer (i.e., third party administrator or VA).
Q: How should COVID-19 testing be billed?
- Once available for community testing, TriWest will pay for HCPCS code (U0001) and code (U0002) to cover the CDC 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test. These codes can be billed as ancillary services and will NOT require a Request for Service (RFS).
- If a Veteran contacts you and has flu-like symptoms, such as fever, cough, or shortness of breath, please advise him/her to call their local VAMC or MyVA311 (844-698-2311, option 3) if you cannot meet their needs through telehealth or an office screening. It is important to encourage Veterans with COVID-19 symptoms to call before visiting a provider office or going to their local VAMC or clinic.
- For coding purposes, please follow CMS guidance found at https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page
Q: What are VA facilities doing to contain potential infections?
- All VA medical facilities are in the initial stages of implementing screening measures for signs of respiratory illness and exposure to COVID-19. Via telehealth services, VHA will provide a first line of defense using virtual screening for symptoms or potential exposure. Standardized screening questions are in place for all administrative call centers and Clinical Contact Centers (CCC). Onsite at medical facilities, VHA is instituting a screening at all points of entry and following escalation pathways for positive screening. Facilities will use standardized screening questions at appointment check in and during initial clinical screening. In addition, facilities will use a two tiered system with an “active” COVID-19 zone and a “passive” zone for standard care unrelated to COVID-19.
Q: How will COVID-19 affect claims payment? How can providers receive payment faster?
- COVID-19 is impacting business processes across the world including TriWest and our claims processing partner WPS MVH. While on-site resources have been reduced to limit the spread of COVID-19, our teams are dedicated to reducing the impact on processing claims for our community providers. Some of that impact that we are trying to mitigate includes potential processing and payment delays for non-electronic claim submissions.
Q: Are providers authorized to use telehealth to treat patients?
- TriWest has determined that providers who wish to utilize virtual or phone visits to treat patients and provide continued care while staying in compliance with CDC guidelines may do so, as long as the provider has an authorization on file first.
Q: Which Place of Service should be used for billing telehealth visits? Which modifiers are appropriate?
- When billing professional claims for non-traditional telehealth services with dates of services on or after March 1, 2020, and for the duration of the Public Health Emergency (PHE), bill with the Place of Service equal to what it would have been in the absence of a PHE, along with a modifier 95, indicating that the service rendered was actually performed via telehealth.
Q: Which telehealth services require a prior authorization?
- All services require a prior authorization from TriWest to prevent claims denials.
Q: Which CPT codes are covered by telehealth?
- The Standardized Episode of Care (SEOC) authorization letter for primary care includes CPT codes to cover virtual treatment.
Q: What rules govern telehealth?
- Telehealth must be conducted consistent with Medicare guidelines.
- Providers must be aware of state and federal laws governing their ability to perform telehealth services.
Q: How will claims be paid and what documentation is required?
- Medical documentation must be submitted to the Veteran’s appointing VAMC, and claims must be submitted to WPS MVH, TriWest’s claims processor.
- Claims should be submitted within 30 days after services have been rendered. Providers will collect no copays, cost-shares, or deductibles.
- Providers will be paid for all authorized care according to their contract.
- According to 38 C.F.R. 17.55 and 38 C.F.R. 17.56, payments made by VA to a non-VA facility or provider shall be considered payment in full. Providers may not impose additional charges to TriWest or the Veteran for services that have been paid by VA.
Q: Is Acupuncture via telehealth covered?
- No, all covered codes indicate being billed involve actual insertion of a needle. Discussions over the phone are not covered. Herbal consultations and consultations to discuss health are not covered by health insurance.
Q: Can providers bill telehealth services on the UB-04 form for PT/OT/SLP?
- Yes. Per CMS guidelines, there are not changes in the UB04 billing practice.
Q: Are chiropractic services covered under telehealth?
- Chiropractic services would be covered comparably to PT for telehealth in that coverage would be extended for some office visits and codes comparable to monitoring exercise (CPT 97110). CMS has provided information on appropriate telehealth coding. CMS has provided guidance to allow face-to-face levels of reimbursement for telehealth; therefore the face-to-face place of service would be used, as example 11, and modifier 95, to show it was done through telehealth.
Q: Is Physical Therapy covered under telehealth?
- Telehealth for Physical Therapy is in fact covered. All appropriate codes and modifiers will be required, in addition to modifier 95, showing care was rendered through telehealth. In terms of consents, authorization is still required.
Telehealth - Behavioral Health Resources
Q: What considerations are made for appointing Behavioral Telehealth?
- When appointing for Behavioral Telehealth, extra considerations should be made. Below are questions TriWest asks Veterans to determine Behavioral Telehealth capabilities and comfort level:
- When would you prefer to use Behavioral Telehealth appointing?
- Do you have a secure (i.e., password-protected) Internet connection?
- Do you have either a webcam with a mic on your computer or front-facing camera on your tablet/smartphone?
- Are you comfortable, able and willing to download a Behavioral Telehealth application and/or other Behavioral Telehealth information to your device?
- Do you have a room or location in your home that will allow you privacy for your Behavioral Telehealth session?
- If Veteran does not have a private location, they are then asked: Are you interested in a point-to-point location?
(A point-to-point location would involve the Veteran commuting to an originating site [usually a small clinic or health center] and attending their telehealth session there via high speed network with a distance telehealth provider.)
Q: What is required for Behavioral Telehealth claim submission?
- TriWest pays providers’ claims for the Behavioral Telehealth services if the Veteran agrees, the scope of services are appropriate for a Behavioral Telehealth visit, and the parties have the ability to have the services be performed as a Behavioral Telehealth service.
- The CPT codes on the SEOCs do not need to be updated for Behavioral Telehealth appointments. VA has directed TriWest to pay Behavioral Telehealth visits even though the CPT codes are not explicitly listed in the SEOC.
- Providers can bill using the Medicare telemedicine methodology and guidance.
Q: Which Place of Service Code should be used?
- The service will need to have the normal Place of Service code with modifier 95 to indicate that the delivery method was telehealth. To receive reimbursement for telehealth services offered between facilities, known as Point-to-Point services, a code of Q3014 must also be submitted. If offering telehealth services into the home, please refrain from using the Q3014 code.
Q: What happens if a Veteran opts for a face-to-face session?
- Should the Veteran become uncomfortable during the session and wish to return to community based face-to-face care, they are allowed to do so at any time.
- A new authorization will be required as this will be considered a new consult.
Q: Must notice be given to cancel and/or reschedule a Behavioral Telehealth appointment?
- The Veteran MUST cancel or reschedule the appointment 72 hours before the scheduled Behavioral Telehealth appointment. Failure to do so will result in a no-call, no-show and the Veteran may lose their ability to use Behavioral Telehealth if a pattern develops.
Q: What other guidelines apply to Behavioral Telehealth appointments?
- The Veteran MUST be dressed appropriately for the session.
- Inform the Veteran that this session is no different than that of a face-to-face appointment. Inappropriate clothing or lack thereof will result in termination of the session.
- All weapons must be secured during the session to avoid any cause for alarm.
- The Veteran MUST have a space to perform Behavioral Telehealth health that is private, safe, and secure. This is to protect the Veteran’s privacy.
Using Telehealth to Treat Veterans
TriWest has determined at this time that providers who wish to utilize virtual or phone visits to treat patients and provide continued care while staying in compliance with the Centers for Disease Control and Prevention (CDC) guidelines may do so, as long as the provider has an authorization on file first.
COVID-19 Billing Guidelines
TriWest is using the following guidelines regarding billing for COVID-19 tests, as well as telehealth treatment, for Veterans:
- Once available for community testing, TriWest will pay for HCPCS code (U0001) and code (U0002) to cover the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test. These codes can be billed as ancillary services and will NOT require a Request for Service (RFS).
- If a Veteran contacts you and has flu-like symptoms, such as fever, cough, or shortness of breath, please advise him/her to call their local VA Medical Center (VAMC) or MyVA311 (844-698-2311) if you cannot meet their needs through telehealth or an office screening. It is important that we all encourage Veterans with COVID-19 symptoms to call before visiting their provider office or going to their local VAMC or clinic.
Points of Contact for Additional COVID-19 Questions
Provider Services: General
- Email: ProviderServices@TriWest.com
Behavioral Health Questions
- Email: BHHelp@TriWest.com
Credentialing/Contracting/Network Participation Issues and Questions
- Phone: 866-284-3743
Claims and Billing Issues and Questions
- Phone: 866-651-4977
Customer Service (Claims, Authorization questions/support, Provider Portal Registration)
- Phone: 855-722-2838
Please visit this page for current updates!