Provider Pulse: November

Provider Pulse

November 2019

Welcome to November!

Are you ready for pumpkin spice, changing leaves, and Thanksgiving? We’re excited to welcome November, too! This month, we have some changes coming to the appointing process, as well as some reminders about unnecessary Requests for Service. Keep reading for these updates, and more, below.

In This Edition:

Partial Scheduling Option Coming to VA Medical Centers

As the Department of Veterans Affairs (VA) continues to transition to the Community Care Network (CCN) across the country, VA is changing the appointment scheduling and authorization process by adding a partial scheduling option for some VA Medical Centers (VAMCs). This may begin as soon as Nov. 1, 2019 for certain VAMCs.

As part of this procedure, you may receive phone calls from either VA or TriWest Healthcare Alliance to schedule appointments. With this change, we ask that providers allow the Department of Veteran Affairs staff to coordinate the scheduling of appointments prior to receiving the TriWest authorization which will be received from TriWest within five days. This is a performance expectation that VA has with TriWest. We appreciate providers assisting us with making that possible.

To help providers better understand the process, TriWest will be adding the appropriate VAMC phone number to all authorization letters so an appropriate VA POC is identified if the VAMC is doing the appointing. Providers should look closely to the authorization letter to verify the phone number that will identify who (TriWest or VAMC) is scheduling the Veteran’s appointment.

In addition, the list of VAMCs that will be fully or partially scheduling will be included in the Appointing Matrix Tool and the Appointment Scheduling Quick Reference Guide. Please be aware that the list is subject to change, and the authorization should be used for final determination of who is scheduling.

Remember, providers should not administer care to Veterans without an authorization (except for urgent or emergency care); otherwise, you risk losing reimbursement for your services.

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Flu Shots Now Covered as VA Urgent Care Benefit

Shots must be included as "incidental" during urgent care visit for urgent condition

VA is now allowing providers to administer the flu shot to Veterans during an urgent care/retail location visit, as long as the shot is appropriate to the condition being treated, or is indicated for the Veteran.

VA will not cover flu shots as a standalone service under the PC3 urgent care/retail location benefit or any other PC3 benefit. If an eligible Veteran goes to an urgent care location for the sole purpose of receiving a flu shot, it will be denied. The only exception is visits to Walgreens, where VA has a separate contract for administration of a flu shot independent of any urgent care needs.

Flu shots will be covered retroactively going back to June 6, 2019, if administered during an urgent care visit. If an urgent care provider previously billed for a flu shot administered during an urgent care visit and was denied, TriWest will automatically adjust for payment. Payments should be received within the next 60 days. If providers have questions regarding their denied urgent care flu shot claim, they should contact the TriWest Claims Customer Service department at 866-651-4977.

Need More Information? Register for a Webinar!

Urgent care providers or retail location clinics that need more information on VA’s urgent care benefit can register for a free webinar! The TriWest Provider Training team conducts regular live, interactive webinars on the urgent care process.

To register:

  1. Go to Availity and log in to your account at
  2. Navigate to the TriWest Payer Space
  3. Click on the TriWest Learning Center
  4. Register for the Urgent Care Webinar at the time that works for you.

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When is an Additional Authorization Request Unnecessary?

Sometimes, providers think they need to send a Request For Service (RFS) to either TriWest or VA to extend or add services to an authorization, when a RFS isn’t necessary.

Most commonly, unnecessary RFS forms (formerly called a “secondary authorization request,” or a SAR] stem from ancillary or downstream providers that don’t see their facilities listed on the original authorization. They therefore submit a RFS to have their facilities added to the authorization.

However, this action is not necessary. The original authorization already covers routine ancillary or downstream services, such as labs or X-rays. These types of providers do not need to request to add their facilities to the authorization.

Instead, ancillary and downstream providers should simply bill TriWest via its claims processor, WPS Military and Veterans Health (WPS MVH), and include the original authorization number on the claim. This will save providers a lot of time and unnecessary paperwork.

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Urgent Care and Walk-In Providers: Four Reminders from VA

VA is now a few months into full implementation of its new urgent care/retail location benefit and wants to remind participating providers of four important points.

These four points will help ensure that Veterans get covered for their care and that urgent medication is not denied at the pharmacy.

Point 1: Call to check Veteran eligibility BEFORE providing care to prevent medication denial.

After a Veteran self-presents to your urgent care facility or walk-in clinic, always call 1-833-4VETNOW (1-833-483-8669) to check the Veteran’s eligibility BEFORE rendering care. Failing to do so could cause a denial for the Veteran’s urgent medication.

Point 2: Make sure all medications are listed on VA’s Urgent/Emergent Formulary.

When prescribing urgent medication, make sure the drug is listed on VA’s Urgent/Emergent Formulary. The formulary is published on TriWest’s website at

Point 3: Veterans can fulfill medications at any Express Scripts network pharmacy without a voucher.

No voucher is required for a Veteran when fulfilling an urgent medication prescription. Instead, the Veteran may fill the prescription at any in-network pharmacy with Express Scripts, available here:

Point 4: Get trained on process updates! Register for an Urgent Care webinar.

The TriWest Provider Education team conducts regular, live webinars that cover the urgent care process. Register for an Urgent Care webinar to ensure you have the latest information on the program.

To register:

  • Log in to Availity at
  • Navigate to the TriWest Payer Space
  • Click on the TriWest Learning Center
  • Register for an Urgent Care webinar at the time of your choice.

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Recommended Steps to Safely Prescribe Opioids to Veteran Patients

Stay Compliant with VA Guidelines

If you need to prescribe an opioid-based medication to a Veteran patient, make sure you’re following VA guidelines.

About two years ago, the President of the United States directed the Department of Health and Human Services to declare the opioid crisis a public health emergency. In response, TriWest partnered with VA to spread awareness, education and information about the issue.

Take the following steps to ensure you’re complying with VA’s guidelines on opioids when prescribing medications to your Veteran patients:

  1. During a TriWest-authorized appointment with a Veteran, determine whether the need for opioid-based medication is present.
  2. Contact the Veteran’s VAMC if you have any question about whether your authorization includes the responsibility of prescribing opioids for that patient.
  3. If you have a valid authorization and need to prescribe opioids to the Veteran, ask the VAMC for the Veteran’s complete history of care, including medical records and past history of pain management.
  4. Write the prescription and print a copy of the authorization letter from TriWest.
  5. Ask the Veteran to hand-carry both the script and the authorization letter to his or her VA pharmacy for fulfillment.

For more information on responsible opioid management, including a letter from VA to providers on how to handle opioid prescriptions, please review our TriWest Opioid Crisis page at

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Chiropractors: Make Sure to Bill with Correct Codes

If you’re a chiropractor treating Veterans under VA’s Community Care programs, make sure you’re billing with the correct codes.

TriWest has determined that some of its network chiropractors are billing our claims processor, WPS Military and Veterans Health (WPS MVH), with incorrect modifiers for massage therapy.

The correct modifier for massage is GP.

Chiropractors billing for massage work should always use the GP modifier on their claims to WPS MVH. For more information on billing, please review the Provider Claims Quick Reference Guide.

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Provider Handbook Updates

There are no updates planned for the Provider Handbook in December 2019.

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Updated: 8/2/2022 3:34:29 PM