Provider Pulse – December 2022

Electronic Funds Transfers Get You Paid Faster

Enroll in the free Electronic Funds Transfer (EFT) process to receive your VA CCN payments faster!

It takes about 30 days for enrollments to be processed. Approximately 37 days later, EFT payments will begin, and will be automatically deposited into your bank account.

How to enroll:

  • Visit and download the PGBA EFT/ERA Enrollment Package.
  • Ask the person with signature authority in your practice to complete and send the EFT form to PGBA at:

    PO Box 108853
    Florence, SC 29502-8853

    Or fax it to: 803-419-3233

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Subscribe to Automatically Receive Claims Status Reports

TriWest now offers you the ability to self-subscribe and receive claims status reports emailed directly to your inbox. Reports can be automatically generated monthly, weekly or on an ad hoc date range based on your preference. This tool puts claims status reports at your fingertips, saving you time by automating the reporting functionality and giving you an improved workflow to review the claims status of your Veteran patients.

With claim status reports delivered securely to your email inbox as an Excel file, you can quickly review the status of submitted claims without being logged into or calling a TriWest contact center agent for the information.

Subscribe Now to Receive Claim Status Reports Emailed to You

To subscribe, log in to your Availity account. Then:

  • Select the Payer Spaces tab.
  • Choose TriWest Healthcare Alliance.
  • Select Provider Claims Reporting Tool.
  • Select your Tax ID number.
  • Click Add New Subscription.
  • Select the frequency you prefer and enter the email address(es) where the reports should be delivered. (Note: Reports can be sent to up to five email addresses at a time.)

For a more detailed look at the Provider Claims Reporting Tool, refer to the Provider Claims Reporting Tool User Guide that displays screenshots on how to subscribe.

If you’re not signed up for Availity, register for a free account to use your single user ID and password to check claims status and access all TriWest information, webinar sessions, quick reference guides, and the CCN Provider Handbook.

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Refresh Your Memory on the Peer Review Process

TriWest’s Peer Review Committee is responsible for oversight of the peer review process. As part of this process, TriWest works with community providers to review cases and discuss appropriate improvement plans for quality of care.

The peer review process has existed for over a century in the medical profession to improve patient safety and quality of care. It ensures that peer reviews are consistent with clinical guidelines and indicates where care may be less supported or incur more risk.

Peer reviews are also completed outside the Peer Review Committee by similar specialists, and the confirmed clinical quality concerns are discussed monthly. Cases include medical, surgical, behavioral, and integrated health. Many medical facilities and insurers are required to have a peer review process included in their clinical quality program to identify and eliminate potential quality concerns.

Hospitals utilize peer reviews for existing doctors to maintain their privileges and for new physicians seeking privileges at the facility to meet accreditation requirements for their clinical quality and credentialing programs. Hospitals, doctors and administrators can request peer reviews of their colleagues if they are concerned about the quality of patient care.

Clinical quality peer review is different from peer-to-peer medical review, which occurs when a licensed clinical reviewer studies a patient and his or her clinical situation to determine coverage or an appeal on a medical claim.

Foregoing participation in a peer review process can lead to loss of privileges at facilities and loss of contract/network participation, and often must be reported to the National Practitioner Databank (NPDB) by any entity engaged in these clinical quality reviews.

Some health care entities possess the resources to conduct peer reviews internally, but many invest in the services of companies that specialize in peer review. They’re able to match the most applicable board-certified physicians to the right cases, resulting in peer reviews that are managed with the highest level of knowledge and expertise using widely accepted criteria.

We sincerely appreciate those of you who participate in the peer review process to help provide a more comprehensive network to care for our nation’s Veterans.

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Provider Handbook Updates

There are no updates planned for the CCN Provider Handbook.

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Updated: 1/26/2023 11:28:18 AM