Provider Pulse – February 2024

*January Provider Pulse Correction: Please note a correction to the 2024 January Provider Pulse sent on January 25, 2024, where the subject line should have read, “January Provider Pulse: 2024 VA Fee Schedule Now Available.” You can find the full newsletter, and archives, on

Key Requirements for CMS 3-Day Payment Window

Please be advised that under the Centers for Medicare & Medicaid Services’ (CMS) “3-Day (1-Day) Payment Window Policy”, a hospital (or entity that is wholly owned and/or operated by the hospital) must include a beneficiary's inpatient stay, the diagnoses, procedures, and charges for all outpatient diagnostic services and admission-related outpatient non-diagnostic services that are furnished to the beneficiary during the 3-day (or 1-day) payment window on the claim. This payment policy has been in effect since June 25, 2010.

Below are some key requirements under the CMS 3-Day Payment Window policy:

  • Bundled: If an admitting hospital (or an entity wholly owned, wholly operated, or under arrangement with the admitting hospital) furnishes diagnostic services three days prior to and including the date of a beneficiary’s inpatient admission, the services are considered inpatient services and are included in the inpatient payment.
  • Unbundled: If a hospital renders non‐diagnostic outpatient services three days prior to and including the date of a beneficiary’s inpatient admission, and the non‐diagnostic outpatient services are unrelated to the inpatient admission, the hospital is permitted to separately bill Medicare Part B for the non‐diagnostic outpatient services.

However, if the non‐diagnostic outpatient services are related to the inpatient admission, the services are considered inpatient services and cannot be billed separately under Medicare Part B.

In a situation where unrelated outpatient services are rendered (not related to the inpatient admission), the facility should append condition code 51 on the UB-04.

For more information, please review the 3-Day Payment Window information on the CMS website.

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Last Day to Submit PC3 Clams is March 1

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

TriWest Healthcare Alliance (TriWest) administers claims for the current Department of Veterans Affairs (VA) Community Care Network (CCN) program in Regions 4 and 5. TriWest has also continued to support the prior version of the PC3 program 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, must 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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Reminder: Check the VA Formulary for Frequent Updates

As a reminder, please check the Department of Veterans Affairs (VA) National Formulary for updates as changes are made periodically.

Don’t Provide Drug Samples to Veterans

Providing drug samples to Veterans could have adverse consequences. Samples often require other criteria for use, do not contain important instructions on the package, or may have interactions with other prescribed medications that are tracked through VA’s pharmacy system.

If a preferred medication is not on the VA drug formulary, you must contact the authorizing VA Medical Center (VAMC) and request a Formulary Review Request form, fill out the form, and return it to the authorizing VAMC for approval or denial. This process can take up to 96 hours for review.

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Discover the Latest Claims Status Report Enhancements

New and exciting enhancements have been made to TriWest’s Claims Status Report. These enhancements will provide additional detail on your claims, as well as make for a more user-friendly experience when using TriWest data in conjunction with your own reports. You can find the report enhancements on the Claims Status Detail tab on

The following details have been added:

  • Patient Control Number/Patient ID Number
  • Check number containing the alpha prefix that is required for the Availity Remit look-up
  • Column data on:
    • EFT or paper
    • Bulk Y/N
    • Bulk check total amount

Please view the Provider Claims Reporting Tool User Guide for instructions on signing up to receive automatic Claims Status Reports through Availity.

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Reminder: Skilled Bundled/Unbundled Home Health Services Reimbursed via PDGM

Providers are reminded that under Department of Veterans Affairs (VA) Community Care Network (CCN) guidelines, skilled bundled home health services are reimbursed via the Medicare Patient-Driven Groupings Model (PDGM).

These types of claims should be billed on a CMS UB-04 claim form using Type of Bill (TOB) 32X. The claim submission must include the VA referral number associated to a skilled bundled home health Standardized Episode of Care (SEOC).

Additionally, skilled unbundled (or non-bundled) services are reimbursed on a fee-for-services basis and can be billed on a CMS-1500 claim form using Place of Service 12, or a CMS UB04 claim form, using TOB 34X. The claim submission must include the VA referral number associated with a skilled unbundled SEOC.

Effective for dates of service Sept. 1, 2023 and after, skilled bundled home health services are rejected if the claim is not submitted with TOB 32X and if it is not submitted with a VA referral associated with a skilled bundled home health SEOC and includes TOB 32X.

Also, effective for dates of service Sept.1, 2023 and after, skilled unbundled home health services are rejected if not submitted with TOB 34X (CMS UB-04) or Place of Service 12 (CMS 1500) and if not submitted with a VA referral associated with a skilled unbundled home health SEOC.

For more information, refer to the Home Health Services Quick Reference Guide. More information can also be found on TriWest’s claims guidelines web page.

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Provider Handbook Updates

There are currently no changes planned for the CCN Provider Handbook.

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Updated: 2/22/2024 8:39:47 AM