Provider Pulse – May 2021

Region 4 Providers: Prepare for PGBA Claims Processing to Begin in June

On June 9, PGBA will start accepting and processing the Department of Veterans Affairs (VA) Community Care Network (CCN) claims and any remaining Patient-Centered Community Care (PC3) claims. PGBA began processing VA CCN claims for Kodiak, Alaska, providers on April 1.

TriWest Healthcare Alliance (TriWest) is encouraging you to begin the process of enrolling in Electronic Funds Transfer (EFT)/Electronic Remittance Advice (ERA) and Electronic Data Interchange (EDI) through PGBA at this time.

In addition, TriWest recommends that you take the new PGBA Claims Training Webinar to better understand this transition to PGBA.

What the Webinar Covers:

  • Background information about PGBA
  • How to submit claims
  • Timelines for each region's transition to PGBA
  • Claims requirements
  • Updated resources and contact information

To register for the webinar, login to your Availity account, go to the TriWest Payer Space, enter the TriWest Learning Center, click on Sessions, then register for the PGBA webinar.

PGBA Claims Submission Details:

  • For EFT/ERA: Login to Availity.com. Navigate to the TriWest Payer Space. Click on the Resources tab. Find the “PGBA EFT/ERA Enrollment Package”. Complete the forms and submit them to PGBA.
  • For EDI: Login to the TriWest Payer Space on Availity.com. Click on the Resources tab, select the PGBA EDI Provider Trading Partner Agreement, complete the forms and follow the instructions to submit them by either fax or mail.
  • Payer ID: Use TWVACCN when submitting claims to PGBA. Share this ID with your clearinghouse if you use a third-party entity.

TriWest has created a special Claims Conversion webpage and a PGBA Claims FAQ document to provide more detailed information regarding this transition.

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Check Veteran Claims Status 24/7 via Chat

TriWest added a new enhancement to its existing online Chat with TriWest feature on Availity. You can now check Veteran claims status 24/7 via Chat with TriWest as a self-service, automated feature.

This new tool will save you time! Chat with TriWest has proven that approximately 70% of providers receive claims status via chat using the self-service feature without having to be transferred to an agent.

To access, go to Avality.com, login and navigate to TriWest’s Payer Space. Select the Applications tab and choose “Chat with TriWest.” There you can:

  • Check claims status for Veteran patients, 24/7, without waiting for an available customer service representative.
  • Check as many claims as you’d like using the automated online chat function, including claims over 180 days old.
  • Get transferred to a customer service representative from 8 a.m. – 6 p.m. in your time zone for CCN, if necessary.

You now have three ways to check Veteran claims status:

  • Use the Chat with TriWest feature for automated, self-service claims check, 24/7.
  • Chat online with a live agent through Availity Monday through Friday from 8 a.m. – 6 p.m. in your time zone for CCN.
  • Call TriWest at 877-CCN-TRIW (877-226-8749).

For more information, refer to the CCN Claims Submission Quick Reference Guides.

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Keep this in Mind: VA Prohibits Solicitation of Veterans

Please remember that network providers are not permitted to market or advertise their care of Veterans, or solicit VA or Veterans for referrals.

A provision in your provider contract with TriWest specifically states, "Provider shall not advertise the award of the Agreement or these T & C in its commercial advertising in such a manner as to state or imply that the Department of Veterans Affairs endorses a product, project or commercial line of endeavor."

Additionally, you are not permitted to use any TriWest logos to promote your relationship with TriWest.

TriWest's official statement regarding provider requests for TriWest logo usage states: "TriWest is not able to approve our logo usage in this situation. Our company has a strict non-endorsement policy because, in our contract with VA, TriWest is prohibited from marketing the VA's program. Any marketing of the programs we administer for VA must be pre-approved directly by the Department of Veterans Affairs."

As an alternative, if you're interested in sharing with your community that you serve Veterans, please visit www.triwest.com/proudlycaring. Here, you can download website badges or print-ready signs that state "Proudly Caring for Veterans" for your online or in-office presence.

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Immediate Response to Complaints Helps Us Better Serve Veterans

There are times when TriWest might reach out to CCN providers to follow up on a complaint or grievance we’ve received from a Veteran (or someone on behalf of a Veteran) or VA contacts.

When this happens, TriWest wants to make sure we get the provider’s side of any issue so we can present a balanced report to VA. Your feedback matters, as it helps us improve the complaint process.

If the request to follow up is urgent, please understand there are strict requirements on how TriWest must submit formal complaints, grievances and Congressional inquiries to VA.

TriWest must report to VA within two business days about any complaints received. As part of your participation in CCN, your role is to respond to inquiries when requested.

If a specific member of the Complaints/Grievances or Congressional Relations team is working a case, the team member working the case will share his/her direct phone number and email address for responses.

If TriWest needs your assistance responding to a complaint, we look forward to receiving it in a timely manner. Thank you for caring for our nation’s Veterans!

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Provider Handbook Updates

To align both the CCN Provider Handbook and the PC3 Provider Handbook to TriWest's transition of claims processing subcontractors, several references to WPS MVH will be changed to PGBA.

Here are the other updates for the CCN Provider Handbook. The PC3 Provider Handbook had similar updates.

  • On Page 17, the following language was added under Provider Claims Submission:
    TriWest recently selected PGBA to be its new claims processor. PGBA began processing CCN claims for Kodiak, Alaska providers on April 1, 2021, and will begin accepting and processing CCN claims in Region 4 on June 9, 2021.
  • On Page 17, under Claims Submission Options, third sentence, the WPS MVH Payer ID of VAPCCC3 changed to PGBA Payer ID: TWVACCN.
  • On Page 17, the following language was added: "If electronic submission is not an option, providers may mail paper claims to:
    TriWest VA CCN Claims
    PO Box 108851
    Florence, SC 29502-8851"
  • On Page 18, the following language was inserted after the third paragraph:
    If your claim was denied because it was sent to another VA payer, requests for reconsideration of claims must be submitted within 180 days of VA's or VA payer's denial. Follow these instructions to successfully correct your claims submission:
    • Retain a copy of the remittance advice from original submission to wrong entity. This serves as documentation of timely filing and should be retained to ensure that the original submission date can be confirmed in the event of an audit.
    • If submitting a Paper Claim: Print out and complete the Provider Timely Filing Form on TriWest's Payer Space on Availity, and submit the Provider Timely Filing Form with your paper claim to PGBA.
    • If submitting an Electronic Claim via EDI: Use an indicator "9"on the 837 in the data element field CLM20 to indicate resubmission for timely filing. The "9" indicator definition is Original Claim rejected or denied for reason unrelated to the billing limitation rules. Claims with the "9" resubmission indicator will bypass automatic timely filing denials.
    Claims that do not meet the above requirements will be denied. TriWest can no longer accept remittance advice documentation from non-VA payers, such as TRICARE, Medicare, or other health insurers. Remember, providers are not allowed to balance bill Veterans or TriWest for services provided under the Community Care Network contract, including any remaining balances or after a timely filing denial."
  • On Page 18 under Returns and Recoupments, the address for overpayments owed to TriWest was changed to the following while some more information was added:
    TriWest VA CCN Finance
    Attention: Refunds
    PO Box 108852
    Florence, SC 29502-8852
    Please include the refund control number (RCN) on your check or money order and the enclosed payment stub with your remittance to ensure proper credit to your account."

  • On Page 19 under Out-Of-Network Billing, second paragraph, the following sentence was changed to read: "Out of network providers must submit healthcare claims directly to TriWest by billing PGBA, TriWest's claims processor."
  • On Page 24, the following was added at the end of the first (1) guideline:
    Here are some EDI resources we have posted on Availity in the TriWest Payer Space:
    • PGBA EDI Provider Trading Partner Agreement
    • PGBA 837I Companion Guide
    • PGBA 837P Companion Guide
    • PGBA EDI FAQs

There are no changes planned for the PC3 Provider Handbook.

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Updated: 6/4/2021 4:22:52 PM