Credentialing and Contract Provisions

TriWest Provider Contract Provisions

The following provisions are applicable to services rendered pursuant to authorizations for care under CCN as administered by TriWest and will be incorporated by reference into the Provider’s Network Agreement as if fully set forth therein. The Spanish version of the Provider Handbook is provided for convenience only; the English version of all contractual documents between TriWest and the provider, including but not limited to the Provider Handbook, shall be exclusively used for legal interpretation. For avoidance of doubt, in the event of any ambiguity or disagreement between the terms of the Spanish version of the Provider Handbook and the original English version, the English version shall take precedence and control.

Definitions

All defined terms herein have the same meaning as they have in the Provider Network Agreement or Program Terms & Conditions unless otherwise defined below.

1. Beneficiary – Any individual enrolled and authorized to receive care through the TriWest Provider network by any Program incorporated into the Provider Agreement.
2. CCN Covered Services – Services, items and supplies for which benefits are available to VA Beneficiaries in accordance with the rules, regulations, polices and instructions of Veterans Administration and the Veterans Health Administration.
3. DME – Durable Medical Equipment to include any equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in a the absence of an illness or injury, and is appropriate for use in the home.
4. Emergency Care – Medical care required within twenty-four hours or less that is essential to evaluate and stabilize conditions of an Emergency/Emergent Need that if not provided may result in unacceptable morbidity/ pain if there is significant delay in evaluation or treatment.
5. Emergency/Emergent Need – Conditions of one’s health that may result in the loss of life, limb, vision, or result in unacceptable morbidly/pain when there is significant delay in evaluation or treatment.
6. Network Subcontractor – An entity that is a party to a Provider Network Agreement and operates as a subcontractor to TriWest to manage provider data, credentialing, and certain other functions as may be designated by TriWest. Some Provider Network Agreements may not have a Network Subcontractor as a party to the agreement, in such cases, references to Network Subcontractor in this Provider Handbook should be interpreted as a reference to TriWest.
7. Party – Any individual or entity that is a party or a third-party beneficiary to the Provider Network Agreement.
8. Prior Authorization – A required process through which VA reviews and approves certain medical services to ensure the medical necessity and appropriateness of care prior to services being rendered within a specified timeframe from a non-VA provider or additional resources in the community. This type of process requires a Prior Authorization be obtained “prior to” the specified service.
9. Provider – Any individual or entity providing healthcare services pursuant to an authorization for care issued by TriWest, or who is otherwise subject to the terms and conditions of a Program or this Handbook.
10. Urgent Care – The medical services defined in 38 C.F.R. § 17.4600(b)(5) provided in an outpatient setting to treat acute or chronic illness or injury.
11. VA Beneficiary – Any person eligible to receive CCN Covered Services under the rules, regulations, policies and instructions of the VA.
12. Veterans Health Administration (VA) – The division of the Department of Veterans Affairs that provides health care services and administers health care benefits for eligible Beneficiaries.

Termination

TriWest and Network Subcontractor shall have the right to immediately terminate Provider Agreements upon written notice to provider upon the occurrence of any of the events listed below:

1. Provider’s state or federal license or authorization to do business is reduced, restricted, placed on probation, suspended, involuntarily revoked, involuntarily terminated, voluntarily terminated or voluntarily revoked by Provider to avoid investigation, or voluntarily terminated or voluntarily revoked by Provider while Provider is under investigation in any state, or Provider’s other applicable license or accreditation necessary to perform any services contemplated by the Provider’s Agreement is reduced, restricted, placed on probation, suspended, involuntarily revoked, involuntarily terminated, voluntarily terminated or voluntarily revoked by Provider to avoid investigation, or voluntarily terminated or voluntarily revoked by Provider while Provider is under investigation in any state; or
2. Provider’s professional liability coverage as required under Provider’s Agreement is reduced below required amounts or is no longer in effect; or
3. Provider fails to meet TriWest’s or Network Subcontractor’s credentialing, re-credentialing, quality management or utilization management criteria, or fails to comply with quality management or utilization management processes; or
4. Provider fails to provide material information or provides erroneous information on Provider’s credentialing application or re-credentialing application; or
5. Provider is no longer Medicare-eligible, Medicaid-eligible, or is not eligible to participate in another government program; or
6. Provider or any one of its officers is arrested or indicted on felony charges that directly or indirectly relate to provisions of services under Provider’s Agreement, and TriWest and Network Subcontractor makes a reasonable and good faith determination that the nature of the charges are such that termination or necessary to avoid unnecessary risk or harm to Beneficiaries that could occur during the pendency of the criminal proceedings.

Notification

1. All notices and other communications to a Party must be in writing, hand delivered, delivered by prepaid commercial courier services with tracking capabilities, faxed, or delivered by the U.S. mail to the address listed on the signature page of the Provider’s Agreement. The Parties may change the address of record by notifying the other Party of the new address. Notice shall be complete upon the earlier of actual receipt or five (5) days after being deposited into the U.S. mail. Notices and other communications in writing need not be mailed either by registered or certified mail, although a signed return receipt received through the U.S. Post Office shall be conclusive proof between the Parties of delivery of any notice or communication and of the date of such delivery.
2. Provider shall notify TriWest or Network Subcontractor in writing immediately upon learning of any action, policies, determinations or internal or external developments that may have a direct impact on Provider’s ability to perform its obligations under the Provider’s Agreement. Such matters shall include, but are not limited to:
   1. Any change in ownership, specialty services provided, Medicare designation (including but not limited to sole community, critical access, etc.) or location of facility(ies);
   2. Action against or lapse of Provider’s license, certification, accreditation or certificate of authority;
   3. Loss of hospital privileges;
   4. Arrest or indictment;
   5. Reduction in insurance coverage below the required limits set forth for the applicable Program, or termination of insurance coverage;
   6. Any activity that compromises the confidentiality and security of the medical records of Beneficiaries;
   7. Exclusion or any other penalty from Medicare, Medicaid, or any other federal health care program.
3. Provider shall complete VA required training that will be determined at a later date and reflected in the next version of the TriWest Provider Handbook.

Provider Directory

TriWest may periodically include provider’s name, gender, work address, work fax number, work telephone number, whether the provider is accepting new patients, specialty and sub-specialty and willingness to accept Beneficiaries in a directory of Network Providers. Provider is responsible for notifying TriWest or Network Subcontractor of any changes of address, phone or fax number, or specialty services rendered within 10 business days.

Compliance

Provider shall comply with all applicable state and federal laws as well as regulations and all rules, policies and procedures of the applicable program including without limitation to credentialing, peer review, referrals, utilization review/management, clinical practice guidelines, VA Beneficiary complaints and grievances procedures, case management and quality assurance programs and procedures established by TriWest or the applicable health care program including submission of information concerning provider and compliance with Preauthorization requirements, care approvals, pharmacy, dental and DME utilization requirements, care approvals, concurrent reviews, retrospective reviews, discharge planning for inpatient admissions, critical event notifications, quality of care audits, return of medical records and Prior Authorization of referrals.

Provider shall promptly respond to TriWest inquiries concerning VA Beneficiary complaints and grievances. Provider’s failure to cooperate with TriWest’s efforts to resolve VA Beneficiary complaints (e.g. not timely responding to TriWest’s letters and/or phone calls regarding VA Beneficiary complaints) is a failure to comply with the terms and conditions of this Provider Handbook, which is a material breach of Provider’s Agreement.

Ancillary Providers

When provider utilizes any ancillary providers to render services for the same episode of care for which provider has accepted an authorization, the referring provider must ensure that the ancillary provider is provided with the authorization number and billing information for the applicable episode of care. Provider should make reasonable efforts to utilize ancillary providers that are CCN contracted providers. Ancillary providers that are not CCN contracted providers must agree to be reimbursed at the Medicare allowable rate for the services billed and in no event can TriWest pay an ancillary provider more than VA’s allowable rate. Ancillary providers may not bill Veterans, including any balance billing; the referring provider is responsible for ensuring that ancillary providers are aware of CCN payment rates and the restrictions against billing the Veteran beneficiary.

Providers are required to share the VA referral/authorization number with the ancillary providers included in a Veteran’s episode of care. The ancillary provider is also required to use this same VA referral/authorization number when submitting their claim for the specific episode of care.

Medical Records and Documents

1. Provider shall submit medical documentation to VA in an EDI 278 transaction format, where available. Providers, who do not have the capability to submit EDI 278 transactions, shall submit via secure e-mail or fax.
2. Initial outpatient medical documentation is medical documentation associated with the first appointment of an episode of care. Initial medical documentation for outpatient care shall be returned within 30 days of the initial appointment.
3. Final outpatient medical documentation is medical documentation that summarizes the result of any medical care provided. Final medical documentation of outpatient care shall be returned within 30 days of the completion of the episode of care.
4. Medical documentation associated with inpatient care shall be returned within 30 days of discharge and shall consist of a Discharge Summary.
5. Medical documentation requested on an urgent basis must be returned to the requesting party within one (1) business day of the request.
6. Ancillary providers who are unable to return medical documentation to VA must send medical documentation to the referring provider for proper care coordination. Please refer to VA’s Facility Contact Information for Care Coordination for assistance.

Credentialing Requirements

1. Provider must meet the requirements of state and local laws and if applicable must have a full, current, non-probationary and unrestricted license in the state where services are delivered.
2. Provider must remain in compliance with the seven (7) elements of the OIG’s Compliance Program Guidance.
   1. Implementing written policies, procedures and standards of conduct.
   2. Designating a compliance officer and compliance committee.
   3. Conducting effective training and education.
   4. Developing effective lines of communication.
   5. Conducting internal monitoring and auditing.
   6. Enforcing standards through well-publicized disciplinary guidelines.
   7. Responding promptly to detected offenses and undertaking corrective action.
3. If applicable, provider cannot have had any state license termed for cause or have relinquished any state license after being notified in writing by that state of potential termination for cause.
4. If applicable, providers shall meet all Medicare Conditions of Participation (CoP) and Conditions for Coverage (CfC), where such conditions exist, subject to CMS modifications, as required by the U.S. Department of Health and Human Services (HHS). These conditions may be met through CMS certification or accreditation by organizations deemed by CMS to meet or exceed the CMS Medicare standards set forth in the CoP/CfC. For additional details regarding these requirements see https://www.cms.gov.

Professional Liability Coverage

Provider shall provide and maintain professional liability insurance in an amount in accordance with the laws of the state in which the care is provided.

OHI Billing and Claim Submission Requirements

When VA determines it is secondary payer as indicated by the authorization for services, the provider must first invoice VA Beneficiary’s other health insurance (OHI), and invoice TriWest second as described herein. When the VA is secondary payer, TriWest will reimburse provider only up to the difference between the amount paid by Beneficiary’s OHI and the rate(s) that provider has negotiated with TriWest for the services. When claims are denied by VA Beneficiary’s OHI, provider must submit the Explanation of Benefits (EOB) or remittance advice (RA) statement indicating the dates of service, amounts of the claim, and reason(s) for denial to TriWest. Provider will be permitted up to 90 days after the other insurer’s adjudication to file claims with TriWest when, (i) provider first submitted the claim to the VA Beneficiary’s OHI, in accordance with this section, and (ii) the adjudication occurred past the CCN claims submission deadline. Any claims submitted to TriWest past this ninety (90) day period will be denied.

Claims Submission Policies and Procedures

The following guidelines are necessary in order to submit claims electronically to TriWest via PGBA:

1. You can submit claims directly to PGBA. New direct submitters must file a Trading Partner agreement to be assigned a submitter ID. The EDI Gateway User manual provides the information you will need to determine if direct submissions are the right option for you. Contact the PGBA EDI Help Desk at 800-259-0264, option 1 or email EDI@pgba.com to request a copy of the EDI Gateway User manual. Use these EDI resources posted on Availity in the TriWest Payer Space:
   1. PGBA EDI Provider Trading Partner Agreement
   2. PGBA 837I Companion Guide
   3. PGBA 837P Companion Guide
   4. PGBA EDI FAQs
2. Provider agrees that all claims submitted via EDI, for all legal and other purpose, will be considered signed by the provider or provider’s authorized representative.
3. Provider agrees to maintain a patient signature file. Provider understands PGBA may validate through file audits, those claims submitted via EDI which are included in any quality control or sampling method required by PGBA. Provider understands if no signed authorization is on file, an authorization must be obtained by the provider from the patient prior to EDI submission to PGBA.
4. Provider acknowledges that PGBA and Network Subcontractor‪ shall have no obligation with respect to the content of the information in claims either to verify, check, or otherwise inspect the information supplied by the health care provider, except to reformat the claim data to the specification required by TriWest. Provider further acknowledges that TriWest will determine whether provider has submitted enough information in the EDI claims in order to determine the completeness, accuracy, and validity of the information and claims, and that source documents for claims data are the responsibility of the provider.
5. The following guidelines are necessary in order for providers to receive Approved Referral/Authorization or Prior Authorization electronically from the VA via the EDI 278 Electronic submission process. The VA shall submit Approved Referral/Authorization or Prior Authorization to provider in an EDI 278 transaction format, where available. Those providers, who do not have the capability to receive EDI 278 transactions, may receive Approved Referral/Authorization or Prior Authorization via secure e-mail or fax.

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Marketing and Advertising

Provider shall not (1) advertise the award of the Provider Network Agreement or the Program Terms and Conditions in such a manner as to state or imply that the VA endorses a product, project, commercial line of endeavor, provider’s practice or services, or (2) solicit, either directly or indirectly, the VA, VA Medical Centers (VAMC) or Veterans through either provider’s commercial advertising or direct outreach. A TriWest network provider may only utilize the approved website badges on provider’s website as well as the approved print-ready signs found on TriWest’s Proudly Caring for Veterans web page to indicate their participating status in the TriWest network supporting VA.

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