Billing and Claims
TriWest Healthcare Alliance, on behalf of the U.S. Department of Veterans Affairs (VA), is the third party administrator (TPA) and payer for the following networks:
- Community Care Network (CCN) Region 4
- Community Care Network (CCN) Region 5
TriWest partners with PGBA to process and pay out claims to CCN providers who have rendered services to Veterans in accordance with an authorized VA referral.
It is a contract requirement that all CCN claims process electronically, regardless of the method of submission. As a result, filing claims electronically is preferred and encouraged. If you choose to submit paper claims, they must scan to an electronic format, creating a potential issue for handwritten or manually typed claims. Claims that cannot be scanned cleanly may reject.
PGBA only reviews claims that have an approved VA referral/authorization number. An approved referral/authorization from VA:
- supports the service rendered by a CCN provider;
- has a specific plan of care; and
- details a specified number of visits and/or services related to a Standard Episode of Care (SEOC).
Billing for Services Rendered to Veterans
- All care requires an approved referral/authorization with the exception of urgent care. A claim submitted without a VA referral/authorization number will be denied/rejected.
- Providers should not collect copays, cost-shares or deductibles. CCN reimburses up to 100% of the allowed amount, including any patient obligation.
- Payments made by TriWest or VA shall be considered payment in full under CCN. Providers may not impose additional charges to TriWest or the Veteran for covered services.
- 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.
- For CCN, TriWest follows Medicare billing guidelines, fee schedules and payment methodology when applicable.
- Remember, providers are not allowed to balance bill Veterans or TriWest for services provided under the CCN contract, including any remaining balances or after a timely filing denial.
Additionally, VA benefits do not coordinate with other Federal programs (TRICARE, Medicare, Medicaid, etc.). If a provider has an approved referral/authorization on file from TriWest, the provider should bill TriWest, not VA, as TriWest pays primary on behalf of VA.
Timely Filing Requirements
All authorized claims must be filed within 180 days from the date the service was rendered. Claims that are submitted beyond the 180-day limit will be automatically denied for timely filing without additional review (See 38 U.S.C. §1703).
If you disagree with a timely filing claim denial, you may request a review/informal appeal of that decision through the Claim Reconsideration Process discussed below.
Reconsideration of Claims Denied for Timely Filing
Submit an Online Provider Claims Reconsideration Form.
- Include a copy of a properly billed claim form, including a valid VA referral
- Provide proof of timely filing to a VA payer within 180 days from date of service or date of discharge (VA payers are TriWest, Optum, and VA)
PGBA Claims Submission Options
TriWest has designated PGBA as the claims payer for all authorized claims. Providers will submit all claims to PGBA either through the electronic claims submission process, or via a paper claim form.
All CCN claims process electronically, regardless of the method of submission. This is a requirement and, therefore, filing claims electronically is preferred and encouraged. If you choose to submit paper claims, they must scan to an electronic format. Claims that cannot be scanned cleanly may reject.
Filing Electronic Claims
Claims submitted electronically are less likely to be rejected compared to paper claims. Improve your claim submission accuracy and get your payments faster by signing up for electronic claim submission and funds transfer. You can do this by enrolling in Electronic Data Interchange (EDI) through PGBA.
Download the form and FAQs on www.TriWest.com/ClaimsInformation.
Providers can submit electronic claims without a clearinghouse account through Availity’s Basic Clearinghouse option. The Basic Clearinghouse option is FREE to CCN providers.
If you submit electronically through a clearinghouse, please use the PGBA Payer ID of TWVACCN.
Electronic Fund Transfer (EFT) and Electronic Remittance Advice (ERA)
TriWest network providers can enroll online for ERA and/or EFT through the Availity Essentials Transaction Enrollment application. Your organization’s Availity administrator can set up user account access and assign roles and permissions to ensure you receive payments more quickly and avoid the hassle of paper checks and/or remits.
Enroll by following these steps:
- Log into Availity.com and navigate to Availity Essentials.
- Select My Providers | Enrollment Center | Transaction Enrollment.
- With Transaction Enrollment permission the user can enroll a single provider or providers in bulk (up to 500 at a time).
Please see the Electronic Enrollment Option for TriWest ERA/EFT for online enrollment instructions. Providers can also find the EFT/ERA Enrollment Package forms and FAQs at www.TriWest.com/ClaimsInformation.
Clean Claim Requirements
In order for a claim to process and pay, TriWest must have visibility to the appointment in its systems.
Once the provider receives an authorization letter from either TriWest or VA, the referral/authorization number is the unique identifier assigned for each approved referral/authorization’s episode of care. TriWest requires that the provider include this number on the claim or the claim will be denied/rejected.
It is important that providers properly submit claims to PGBA with the following documentation, and in the correct format:
- VA referral number (Proper format example: VA1234567890) AND one of the following:
- 17-digit Master Veteran Index (MVI) ICN
- Social Security number (SSN)
- 10-digit Electronic Data Interchange Personal Identifier (EDIPI)
- Last 4 digits for SSN with preceding 5 zeros (e.g., 00000XXXX)
- It is extremely important that you do not use any extra characters, spaces, or words with the referral/authorization number or the claim will deny. For example, if the correct referral/authorization number is VA0001234567, referral numbers included in the following format would be denied/rejected:
- Auth VA0001234567
- Auth # VA0001234567
- Ref VA0001234567
- Ref # VA0001234567
- VA 0001234567
- Solo practitioners without an organizational NPI should use an individual NPI.
- Ensure all coding aligns with Medicare criteria, if applicable. When Medicare policy does not apply, please follow language in the authorization information, VA consult notes, the Provider Handbook, or other training materials provided by TriWest and VA.
Corrected/Void Claims
A corrected claim should be submitted when you need to replace or correct information on a claim that was previously submitted and/or processed by PGBA. Submitting a corrected claim will have the effect of completely replacing your previously filed claim with the information on the corrected claim.
Examples of a corrected claim include (but are not limited to):
- Providing a referral number or rendering NPI originally omitted
- Changing procedure or diagnosis codes, or the patient’s name or demographic information, or any other information that would change the way the claim was originally processed.
Submit a void claim when you need to cancel a claim already submitted and/or processed by PGBA. See VA's Veteran Care Claim page for more information under "Corrections and Voids".
How to File a Corrected/Void Claim
Corrected claims can be submitted electronically as an EDI 837 transaction with the appropriate frequency code. For more details, go to VA's Corrections and Voids claim page.
When correcting information on 837 institutional claims, use bill type xx7, Replacement of Prior Claim or bill type xx8 to void a previous claim.
When correcting a paper CMS 1500 professional claim, use the following frequency codes in Box 22 and use left justified to enter the code. Include the 12-digit original claim number under the Original Reference Number in this box.
- Frequency code 7: Replacement of Prior Claim: Corrects a previously submitted claim.
- Frequency code 8: Void/Cancel of Prior Claim: Indicates this bill is an exact duplicate of an incorrect bill previously submitted. This code will void the original submitted claims.
Claim Reconsideration
Submit a claim reconsideration when you need to dispute the outcome of a claim previously submitted and processed. It is appropriate to submit a claim reconsideration when you believe the information originally submitted was complete and accurate (to your knowledge), but you disagree with the claim determination and are requesting a secondary review.
If you are submitting additional or different information that was NOT included in the original claim submission which resulted in a denial or payment discrepancy, please DO NOT submit a Claim Reconsideration Request. Any changes to a previously submitted and or processed claims should be filed through the corrected claims process (See above).
How to File a Claim Reconsideration
Submit claims reconsiderations electronically by completing the online Provider Claims Reconsideration Form.
The easy online form enables secure and efficient claims reconsideration submissions, eliminating the added tasks of printing and mailing the forms, saving you time and money!
The form can also be submitted by mail. Download and fill out TriWest’s Provider Claims Reconsideration Form, and mail it and all supporting documentation to:
TriWest CCN Claims
P.O. Box 42270
Phoenix, AZ 85080-2270
As a reminder, you must submit separate Reconsideration requests for each disputed item.
Claim Status Check
Providers can check the status of claims through Availity. The tool gives providers a more intuitive and robust workflow to check the claim status of Veteran patients. Login to Availity and then click on the Claims & Payments option located on the top-left corner of the main screen. Under Claims & Payments, select the Claim Status option. The Claim Status tool allows providers to check the status of a submitted claim and view remittances.
Providers can also search claims by:
- Member ID
- Tax ID Service date
- Claim number
If a claim cannot be found, there may have been errors with the submission. If a claim is visible, it is in process. Please do not resubmit for in-process claims.
For missing claims, please verify that:
- It has been at least 10 business days since you uploaded the claim or 15 business days since the provider mailed the claim.
- A paper claim was not handwritten and all information was typed correctly.
If you have problems checking your claims status, visit Availity to use the secure "Chat with TriWest" feature, or call TriWest Claims Customer Service at 877-CCN-TRIW (877-226-8749) from 8 a.m. to 6 p.m. in your time zone.
Automatically Receive Claims Status Reports
TriWest offers the option 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.
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.)
- Submit.
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.
Claims Processing Time
TriWest strives to pay all clean claims within 30 days.
Due to its contract status, TriWest is exempt from penalties associated with Medicare's prompt payment requirements. If a claim shows as paid, but the provider has not received a remittance, please contact TriWest CCN Customer Service at 877-CCN-TRIW (877-226-8749) so that TriWest can verify the accuracy of the remit address in our system.
Notification of denial is provided within 45 days of receipt of the claim in TriWest systems.
Signature on File Requirements
As a requirement of participation in CCN, network providers need to have a Signature on File for any Veteran who will receive care. Similar to standard insurance policies, the Signature on File will indicate that the provider is authorized to submit a claim on behalf of the Veteran, and authorizes payment of medical benefits to the provider.
Returns and Recoupments of Claims
When TriWest or PGBA identifies an overpayment, a recoupment is initiated. A letter is sent to the provider’s office with information regarding the reason for recoupment.
If a provider promptly returns funds, the recoupment case is closed. For an overpayment balance, PGBA offsets against current and future claims. The Provider Remittance Advice (PRA) will detail these amounts. For overpayments owed to TriWest, send monies to:
TriWest VA CCN Finance
Attention: Refunds
PO Box 108852
Florence, SC 29502-8852
Please include the refund control number (RCN) on the check or money order and the enclosed payment stub with the remittance to ensure proper credit to your account.
To ensure refund credit to the correct claim, include a copy of the remittance advice. If the remittance advice is not available, include the claim number and the Veteran’s EDIPI number or the last four digits of the SSN and the Veteran’s date of birth.
Claims for Out-of-Network Providers
TriWest can reimburse certain out-of-network providers under CCN for services provided under a CCN-approved referral. The only out-of-network providers who are eligible for this type of reimbursement are:
- Ancillary providers when services are provided as an adjunct to medical or surgical services provided by in-network providers; and
- Out-of-network facilities, at which the services provided, are performed by an in-network physician performing scheduled, non-emergent care.
Ancillary providers are defined as those providers who perform diagnostic or therapeutic services as an adjunct to basic medical or surgical services such as facility-based physicians, assistant surgeons, anesthesiologists, specialty physicians, radiologists, pathologists, and emergency care physicians.
Out-Of-Network Billing
Providers should always include the original VA referral number from the approved referral/authorization when billing TriWest.
If out-of-network providers do not know the original referral/authorization number, they should contact the CCN provider who received the approved referral/authorization to acquire it.
Out-of-network providers must submit health care claims directly to TriWest by billing PGBA, TriWest’s claims processor. Medical documentation related to care should be submitted to VA, preferably through HSRM, VA’s secure, web-based system used to generate and submit referrals and authorizations to community providers.
Under CCN regulations, payment from TriWest is considered payment in full from VA, and out-of-network providers are never allowed to balance bill a Veteran. The scope of care provided to a Veteran by an out-of-network provider must be included on an approved CCN referral/authorization.
CCN Provider - Agency Agreement With A Third Party Billing Entity
Occasionally, a CCN provider may enter into an agency agreement with a third party to act on its behalf in the submission and the monitoring of CCN claims. Such arrangements are permissible as long as the third party is not acting simply as a collection agency. There must be an agency relationship established in which the agent is reimbursed for the submission and monitoring of claims, but the claim remains that of the provider and the proceeds of any CCN payments are paid to the CCN provider. TriWest may interact with these agents in much the same manner as TriWest interacts with the provider’s accounts receivable department. However, such an entity is not the provider of care and cannot act on behalf of the provider in the filing of an appeal unless specifically designated as the appealing party’s representative in the individual case under appeal. The provider is the party directly contracted with TriWest and cannot assign any rights and responsibilities to a third party unless TriWest agrees pursuant to the terms of the provider’s agreement with TriWest. As such, under the provider’s agreement, any third party billing entity or its legal counsel are not a contracted party and may not pursue direct legal action against TriWest.