Provider Pulse – April 2024
Last Day to Submit PC3 Claims with a Retroactive Referral is June 30
This is a notice to all providers that claims containing a retroactive referral filed under the Patient-Centered Community Care (PC3) program must be submitted on or before June 30, 2024.
TriWest Healthcare Alliance (TriWest) administers claims for the current Department of Veterans Affairs (VA) Community Care Network (CCN) 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 must be submitted by June 1, 2024, to be considered.
- All other PC3 claims requests, unrelated to Retroactive Referrals (adjustments, reconsiderations, recoupments, etc.) are no longer accepted due to program close-out.
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 section of the CCN Provider Handbook.
- Community care claims reconsideration requests must be submitted within 90 days from the original claim decision date. Please reference the Claims Reconsideration Request Form and its instructions.
Register Now for New VA CCN Chiropractic, Acupuncture and Massage Therapy Webinar
All Complementary & Integrative Healthcare Services (CIHS) providers in VA CCN are invited to take the new and improved webinar for a comprehensive review of chiropractic, acupuncture and massage therapy care.
New CIHS providers, and those who have taken a previous webinar on this topic, are encouraged to attend this updated training hosted by TriWest. Among the webinar topics that will be covered include:
- Referrals/Authorizations
- Request for Service (RFS)
- Reimbursement
- Claims
- Massage Therapy Requirements
- Medical Documentation
- Using VA’s HealthShare Referral Manager (HSRM) website
- Provider Resources
Register today by taking the following steps:
- Log in to your Availity account at availity.com.
- Navigate to the TriWest Payer Space.
- Click on the TriWest Learning Center.
- Register for live or on-demand training*.
* For help registering for training, see the TriWest Learning Center Quick Reference Guide.
Investigational Services Excluded from VA CCN Health Benefit Package
As a reminder, investigational services are not reimbursable for payment, and are excluded from the VA CCN Health Benefit Package. Services that are excluded by regulation (38 C.F.R. § 17.38(b)) or not permitted to be provided by TriWest’s contract with VA, cannot be paid under CCN.
Claims submitted for services that are not approved by the Food and Drug Administration (FDA), or that fall outside of a limited FDA-approved scope of application, will subsequently be denied.
For more information regarding covered and non-covered services, please refer to the Veteran Eligibility and Covered Services section of the CCN Provider Handbook. The CCN Provider Handbook contains an up-to-date list of services excluded from the CCN medical benefits package for Veterans.
VA Community Care Medical Policies now Clinical Determinations and Indications
VA recently renamed “Community Care Medical Policies” to “Clinical Determinations and Indications” (CDI). Veterans often have unique, service-connected conditions, so VA develops CDIs as a reference for community providers to use when determining whether a service is medically appropriate for a Veteran.
There are currently two published CDIs:
- Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (OSA)
- Tumor Treating Fields (TTF) Therapy
The following CDIs will be released in the coming months:
- Osseointegrated Prosthesis for the Rehabiliation of Amputees (OPRA)
- Thermal Evacuation and IPL Therapy for Meibomian Gland Dysfunction (MGD)
- Transurethral Waterjet Ablation for Beingn Prostatic Hyperplasia (BPH)
- Cataract Extraction and Intraocular Lenses
- Proton Beam Therapy
- Ultrasound Guided Radiofrequency Ablation (RFA) for Uterine Fibroids
CDIs are published regularly on the CDI library. Bookmark the page and check back often for updates.
VA CCN Provider Handbook Updates
There are currently no changes planned for the VA CCN Provider Handbook.