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$: Confidential and Proprietary - TriWest Healthcare Alliance PROCEDURES VA Veterans Choice Program and Patient-Centered Community Care \ Confidential and Proprietary 2 Communication$
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BILLING PROCEDURES VA Veterans Choice Program and Patient-Centered Community Care

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Confidential and Proprietary

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Communication VCP and PC3 Billing Procedures - Webinar

Questions? Just ask! Use the Q&A pod to your right to

submit questions so we don’t miss them!


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Presentation Outline

Background, Need, Program Overview Appointment Scheduling & Authorization Overview Differences Between VA, TRICARE, Medicare, & Medicaid Provider Claims and Medical Documentation Provider Resources Provider Portal Demo

VCP and PC3 Billing Procedures - Webinar

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Presentation Notes

This presentation will describe the VAPC3 program and TriWest processes. The topics included in this discussion are: An overview of VAPC3 Program VAPC3 requirements and standards, Health Care Management, Provider Claims Choice program Requirements and Standards, and Provider resources


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TriWest Provider Portal

The TriWest Provider Portal is your one-stop shop for information on filing claims and navigating the Department of Veterans Affairs (VA) programs outlined in this training www.triwest.com/provider


http://www.triwest.com/provider


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Background

Department of Veterans Affairs (VA) needed to expand health care access for Veterans in communities across the nation VA awarded TriWest the Patient-Centered Community Care (PC3) contract in 2013 In 2014, Congress introduced and President Obama signed into law the Veterans Access, Choice and Accountability Act Section 101 established the Veterans Choice Program (VCP) and went live on Nov. 5, 2014



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Background – Regions VCP and PC3 Billing Procedures - Webinar Health Net Regions

Health Net Federal Services, Inc. HealthNetFederalServices.com

TriWest Regions 3,5,6 TriWest Healthcare Alliance

1-855-PCCCVET (855)-722-2838

www.triwest.com/provider

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Regions�Administration of the VAPC3 program in the United States is divided into 6 regions, which has been awarded to 2 contractors. TriWest has been awarded regions 3, 5, and 6 to administer the VAPC3 program and HealthNet Federal Services has been awarded regions 1, 2 and 4. The states within the TriWest regions include: In region three – Alabama (southern portion) Arkansas, Florida (western portion), Illinois (southern portion), Indiana (southern portion), Kansas, Kentucky, Louisiana, Missouri, Mississippi, Oklahoma, Tennessee, Texas, Virginia (western portion), and West Virginia In region five – Arizona, California, Colorado (southern portion), Hawaii, Idaho, Nevada, New Mexico, Oregon, Texas (western portion), Washington and the territories of American Samoa, Guam, and the Northern Mariana Islands. In region six – the state of Alaska .

http://www.triwest.com/VAPCCC/provider


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Veterans Choice Program (VCP)

The Veterans Choice Program (VCP) is the newest addition to VA’s Patient-Centered Community Care (PC3) program VCP provides eligible Veterans with community access to primary care, inpatient and outpatient specialty services, and behavioral health care VCP is Veteran-driven All Veterans enrolled for care with VA as of Aug. 1, 2014 received a Choice Card


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*** On August 7, 2014, President Obama signed into law the Veterans Access, Choice and Accountability Act of 2014 (Public Law 113-146) (“Choice Act”). *** ***Beginning November 5, 2014, the new Choice Program began to cover non-VA care for eligible Veterans enrolled in VA healthcare.***


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Veterans Choice Program (cont.)

Veterans’ eligibility to use their Choice Card in the private sector is determined by VA using the following criteria:

The closest VA Medical Center (VAMC) or Community-Based Outpatient Clinic (CBOC) with a full time PCM is greater than 40 miles from their home; or They are, or will be, on a wait list of 30 days or more with a VAMC The closest VA medical facility is not easily accessible from their home, due to geographic barriers, or does not offer the necessary services



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Veterans Choice Program (cont.)

When a Veteran needs to make an appointment, refer them to the number on the back of their Choice Card. If you would like to schedule an appointment on their behalf, call TriWest to make the appointment: 1-866-606-8198.


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*** Please note- The use of the card is strictly voluntary- a choice. In addition, any veteran currently using VA’s health care system will retain that eligibility even if he or she uses the Choice Card to obtain care in the community. ***


Appointment and Authorization Overview

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VA sends referral to

TriWest (PC3 or VCP, 30 day

wait list for Choice First)

PSR locates VCP/PC3 provider

PSR makes appointment on behalf of

Veteran

TriWest sends authorization

to provider via fax

Appointment Scheduling & Authorization

Veteran calls TriWest to

confirm VCP eligibility

OR

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Presentation Notes

When TriWest receives an authorization from a VA Medical Center (VAMC) for services for a Veteran, a TriWest Patient Service Representative (PSR) will locate a network provider within the VA Access to Care standards. The PSR will complete a three-way conference call with the Veteran and Provider to coordinate scheduling the appointment. The appointment will be scheduled so that it will take place within 20 business days of TriWest’s receipt of the approved authorization from the VA ,unless a desired appointment date is otherwise noted during the scheduling process with the Veteran. It is also expected that the Veteran will be seen within 20 minutes of scheduled appointment time. The PSR will give both the Veteran and the Provider the authorization number. If TriWest is unable to make contact with the Veteran to coordinate the appointment, TriWest has the authority to make the appointment on behalf of the Veteran and will notify the Veteran of the appointment via letter within 5 days of receipt of VAMC authorization. The authorization is available to the Provider on TriWest’s secure portal.


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To avoid claims denials, all care requires an authorization from TriWest before services are rendered If a provider renders care without an authorization, he/she risks losing reimbursement Providers CANNOT balance-bill Veterans or charge for no-shows


Appointment Scheduling & Authorization (cont.)


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Labs, X-rays, Ancillary Providers

Routine labs and X-rays are included in TriWest authorizations For surgeries, anesthesiology services are also included in authorizations Include the authorization number with your order form for the labs, X-rays, or anesthesiologist Instruct the ancillary provider to include the authorization number on its claim when billing TriWest

Introduction to VCP and PC3 – Webinar


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Labs, X-rays, Ancillary Providers (cont.)

If you’re an ancillary provider and receive an order to treat a Veteran using his/her VA community benefits:

The order should include the authorization number If you’re not sure, call the prescribing provider’s office to confirm, and obtain an authorization number Bill TriWest for your services and include the authorization number on your claim

Introduction to VCP and PC3 – Webinar


VA, TRICARE, Medicare, Medicaid


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Definition – VA

VA – Veterans (Prior Military Service) Covers those who once served in the military, but have now either separated or retired and are no longer active duty Benefits fall under the Department of Veterans Affairs (VA) Different than the Department of Defense TriWest only administers VA community programs



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Definition – TRICARE

TRICARE – Active Duty Service Members, National Guard/Reserve, and Their Families

Covers those who are currently serving in the U.S. Armed Forces, and their families Military retirees are also TRICARE eligible (dual eligible) Program falls under the Department of Defense Receives funding through the defense budget Never bill TRICARE for a Veteran with a TriWest authorization



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Definition – Medicare

Medicare – Civilians Ages 65 Years and Older or Disabled

Federal health care benefit available to U.S. civilians ages 65 and older Veterans may have both Medicare and VA benefits If you have an authorization from TriWest, always bill TriWest – not Medicare



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Definition – Medicaid

Medicaid – Medical Insurance for Financially Disadvantaged

Federal health care program for individuals living at or under the poverty line Threshold for eligibility varies from state to state Veterans may have Medicaid and VA benefits If you have an authorization from TriWest, always bill TriWest – not Medicaid



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TriWest and VA

TriWest does not contract with TRICARE, Medicare, or Medicaid programs TriWest authorizations apply to Veterans only (not TRICARE) When you see a TriWest authorization, think “VA”



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TriWest and VA (cont.)

Never bill TRICARE for services provided to a Veteran with a TriWest authorization Claims may be denied Always bill TriWest for Veterans with a TriWest authorization

Don’t bill Medicare Don’t bill Medicaid



Claims and Medical Documentation

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Claims Submission Process

Step 1 – Submit medical documentation to TriWest Upload to Provider Portal at www.triwest.com/provider

Documents up to 5 MB can be uploaded in PDF or TIF format

Fax (if portal not available) to 1-866-259-0311 Step 2 – Submit claims to Wisconsin Physicians Service (WPS), TriWest’s claims processor

Electronic: call WPS at 1-800-782-2680 (Option 1) to set up EDI Mail: mail paper claims to:

WPS-VAPC3 PO Box 7926 Madison, WI 53707-7926




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Don’t Delay, Cut Paper Today!

Don’t delay, cut paper today! It’s as easy as E3:

EDI – submit claims electronically EFT – receive payment electronically ERA – receive remittance electronically

To go E3, visit https://CommunityManager.wpsic.com/tcm


https://communitymanager.wpsic.com/tcm

https://communitymanager.wpsic.com/tcm


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Benefits of Going ‘E3’ VCP and PC3 Billing Procedures - Webinar


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Claims Processing and Billing Information

Providers collect no copays, cost-shares, or deductibles from Veterans Providers will use best efforts to submit claims within 30 days after services rendered Medical documentation must be submitted to TriWest for provision to VA

Inpatient discharge summary within 30 days Summary of initial visit and summary of the episode of care after final visit

No payment will be made for claims submitted after 180 days


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Providers will submit claims for VAPC3 authorized services on behalf of VA beneficiaries and use best efforts to submit clean claims within 30 days after the provision of the services. Providers will submit health care claims via HIPAA-compliant Electronic Data Interchange (EDI) transaction sets through a clearinghouse within 120 days of the end of episode of care. Medical documentation must be submitted to TriWest in order for the claim to be reimbursed . No payment will be made for a claim submitted more than 120 days after the services are rendered, for services provided to Veterans that were not authorized by TriWest, or for services for Veterans for which required consult or medical reports have not been received by TriWest. **Reminder** Claims will not be paid until the medical documentation and /or applicable form(s) supporting the episode of care that the provider is billing for has been received by TriWest. A claim is not considered “complete or clean” claim until the appropriate medical documentation has been received. Reference: Medical documentation QRG and Provider Claims QRG


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Reimbursement

No payment will be made to providers for services rendered without a prior authorization from TriWest For more information, refer to the Provider Claims Quick Reference Guide located at www.triwest.com/provider


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In addition, provider understands that no payment may be made to provider for services rendered to Veterans which are not authorized by VA. For more information, please refer to the Provider Claims Quick Reference Guide located at www.triwest.com/provider.

http://www.triwest.com/vapccc/provider


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Provider Claims Status

You may check the status of your claims by registering for a secure account on the TriWest Provider Portal at www.triwest.com/provider


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Presentation Notes

To check the status of your claim, log in to the secure provider portal at www.triwest.com/provider

http://www.triwest.com/vapccc/provider


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Medical Documentation Requirements

Medical documentation must be submitted to TriWest for all services to ensure coordination of care for Veterans Submit medical documents before submitting claims VA requires Choice outpatient medical documentation include the initial appointment and end-of-episode-of-care records Inpatient discharge summary


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All services require authorization from TriWest for Veteran participating in the VAPC3 Program to prevent claim denials. Medical documentation is required for all services provided to a Veteran under the VAPC3 Program PRIOR to provider being reimbursed by TriWest for services rendered. There are specific specialties that require additional medical documentation to be submitted. This information will be covered in the following slides.


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Medical Documentation Requirements (cont.)

Outpatient care: VCP: submit to TriWest within 75 calendar days PC3: submit to TriWest within 14 calendar days

Inpatient care: Submit discharge summary to TriWest within 30 business days after discharge


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Medical documentation regarding an authorized episode of outpatient care must be submitted to TriWest within 14 calendar days after completion of an initial appointment. If additional appointments are conducted, medical documentation should be submitted to TriWest within 14 calendar days of each appointment. On occasion the authorization may request medical documentation be returned sooner than 14 calendar days based on clinical need. Communication of information by telephone may be required when results or clinical findings necessitate an urgent response. This will be followed up by submission of complete medical documentation within 14 calendar days.


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Urgent specialty care: VCP: submit to TriWest within 2 business days PC3: submit to TriWest within 48 hours Oral reports should be provided to VA POC within 48 hours when indicated on the authorization form

The authorization may request medical documentation be returned sooner based on clinical need


Medical Documentation Requirements (cont.)

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Medical documentation regarding an authorized episode of inpatient care will be submitted to TriWest within 30 business days after discharge. Medical documentation for urgent specialty care is required within 48 hours of the visit or sooner if clinically appropriate. Oral reports will be provided to VA within 48 hours when indicated on the authorization form.


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Provider Claims Appeal Process

Provider claim appeals should be submitted within 90 days of the date of the Explanation of Benefits (EOB) Written appeals can be sent to:

Mail WPS-VAPC3 PO Box 14491 Madison, WI 53708-0491


Quick reference guide available at www.triwest.com/provider

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Claims appeals should be submitted within 90 days of the date the EOB is received. Appeals can be submitted to: Fax x-xxx-xxx-xxxx [email protected] MailWisconsin Physician Services (WPS) For additional information reference the Quick Reference Guide for Provider Claims


Provider Resources


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TriWest Provider Portal

TriWest.com/provider: your one-stop shop for information on filing claims and navigating VCP and PC3

Provider handbook Quick reference guides eSeminars (training you can take at your own pace) Webinars (instructor-led online training) Additional resources and links to important information


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TriWest’s website provides you with access, at all times, to the information you need regarding the VAPC3 program. All Provider Education materials consisting of VAPC3 Provider Handbook, Quick Reference Guides, necessary forms, and Provider Newsletters are on the Provider Portal. In addition, eSeminars (educational session you can take at your own pace) and Webinars (instructor-led educational session) are available for you. For access to this material, go to www.triwest.com/VAPCCC/provider.

http://www.triwest.com/VAPCCC/provider


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TriWest Provider Portal (cont.)

Register for a secure account to: Upload medical documentation Check authorization status (including SARs) Print authorization information Check claims status

Visit www.triwest.com/provider and click “Register for Secure Access”


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Presentation Notes

Registering for the secure portal will give you access to important information you need including authorizations that contain pertinent information such as referral number, referral date range and authorized services. The portal gives you 24/7/365 access and eliminates the need for unnecessary administrative burdens. Additional functionality of the secured website includes checking authorization status, ability to print authorization information, attaching medical documentation, downloading required forms and checking claims status.



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Interactive Voice Response (IVR) System

Press “1” with authorization questions Press “2” for assistance with the Provider Portal Press “3” for claims questions Press “4” for provider contracting


1-855-PCCCVET (1-855-722-2838) Option #3

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Presentation Notes

TriWest offers an interactive voice response (IVR) system to assist providers with routine questions. Follow the greeting and select the applicable touch tone prompts to get quick information and accurate answers on many topics, such as authorization status and checking the status of claims: Press “1” with authorization questions Press “2” for assistance with the secure provider portal registration Press “3” for detail reimbursement questions Press “4” for provider contracting Remember to also use the website to quickly access pertinent information.

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Thank You!

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Presentation Notes

This completes your Introduction to VAPC3 Program. Thank you for taking the time today to participate in this training. If you are interested in additional provider education, TriWest has provided on demand 24/7/365 eSeminars located on the TriWest provider website at www/TriWest.com/VAPCCC/provider. You can also check this website for schedules of future webinars. [Note to presenter: After you have ended your session in Adobe Connect (Click on: Meeting>End Meeting), please check the Attendees List and verify that there are no remaining attendees appearing in the window. Then, you may close the Adobe Connect Program.]