Veterans Choice Program
<p><strong><strong><sup>PROVIDERS</sup></strong><br /> COVERED SERVICES, CLAIMS AND ADMINISTRATORS</strong><br /> Third Party Administrator claim requirements</p> VeteransProviders

PROVIDERS
COVERED SERVICES, CLAIMS AND ADMINISTRATORS

Third Party Administrator claim requirements

Covered services, claims & Administrators

Claims
Providers must submit claims for authorized services on behalf of veterans. Health Net and TriWest require that “clean claims” (claims compliant with billing guidelines and additional TPA requirements) be submitted:

  • Within 30 days after rendering services
  • Via HIPAA-compliant Electronic Data Interchange (“EDI”) transaction sets through a clearinghouse

Medical documentation as set forth by TPA requirements must be submitted.

Before submitting a claim, participating providers must be aware that veterans, VA, or the TPA are not to be billed for:

  • No-show, missed, or cancelled appointments
  • Rendered care not included on the authorization form
  • Claims submitted beyond the required time frame for filing (120 days post service).
  • Claims received without the proper medical documentation

VA established the Community Care Call Center to assist community care medical providers with delayed payments. Providers experiencing problems can call the center at 1-877-881-7618 for assistance.

Third party administrators
Health net federal services
  • Health Net partners with the Department of Defense TRICARE Program to provide healthcare to active duty and retired service men and women and their families
  • Health Net also contracts care for veterans through the VAPC3 and the VACAA Veterans Choice Program
  • Providers will submit claims for authorized services on behalf of veterans and use best efforts to submit clean claims within 30 days after services have been rendered
  • Electronic data interchange claim submissions through Change Healthcare (formerly Emdeon) are accepted and encouraged
    • Payer Name: Health Net – VA Patient-Centered Community Care Program
    • Payer ID: 68021
  • Veterans with private health insurance are still eligible for Veterans Choice Program coverage. Non-service-connected claims must be filed with the other health insurance (OHI) carrier before submitting claims to Health Net with the Explanation of Benefits (EOB) from the primary payer for payment determination. It is appropriate to collect a copayment from the veteran for the OHI, if applicable. Service-connected claims must be sent to Health Net and should not be submitted to the OHI
  • Veterans Choice Program does not coordinate benefits with other government programs such as Medicare, Medicaid and TRICARE


Health Net Claim Submissions:
  • Electronic Claim Submissions: Health Net’s Veterans Choice Program accepts Electronic Data Interchange (EDI) claim submissions through Change Healthcare (formerly Emdeon)
  • To Register, visit https://changehealthcare.com/solutions/providers
  • Paper Claim Submissions must be mailed to:

Veterans Choice Program - VACAA
P.O. Box 2748
Virginia Beach, VA 23450

Triwest healthcare alliance
  • TriWest formerly provided healthcare benefits for active duty Service members, retirees and their families under the Department of Defense TRICARE Program
  • While no longer administering the TRICARE Program, TriWest contracts care for veterans through the VA Patient Centered Community Care program (PC3) and the VACAA Veterans Choice Program
  • The U.S. Department of Veterans Affairs Patient-Centered Community Care (PC3) plan operates separately from the Veterans Choice Program. To understand the similarities and differences, download this provider fact sheet
  • Providers will submit claims for authorized services on behalf of veterans and use best efforts to submit clean claims within 30 days after services have been rendered
  • Claims should be submitted electronically on a CMS1500 or UBO4 claim form
  • When TriWest is the payer, providers are not responsible for collecting copayments or other out-of-pocket costs from veterans. TriWest reimbursement is for the entirety of the allowable fee
  • Veterans with private health insurance are still eligible for Veterans Choice Program coverage. If the veteran has private health insurance and is receiving care for non-service-related conditions, providers must first bill the veteran’s other health insurance before billing TriWest. Explanation of benefits must be submitted to TriWest when other health insurance is utilized
  • TriWest will make every effort to let providers know when billing private insurance is required. In all other instances, TriWest will reimburse providers for authorized care at the allowable rate. Veterans Choice Program does not coordinate benefits with other government programs such as Medicare, Medicaid and TRICARE
  • For claims questions, call 1-855-722-2838
TriWest Claim Submissions:
  • Electronic Claim Submissions: TriWest accepts EDI claim submission through WPS - phone: 1-800-782-2680
  • To Register, visit http://www.wpsic.com/edi, email EDI@wpsic.com, or call 1-800-782-2680
  • Paper Claim Submissions must be mailed to:

WPS-VAPC3
P.O. Box 7926
Madison, WI 53707-7926