COVERED SERVICES, CLAIMS AND ADMINISTRATORS
Third Party Administrator claim requirements
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.