Veterans Choice Program
<p><strong><strong><sup>PROVIDERS</sup></strong><br /> MEDICAL DOCUMENTATION</strong><br /> Third Party Administrator requirements for medical documentation</p> VeteransProviders

PROVIDERS
MEDICAL DOCUMENTATION

Third Party Administrator requirements for medical documentation

Medical Documentation

Claims will be paid only after complete medical documentation set forth by TPA requirements is returned.

Health net federal services

To ensure continuity of care for veterans receiving services outside a VA medical facility, medical documentation from authorized visits must be returned to Health Net.

Return medical documentation within the time frame indicated in each individual provider packet.

Providers should refer to the below guidelines when submitting medical documentation:

  • Fax documentation to 1-855-300-1705
  • Refer to the Required Content of Medical Documentation Content checklist in your provider notification packet or visit Health Net’s website at www.hnfs.com for more details
  • Use the cover sheet with the barcode provided by Health Net to submit the medical documentation
  • Hand-write patient sex, date of birth and last four Social Security numbers on each sheet of medical documentation
  • Do not combine documentation for multiple authorizations
  • Do not submit claims with medical documentation

Minimum requirements for content of medical documentation, as applicable to the care, include:

  • A summary of the encounter to include any procedures performed and recommendations for further testing or follow-up (i.e. discharge summary for inpatient);
  • Results of community testing or imaging such as MRI, CT scan;
  • Actual results of any ancillary studies/procedures which would impact recommended follow-up such as biopsy results; and
  • Any recommended prescriptions and treatment plans

 

Triwest healthcare alliance

To ensure continuity of care for veterans receiving services outside a VA medical facility, medical documentation from authorized visits must be returned to TriWest. Providers must submit within the following time frames to avoid recoupment efforts:

  • Within 75 calendar days after the initial appointment for outpatient specialty services. If additional appointments are authorized, submit to TriWest within 75 days upon completion of episode of care (includes surgery)
  • Within 30 calendar days post-discharge for an authorized episode of inpatient care (includes surgery)

Minimum requirements for content of medical documentation, as applicable to the care, include:

  • An executive summary of the encounter to include any procedures performed and recommendations for further testing or follow-up (i.e. discharge summary for inpatient);
  • Results of community testing or imaging such as MRI, CT scan;
  • Actual results of any ancillary studies/procedures which would impact recommended follow-up such as biopsy results ( i.e. positive biopsy results from EoC GI provider who recommends a follow up such as surgery); and
  • Any recommended prescriptions and treatment plans

Medical documentation should be submitted to TriWest before submitting claims to Wisconsin Physicians Service (WPS), TriWest’s claims processor, and is necessary to retaining VA continuity of care. Providers may submit medical documentation to TriWest in one of the following manners: