CHA News

VA to Reconsider Payments to Providers for Some Denied Claims

For CFOs, finance & reimbursement staff

This post has been archived and contains information that may be out of date.

The U.S. Department of Veterans Affairs (VA) and its third-party administrators, Optum and TriWest, will reconsider payments to providers whose claims were denied because of simple routing errors, including claims that were submitted to the wrong VA payer (VA or a TPA).

The original claim must have been filed with a VA payer on time, within 180 days of the date of service.

The provider must resubmit a reconsideration request to the correct VA payer within 180 days of the initial denial. A copy of the remittance advice from a claim that was submitted to a VA payer within 180 days of date of service satisfies this requirement.

Additionally, Optum and TriWest have the authority to process provider payment requests that were previously denied prior to this direction and over 180 days after the date of the remittance advice if the original claim was submitted on time. The 180 days from the date of the remittance advice was through Dec. 1, 2020.

Claims not submitted because of missing affiliation/network information on the VA referral are also eligible to be reconsidered if the claim is within 180 days of the date of the referral allocation. VA Medical Center staff will send the provider an offline referral created in Health Share Referral Manager (HSRM) to the community provider with the authorization number. The HSRM offline referral will also explain who to correctly bill.

In-network providers can view the authorization number and original received date in HSRM. Providers in Optum’s network can also find the original received date in the Optum Provider Portal.

For more information, visit VA’s “File a Claim for Veteran Care” web page or call the Community Care Contact Center at (877) 881-7618.