VA and Third-Party Administrators to Consider Some Denied Claims for Payment

Posted on November 11, 2020 by Roni Falck

Some Minnesota providers have experienced issues with timely and approved VA payments and there may be some options available. VA and its third-party administrators (TPA), Optum and TriWest, will reconsider payment to providers who had a claim denied for simple routing errors.

Providers whose claims were denied because they were submitted to the wrong VA payer (VA or a TPA) are eligible for reconsideration if the original claim was 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.

Optum and TriWest also 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 is through Dec. 1, 2020.

In addition, 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. VAMC 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.