Q/A: I Submitted a Claim to the VA and it’s Being Denied. Why?

April 1st, 2019 - Wyn Staheli, Director of Research
Categories:   CPT® Coding   Modifiers   Chiropractic   Reimbursement  
0 Votes - Sign in to vote or comment.

Question

I submitted a claim to the VA and it’s being denied. Why?

Answer

There are several reasons why your claim might be denied by the Veterans Administration (VA). However, without more information about the claim itself (e.g., services billed), we can only provide the following general information about the VA and chiropractic care.

Although the VA has expanded care options for veterans, like all payers, they do have policies that need to be followed. Unless you are contracted directly with the VA, you are most likely billing through their Patient-Centered Community Care Program (PC3) or the Veterans Choice Program (VCP). The information presented here relates to these programs.

The following are some key points to evaluate when deciding why the claim has been denied:

  • Do you have a referral? According to the ACA, a referral from a VA primary care or specialty provider is a requirement prior to rendering care.
  • Are you contracted with the associated payer? This varies depending on the region and/or plan. For example, for PC3, you will need to have a contract with TriWest.
  • Did you obtain an authorization for these services? An authorization is not necessarily the same thing as a referral. Check with the provider relations department to determine their requirements. Although the first visit does not need to be authorized under the Choice Program, you will need to obtain an authorization number for subsequent visits which would need to be entered on Item Number 23 of the 1500 Claim Form.
  • Did you include the proper modifiers? For example, CMT services need the AT modifier to identify active treatment. Physical therapy services (e.g., 97014) need the GP modifier and modifier 59, where applicable, to indicate a separate region. If a separate E/M visit took place, you will need to add modifier 25 to the E/M code.

If you have all of the previous items in order, it may be necessary to contact the provider relations department of the applicable program to address specific questions.

Correction Notice 2019-04-01: While technically you may treat the patient with one visit under the Choice Program, additional visits must be authorized through TriWest. To clarify the policy, the paragraph relating to authorizations was revised to state that subsequent visits must have an authorization number.

Also, as of September 30, 2018, HealthNet no longer has a contract with the VA so they were removed from the bullet about contracts.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

2023 ICD-10-CM Code Changes
October 6th, 2022 - Christine Woolstenhulme, CPC, CMRS, QCC, QMCS
In 2022 there were 159 new codes; the 2023 ICD-10-CM code update includes 1,176 new, 28 revised, and 287 deleted codes, a substantial change from last year. The 2023 ICD-10-CM codes are to be used for discharges from October 1, 2022 through September 30, 2023, and for patient encounters from ...
Emergency Department - APC Reimbursement Method
September 15th, 2022 - Christine Woolstenhulme, CPC, CMRS, QCC, QMCS
CMS pays emergency department visits through a payment method using Ambulatory Payment Classifications (APCs). Most payers also use the APC reimbursement system; however, there may be some differences in payer policies (always review your specific payer policy). APCs are the primary type of payment made under the OPPS, comprising groupings ...
Why Medical Coding and Billing Software Desperately Needs AI
September 7th, 2022 - Find-A-Code
It has been said that the healthcare industry is notoriously slow in terms of technology adoption. One need only look at how convoluted medical coding and billing are to know that it needs a technology injection. Specifically, medical coding and billing software desperately needs artificial intelligence (AI).
CMS says Less Paperwork for DME Suppliers after Jan 2023!
August 18th, 2022 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Attention providers, suppliers, billers, and vendors who bill Durable Medical Equipment (DME) to Medicare!  Currently, a supplier receives a signed Certificate of Medical Necessity (CMN) from the treating physician or creates and signs a DME Information Form (DIFs); these are required to be sent with the claim. However, this is about ...
Things to Consider Before Upgrading Medical Billing Software
August 11th, 2022 - Find-A-Code
Your practice has utilized the same medical billing software for years. The medical billing staff says it is time for a change. You don't necessarily disagree, but you also don't know where to begin your search for new software. There are so many vendors offering so many products that making sense of it all can be challenging.
Calendar Year 2023 Medicare Advantage and Part C & D Payment Policies
August 9th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Each year CMS publishes an Advance Notice of the upcoming years Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies and asks for comments related to it. Each of the comments are carefully reviewed and responded to and often are impactful to changes seen between the Advance Notice and final publication referred to as the Rate Announcement. With health equity as a primary focus for 2023, CMS announced some policy changes that may impact your organization.
How CMS Determines Which Telehealth Services are Risk Adjustable
August 9th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Medicare Advantage Organizations (MAOs) have gone back and forth on whether or not to use data collected from telehealth, virtual Care, and telephone (audio-only) encounters with Medicare beneficiaries for risk adjustment reporting, but the following published documents from CMS cleared that up once and for all by providing an answer to a question specifically related to this question.



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2022 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association