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  

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.

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