Triwest healthcare alliance provider claims reconsideration form

Requires the 17 alpha-numeric internal control number (ICN) [format: 10 digits + "V" + 6 digits] or 9-digit social security number (SSN) with no special characters.

ICD 10 codes must be used for DOS after 09/30/2015.

Requires the 17 alpha-numeric internal control number (ICN) [format: 10 digits + "V" + 6 digits] or 9-digit social security number (SSN) with no special characters.

ICD 10 codes must be used for DOS after 09/30/2015.

Duplicate claim – Previously processed

Our payment system determined that this claim is an exact match of a claim that we previously processed. Our claim number for the duplicate claim should be shown in the comment at the bottom of our explanation of benefits (EOB). If you do not believe that this is correct, you will need to contact the Customer Call Center and speak to a customer service representative to resolve this issue.

IMPORTANT NOTE: Do not resubmit this claim without contacting us as it will only result in another denial.

EOB from other insurance required – VHA OCC secondary payer

We need to see the explanation of benefits (EOB) generated by the primary health plan before we can process this request. Our files indicate the patient is enrolled in a health insurance plan that, by law, must process this request prior to the VHA OCC program. Please resubmit this request with the EOB from the primary plan and include a copy of the VHA OCC EOB, or have the patient contact us to update their other health insurance (OHI) status. We can accept OHI updates through the Customer Call Center.

Claim not timely filed. (See applicable VHA OCC program guide.)

A beneficiary or health care provider must file claims for current treatment within 365 days from the date of service. Upon initial enrollment into the plan, we grant a 180‑day grace period for the enrollee to file any applicable claims that were more than 365 days old. Based on the date this claim arrived at our mail room, it did not meet these requirements. You may submit a written appeal if you were unable to file the claims due to exceptional circumstances. Send your written appeal to:

VHA Office of Community Care
ATTN: Appeals
PO Box 460948
Denver, CO 80246

VHA OCC Program Guides

NOTE: Do not send your written appeal to the claims processing address as this will only delay your appeal.

Multiple primary insurance coverage. Please resubmit EOBs from each payer.

A secondary review in our claims payment area determined that this claim or service is an exact match of a claim or service we previously processed. If this is an exact match of a previous claim, the matching VHA OCC claim number will be shown in the comments at the end of the explanation of benefits (EOB). If you do not believe this is correct, you will need to contact the Customer Call Center and speak to a customer service representative to resolve this issue.

IMPORTANT NOTE: Do not resubmit this claim without contacting us as it will only result in another denial.

Claim denied – Chiropractic services not covered.

If you do not believe this is correct, you will need to contact the Customer Call Center and speak to a customer service representative to resolve this issue.

IMPORTANT NOTE: Do not resubmit this claim without contacting us as it will only result in another denial.

Beneficiary not eligible on date of service claimed.

This claim is for a date of service or period of hospitalization that is not covered under the VHA OCC health benefits plan. Please consult the period of eligibility listed on the member card and check the date of service, or period of admission, in your records. If the bill was submitted with an incorrect date, please send a corrected bill. If the service or admission date is correct, then we cannot pay the claim since the patient was not covered by our plan at that time.

Must provide medical history/documentation to support treatment.

Please resubmit the claim for reconsideration, and include a copy of the VHA OCC explanation of benefits (EOB) form. If you have questions, please contact the Customer Call Center.

Clarification of OHI information required. Certification sent to beneficiary.

We do not have an Other Health Insurance (OHI) Certification on file for the patient/beneficiary. We cannot process any claims until we know if the individual is covered by another health plan. Even if the individual has no OHI coverage, we still need them to attest to this fact. Please submit a CHAMPVA OHI Certificate, VA Form 10-7959c, or call the Customer Service Center and a customer service representative can help complete the certification over the phone.

CHAMPVA OHI Certificate, VA Form 10-7959c

Not a covered service and/or benefit for diagnosis listed.

Some services/procedures are only covered for specific conditions as outlined in the applicable VHA OCC policy manual. Services which do meet these conditions will be denied. You can access all VHA OCC policy manuals from our Publications page. There is a search function within each policy manual to help you to quickly locate the section of our policy that covers this request.

VHA OCC Publications

ICD diagnostic code(s) missing/unreadable/invalid. Resubmit with EOB form.

A diagnosis is required to determine if the service denied on this claim is covered under the applicable VHA OCC health benefits program. We were unable to pay this claim due to a missing/unreadable/or invalid ICD code. Please check the accuracy and readability of the claim and resubmit it with a copy of the VHA OCC Explanation of Benefits form for reconsideration.