Hot Topics from the KMC University Helpdesk | October 30, 2020

VA claims that have been denied in error are eligible for reconsideration

As VA navigates contracts with Third-Party Administrators to handle VA claims, it appears some claims have been denied in error. Most are due to simple routing errors.

According to VA Provider Advisor newsletter, “ 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) ….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.”

What You Need to Do

Listed below are directions from the VA:

    • “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.”
    • If the denial is due to missing information on the referral, “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.”

Do not forget how handy the HSRM system can be for managing referrals and claim status. 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, 877-881-7618.

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