FAQs

Credentialing timelines vary by TPA and region, but most agencies can expect:

• 30–90 days for application review and approval
• Delays if documentation is incomplete, especially licensure or ownership details
• Longer timeframes for multi-state agencies or those new to Medicaid

Yes. You must:

• Be licensed in every state you plan to provide services
• Register with the correct TPA based on CCN region (Optum = Regions 1–3, TriWest = Regions 4–5)
• Update your profile if you expand your service area

No. You must be:

• Contracted and credentialed with the appropriate TPA
• Authorized for services before care begins. Otherwise, you risk non-payment and compliance violations.

These are typically HCPCS codes:

• S5125 – Personal care, per 15 minutes
• S5130/S5131 – Respite care, hourly or daily
• T1005 – Respite for short-term relief under some waiver programs

Always refer to your authorization for approved codes, units, and modifiers.

Most clean claims are paid within 14–30 days if submitted electronically via Optum or TriWest portals.

Delays may occur due to:

• Authorization mismatches
• Missing documentation
• Eligibility lapses or incorrect patient data

You may resubmit or appeal if:

• Timely filing deadlines are met (usually 180 days)
• Denial reasons are corrected (e.g., code errors, expired auth)
• Supporting documentation is added (e.g., care notes, VA referral)

Referrals are generated by VA physicians or case managers, often through a consult process. Agencies do not initiate referrals, but may request the VA to issue or renew one when clinically appropriate

Log in to your TPA portal (Optum or TriWest) and confirm the authorization includes:

• HCPCS codes
• Units/hours approved
• Start/end dates
• If unclear, contact the VA case manager or TPA provider support line

A referral is not sufficient for billing. Always confirm:

• A formal authorization is attached
• Services match the scope and units listed If unsure - pause services and escalate to the VA or TPA before proceeding.

For each VA client:

• Signed Plan of Care
• Progress notes per visit
• Caregiver timesheets or EVV data
• RN supervision logs (if required)
• Valid authorization documents
• Proof of eligibility
• Signed referral from the VA (if available)

Prepare by:

• Verifying all documentation is complete, legible, and date-aligned
• Reviewing claim history for the audit period
• Assigning an internal point person to handle all VA/TPA communication

Audits may be on-site or remote. Keep documents organized digitally for easy submission.

1. 1
   Contact the VA case manager by phone or secure email
2. 2
   Clearly explain the Veteran’s clinical need, care gap, or risk
3. 3
   Provide supporting documents (physician orders, discharge summaries, etc.)
4. 4
   If unresponsive, escalate through the TPA regional contact or VA Community Care Office

• Communicate respectfully and provide clinical rationale for the change
• Offer alternatives that still fall within the approved scope of service
• Document all communication attempts and responses

Remember: VA case managers balance budget constraints, Veteran safety, and system compliance. Clarity and professionalism go a long way.