May 2025 Provider Pulse

Navigating the Pharmacy Process with Ease

TriWest has developed a Pharmacy Process Quick Reference Guide to outline key steps for providers when coordinating pharmacy services through VA’s Community Care Network (CCN), and ensure Veterans receive timely access to prescribed medications.

In this guide you will find instructions for submitting prescriptions, authorization guidelines, and tips for avoiding delays in medication fulfillment.

If the Veteran needs a medication that is not on VA’s National Formulary (i.e., non-formulary or prior authorization required), take these steps before prescribing:

• Use the VA Formulary Search Tool to identify formulary alternatives to non-formulary drugs in the same VA drug class.
• If unable to identify a formulary alternative or if prior authorization is required, contact the VAMC listed on the referral and ask for a Formulary Request Review Form.
• Complete the form, including justification or required medical records, and return it to the VAMC immediately.
• VA will either approve or deny your request.
• If approved, continue prescribing the medication as described above.

By following this outlined process, providers can ensure Veterans receive their medications without obstacles or delays. For more information, see the Pharmacy Process Quick Reference Guide.

Need to Submit a Veteran Patient’s Medical Documentation? Here’s How

As required under the Department of Veterans Affairs (VA) Community Care Network (CCN), providers must provide copies of medical documentation to a Veteran if it is requested.

As a reminder, providers must submit medical documentation to VA to ensure continuity of care and correct claims processing after delivering authorized care. It is preferred that documentation be submitted within 30 days of rendered care.

Medical documentation can be submitted in any of the following ways:

• Submit through HealthShare Referral Manager (HSRM).
• E-Fax: Contact your local VAMC for fax number.

For more information, visit VA’s review medical records online web page.

Qualifications for the High Performing Provider Designation

VA CCN providers who excel in a set of standard health care evaluation metrics are designated as High Performing Providers (HPP). The HPP designation is one, but not the only, measure of provider practice quality.

Provider performance is analyzed and monitored against a standard set of quality metrics determined by TriWest, including clinical outcomes, patient satisfaction, cost-effectiveness, and adherence to established guidelines. Providers can achieve the HPP designation by consistently meeting or exceeding measures of performance expected under the guidelines set forth by Blue Health Intelligence and Centers for Medicare and Medicaid Services (CMS).

VA staff consider the HPP designation during the Veteran appointment scheduling process to help Veterans select a community provider to meet their needs.

Scoring and Eligibility

VA’s HPP designation applies to individual practitioners, practitioners in a group setting, and institutional providers, such as hospitals. The three types of providers are scored differently:

• Individual providers are evaluated based on Primary Care and Specialty Measures from Blue Health Intelligence.
• Provider practice groups are scored as a single entity, and providers in those groups are assigned the score of the overall group.
• Institutional providers are scored on a selection of CMS measures from the Hospital Compare system.

HPP only applies to a certain subset of specialties, so not all providers are eligible for the designation. There is no action on the part of providers. The HPP designation is informative and not an endorsement or a guarantee of a provider’s ability to provide health care services. Contact us to learn more about HPP eligibility.

Resources

A summary of your specific provider metric results is available on request by completing the HPP Inquiry Form on the TriWest Payer Space on Availity.

For more information on the HPP designation, please review the HPP Quick Reference Guide and CCN Provider Handbook. Providers should send the completed HPP Inquiry Form to CQHPP@TriWest.com.

Learn More about Available Mental Health Resources for Veterans

May is Mental Health Awareness Month, and VA has a variety of mental health resources, information, treatment options, and more. All options are accessible to Veterans, their supporters, and the public.

A mobile application was also developed to allow Veterans to take a variety of mental health assessments from the comfort of their home.

VA CCN Provider Handbook Updates

There are currently no updates to the CCN Provider Handbook.