VA CCN July 2026 Provider Pulse

Stay Up to Date with VA Clinical Determinations and Indications

The Department of Veterans Affairs (VA) develops Clinical Determinations and Indications (CDIs) as a reference for community providers to use when determining whether a service may be considered medically necessary/covered for a Veteran. CDIs define clinical criteria and parameters to determine medical necessity to drive the most appropriate, evidence-based determinations for care.

All current CDIs are available online in the CDI Library. Bookmark this webpage and check back often for updates. To submit a question about a published CDI, please use the CDI Question Submission Form and follow the instructions located at the bottom of the CDI webpage.

The Clinical Determinations Unit (CDU) published one CDI last quarter:

For more information on CDIs, please check out the CDI Overview webinar on VHA TRAIN. If you have not already, you will need to create an account to access this webinar.

Help Shape the Future of Veteran Care: Join the VA IRIS Pilot

Strong care coordination between VA and community providers is one of the most important things we can do for the Veterans we serve together. When information moves quickly and securely between care teams, Veterans experience safer transitions, better treatment planning, and fewer gaps in care.

That's why we're excited to share a new opportunity from VA's Office of Suicide Prevention, Office of Mental Health, and VA Direct National team.

What Is IRIS?

The Improving Recovery via Information Sharing (IRIS) pilot is a new VA initiative designed to make real-time collaboration between VA and community providers easier. It uses Direct Messaging, a secure, HIPAA-compliant tool to exchange health information quickly, cut administrative burden, and strengthen treatment planning for Veterans.

Participating providers can expect to:

• Reduce delays in care coordination.
• Improve communication between VA and community teams.
• Support national priorities, including the Veterans' Access Act of 2025, the Elizabeth Dole Act, and the COMPACT Act.

How to Get Started

VA has started this project across three key areas: Big Spring, TX, Harlingen, TX, and Prescott, AZ. If you are located outside of these areas and have questions or would like to confirm your interest, please email VHAIRISPILOT@va.gov. If you are confirming your interest, please include your answers to these questions in your email to VA.

• Does your organization currently use Direct Messaging?
• Who is your Direct Health Information Service Provider (HISP)?
• What user interfaces do you use (e.g., web portal, EHR system)? Please include your EHR vendor name.
• What file types can you share via Direct Messaging (e.g., PDF, C-CDA)?
• Which use cases do you support or want to support (e.g., transitions of care, referrals, ADT notifications, provider messaging)?
• Would your organization be willing to conduct validation testing with VA? If so, please share a contact.
• Are you part of a parent company or strategic partnership with a shared EHR? If so, please identify it.

If you'd like a quick overview of Direct Messaging first, or have any questions, email TriWest Vice President of Integrated Health Strategies Keita Franklin at Kfranklin6@triwest.com.

Thank you for your continued partnership in delivering safer, more connected care for Veterans.

VA CCN Reminder: Proper Use of the JW Modifier

TriWest follows Centers for Medicare & Medicaid Services (CMS) guidelines for the JW modifier under VA CCN, which indicates the amount of a drug discarded from a single-use container and not administered to a patient. Please be reminded that providers must report the JW modifier on all drugs and biologicals claims separately payable under Medicare Part B. Providers and suppliers must also document the number of discarded drugs in patient medical records.

CMS requires providers to report the JZ modifier on all claims that bill for drugs from single-dose containers that are separately payable when there are no discarded amounts.

Billing Guidelines when Submitting JW and JZ Modifiers

The following serves to clarify billing guidelines and provide examples of proper billing with a single-dose vial and discarded drug billing:

• CMS requires the JZ modifier on all claims for single-dose containers where there are no discarded amounts.
• When submitting claims, units of service (UOS) should be reported in multiples of the dosage included in the long HCPCS code descriptor.
• If the provider must discard the remainder of a single-use vial or other package after administering the prescribed dosage of any given drug, the amount of the drug discarded along with the amount administered may be covered.
• Clearly document in the patient’s medical record the actual dose administered in addition to the exact amount wasted and the total amount the vial is labeled to contain.
• Discarded drugs must be reported with the JW modifier on a separate line. The total number of discarded units reported should not include amounts of the drug also included on the administered line due to the rounding up of units.
• Due to single-use vial type, the provider may bill for the amount administered as well as the amount appropriately discarded. The discarded amount is reported with the JW modifier. For more information see Chapter 17, Section 40 of the Medicare Claims Processing Manual.

Reimbursement for Claims Billed with JW and JZ Modifiers

When a provider must discard an amount of drug from a single-dose container after administering a dose, payment for the discarded amount will be provided, as well as the dose administered, up to the amount of the drug indicated on the vial or package labeling. The discarded amount is any amount that is not part of the prescribed dose and not intended for administration to the patient.

For more information see the Billing and Coding: JW and JZ Modifier Billing Guidelines, CMS’s JW Modifier and JZ Modifier Policy, and Noridian’s Drug Waste – JW and JZ Modifiers.

Telehealth – A Viable Option for Veterans Care in CCN

Telehealth for behavioral health care is a practical option for community care appointments under the VA CCN for both initial and follow-up appointments as appropriate for the referred condition. It can be used as needed along with face-to-face care where some physical evaluation or procedures are required.

TriWest Healthcare Alliance (TriWest) has captured which providers have telehealth capabilities in appointing systems to quickly identify and appoint to these providers if a Veteran prefers a telehealth appointment.

Here are some important details regarding telehealth and CCN:

• Telehealth services are provided through CCN utilizing current Medicare guidelines.
• TriWest pays the providers’ claims for telehealth services if there is an authorization on file (except for urgent care where no authorization is required), the scope of services is appropriate for a telehealth visit (no physical procedures are billed that would require face-to-face delivery of care), and the claim is consistent with Medicare guidance for place of service and modifiers.
• CPT codes on the Standardized Episode of Care do not need to include any additional telehealth specific codes for a telehealth claim to be paid.

There are extra considerations made when appointing for telehealth. TriWest asks Veterans several questions to determine their Telehealth capabilities and comfort level, including:

• What care are you comfortable receiving via telehealth?
• Do you have a secure (i.e., password-protected) Internet connection?
• Do you have either a webcam with a microphone on your computer or front-facing camera on your tablet/smartphone?

Additionally, there are specific guidelines the provider must follow to ensure a positive experience for the Veteran. These guidelines and other information can be found in TriWest’s telehealth quick reference guide. There also is a Behavioral Health Care section in the CCN Provider Handbook that highlights telehealth and other behavioral health topics.

Determining a VA CCN High Performing Provider Designation

VA created a High Performing Provider (HPP) designation for CCN providers who excel in health care evaluation metrics. These standard quality metrics determine a provider’s HPP designation.

VA and/or TriWest Healthcare Alliance (TriWest) use the designation when selecting a provider to see a Veteran.

The HPP designation is not the sole factor in selecting a CCN provider during the appointing process. Regardless of HPP designation, all CCN network providers must meet credentialing requirements and be qualified to provide health care to Veterans.

VA CCN providers include those practicing at the individual level, practicing in a group setting, and institutional providers such as hospitals. These three types of providers are scored as follows:

• Individual providers are evaluated based on a combination of VA priority measures and standard measures from Blue Health Intelligence.
• Provider practice groups are scored as a single entity. Providers in those groups are assigned the overall group score.
• Hospitals are scored on a selection of CMS measures from the Hospital Compare system.

To receive a summary of specific provider metrics, email a complete HPP Inquiry Form to CQHPP@TriWest.com. The form is available for download on the TriWest VA CCN Payer Space on Availity under the “Resources” tab.

For more detailed information, refer to the High Performing Provider quick reference guide or the High Performing Provider section of the CCN Provider Handbook. Submit inquiries regarding the VA CCN HPP process to CQHPP@TriWest.com.

VA CCN Provider Handbook Updates

There are no updates to the VA CCN Provider Handbook this month.