CMS Claims​/Tri West​/VA CCN consultant

VA / Tri West Claims Remediation Consulting Scope (Short-Term Advisory Engagement – No Billing Outsourcing) Background

We are a small locally owned Maryland-based home health agency providing non-skilled services to Veterans through the VA Community Care Network (Tri West / Optum). We currently submit CMS-1500 claims electronically via our agency software and a clearinghouse.

We are experiencing recurring claim denials related to authorization numbers, resubmission logic (corrected vs replacement claims), and claim reference requirements
, and we are seeking short-term expert consulting to identify root causes, correct existing issues, and train our internal team for ongoing compliance.

We are not seeking a billing company or outsourcing services.

• Audit denied VA / Tri West claims to identify recurring errors and systemic issues
• Diagnose resubmission failures
  , including:
  • CMS-1500 Box 22 usage (Code 6 – Corrected vs Code 7 – Replacement)
  • Original VA claim reference requirements
• Validate authorization handling
  , including:
  • Proper population of Box 23
  • Date-of-service alignment with authorization windows
  • Authorization matching logic used by Tri West / Optum
• Confirm software and clearinghouse data flow (agency software > clearinghouse > VA)
• Correct and successfully resubmit a sample set of claims
• Develop a clear, repeatable SOP so our internal team can handle VA billing correctly going forward
• Provide live training for staff responsible for VA claims submission and follow-up

• Review 10 denied or rejected VA claims
• Identify patterns related to:
  • Authorization issues
  • *** KEY ISSUE*** ----->
    Change over from old authorization number to new authorization number
  • Incorrect resubmission codes
  • Missing or incorrect original claim references
  • Payer-specific requirements unique to Tri West / Optum
• Deliver written findings and recommended corrections

• Correct a subset of claims using proper VA logic
• Guide resubmission using appropriate CMS-1500 standards
• Confirm acceptance or identify remaining payer responses

• Deliver a concise (1–2 page)
  VA Billing SOP covering:
  • Original vs corrected vs replacement claims
  • Authorization validation checklist
  • Resubmission decision rules
• Conduct 60–90 minute live training (virtual acceptable)

• Written claims audit summary
• Identified root causes and system/process fixes
• At least one successfully resubmitted claim example
• VA billing SOP (internal use)
• Staff training session

• Demonstrated experience with VA Community Care / Tri West / Optum billing
• Strong knowledge of CMS-1500 claim standards
• Experience in claims auditing, remediation, or revenue cycle consulting
• Independent consultant (not a billing services firm)
• Willing to work collaboratively with internal staff

• Short-term consulting engagement (2–4 weeks preferred)
• Hourly or fixed-fee acceptable
• Remote work acceptable

• Ongoing billing management
• Percentage-of-collections arrangements
• Full revenue cycle outsourcing

Please include:

• Relevant VA / Tri West experience
• Proposed approach and timeline
• Fee structure
• Availability to begin