Cornerstone

Understanding Triwest Drug Treatment Coverage

Learn about using your TriWest insurance policy to cover substance abuse treatment

Alcohol and Drug Treatment Coverage with TriWest

If you’re a veteran or an active-duty service member seeking help for alcohol or drug addiction, TriWest Healthcare Alliance is here to support you on your journey to recovery.

As a third-party administrator of the VA’s Community Care Network in regions 4 and 5, TriWest works with a vast network of healthcare providers to ensure you receive the quality care you deserve.

This guide will explore how TriWest can help you access drug treatment services, including in-network and out-of-network coverage options, the claims approval process, types of plans accepted, deductibles, and assistance for financial hardships.

We aim to empower you with the knowledge and resources to make informed decisions about your treatment and overall well-being.

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Addictions we treat at Cornerstone

TriWest drug treatment coverage

When seeking drug treatment through TriWest, choosing an in-network provider can offer several advantages. In-network treatment centers have established contracts with TriWest, which often means more streamlined access to care and potentially lower out-of-pocket costs.¹ These providers are also well-versed in TriWest’s policies and procedures, making the administrative aspects of your treatment more efficient. However, while TriWest has an extensive network of providers, your options may be more limited compared to out-of-network facilities. It’s crucial to prioritize finding a treatment center that meets your needs and provides the care you require, even if it means considering out-of-network options.

While TriWest encourages using in-network providers, there may be situations where you prefer or require treatment at an out-of-network facility. The primary advantage of choosing an out-of-network treatment center is the expanded range of options available. This can be particularly beneficial if you’re seeking specialized care or have specific preferences for your treatment environment. It’s important to understand that out-of-network care may come with higher out-of-pocket costs, as these providers have yet to negotiate rates with TriWest. You may need to be responsible for submitting claims and coordinating communication between the treatment center and TriWest.

Information about TriWest Programs and Plans

This program was designed to provide veterans with a comprehensive, nationwide network of high-quality community healthcare providers. The VAPC3 program focuses on ensuring that veterans receive care that is both timely and geographically accessible.

Launched as part of the Veterans Access, Choice, and Accountability Act of 2014, this program allows veterans to receive care from non-VA doctors if they have been waiting more than 30 days for VA medical care or live more than 40 miles from a VA healthcare facility.²

TriWest is a contractor for the VA’s CCN in various regions, which is the VA’s direct link with community providers for delivering healthcare to veterans outside of VA facilities. The CCN is part of the VA’s effort to provide veterans with timely, high-quality care.³

Like the CCN, the PC3 program also provides veterans access to community care when VA facilities are not readily accessible. This includes various medical services, from primary care to specialty and mental health services.

TriWest facilitates the VA’s program, allowing eligible veterans to visit urgent care providers within TriWest’s network without prior authorization. This benefit is intended to offer veterans convenient care for non-emergency situations.

Understanding Policy Definitions

A deductible is the amount you’ll need to pay out-of-pocket for covered services before your insurance starts to pay its portion. TriWest usually has no deductibles because its goal is to make veteran care fully accessible.

TriWest Approval Process for Treatment

The first step in using your TriWest insurance for drug treatment is verification. During this process, your chosen treatment center will contact TriWest to confirm your active coverage and determine your plan’s specifics. The treatment center will learn essential details such as your deductible, co-insurance, and out-of-pocket maximum. They will also find out if there are any specific requirements or limitations related to drug treatment coverage. Once verification is complete, the treatment center will clearly explain your financial responsibility, if any, for your treatment.

After you’ve started treatment, the next step is claim submission. Your chosen treatment center will manage this process on your behalf. They will gather all the necessary information about the services you’ve received, such as dates of treatment, specific therapies, and associated costs. They will then create a formal claim using standardized codes and formats TriWest requires and submit it directly to the insurance provider. By entrusting this task to an experienced treatment center, you can be confident that the process will be efficient and accurate, minimizing the risk of delays or denials. Stay in communication with your treatment center throughout the submission process, as they can keep you informed about the status of your claims and address any questions or concerns you may have.

After submitting your claim to TriWest, the next step is adjudication. During this process, TriWest will review the submitted claim to determine if the services provided are covered under your specific plan and meet the necessary medical criteria. The adjudication process involves verifying the patient’s eligibility, the treatment’s appropriateness, and the claim’s accuracy. TriWest will also check for any potential errors or missing information that must be addressed. If everything is in order and the services are deemed covered, the claim will be approved, and payment will be issued to the treatment center. If there are any issues or discrepancies, TriWest may request additional information or deny the claim, leading to the appeal process if necessary.

Once your claim has been submitted and processed by TriWest, the next step is payment. If your claim is approved, TriWest will pay the covered portion of your treatment costs directly to the center. Depending on your specific plan and coverage details, you may be responsible for paying some expenses, such as your deductible or co-insurance. The treatment center will typically bill you for any remaining balance after receiving payment from TriWest. It’s essential to stay in communication with TriWest and your treatment center throughout this process to ensure you understand your financial responsibilities and address any questions or concerns that may arise.

In some cases, TriWest may deny a drug treatment claim. This can happen for various reasons, such as a lack of medical necessity or a service not covered under your specific plan. If your claim is denied, don’t lose hope—your treatment center will likely file an appeal on your behalf. Treatment centers have experienced billing departments that are well-versed in handling denials and appeals. They will work diligently to gather additional information, provide supporting documentation, and make a strong case for why the denied service should be covered. It’s important to remember that treatment centers aim to provide only services that are likely to be approved. Still, in the event of a denial, they will be your advocate and work hard to get the decision overturned.

Get Help Paying Your Deductible

File a Hardship With TriWest

If you’re struggling to pay your deductible for drug treatment, one option is to file a hardship with TriWest. A hardship is a situation that prevents you from affording your medical expenses, such as a job loss, family crisis, or unexpected financial burden. To file a hardship, contact TriWest directly and provide documentation of your financial situation. If approved, TriWest may waive or reduce your deductible, making the necessary treatment more accessible. Remember that the success of your hardship application depends on your specific circumstances and TriWest’s assessment.

Assistance Programs & Payment Plans

Many drug treatment centers offer assistance programs and payment plans to help make treatment more accessible and affordable. These programs can help you manage out-of-pocket expenses, such as deductibles and co-insurance. Some centers offer sliding-scale fees based on your income, while others may provide scholarships or grants to eligible individuals. Treatment centers may allow you to spread your payments over time through a payment plan, making it more manageable to cover your share of the costs. When selecting our treatment center, inquire about available assistance programs and payment plans.

Community Resources & Charitable Organizations

In some cases, community resources and charitable organizations may be able to help you cover your drug treatment deductible. These organizations recognize the importance of accessible and affordable addiction treatment and may provide financial assistance to those in need. Some examples include faith-based organizations, local non-profits focused on addiction recovery, and national charities dedicated to helping individuals overcome substance abuse. Research the organizations in your area and contact them to learn more about their assistance programs.

FAQs About Using TriWest Benefits
to Pay for Alcohol and Drug Treatment

Does TriWest cover both Inpatient and Outpatient drug treatment?

Yes, TriWest provides comprehensive coverage for various drug treatment options.

Here’s a detailed breakdown:

Inpatient or Residential Programs: These programs offer 24-hour care in a structured environment, ideal for individuals with severe addiction or co-occurring mental health disorders. Patients stay at the treatment facility for a specified period, typically 15 to 90 days, receiving intensive medical supervision, therapy sessions, and support activities.
Partial Hospitalization Programs (PHP): PHPs provide intensive treatment similar to inpatient care but allow patients to return home daily. This option benefits those who need structured support but do not require overnight stays. PHPs typically involve multiple therapy sessions and medical monitoring throughout the day.
Intensive Outpatient Programs (IOP): IOPs offer a flexible treatment option. Patients attend therapy sessions weekly while maintaining their daily responsibilities, such as work or school. This program suits individuals who need regular support but can manage their treatment outside a residential setting.
Standard Outpatient Programs: These programs involve regular therapy sessions and support groups that patients attend at home. They are ideal for individuals with milder addiction issues or those transitioning from more intensive treatment programs. Outpatient care allows patients to continue their daily activities while receiving ongoing support.

What addictions does TriWest insurance cover for treatment?

TriWest insurance generally covers a variety of substance use disorders, including alcohol use disorder and opioid use disorder.

The specific coverage can vary based on your plan and state regulations.

Coverage typically includes detoxification services, medication-assisted treatment (MAT) with FDA-approved medications like methadone and buprenorphine, and various therapeutic services such as individual and group therapy.

Does TriWest cover mental health treatment?

Yes, TriWest typically provides mental health treatment coverage, which includes those struggling with dual diagnosis.

This includes therapy, medication management, and other interventions aimed at addressing psychiatric conditions.

Covered treatments may involve Cognitive-Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), and Motivational Interviewing (MI), which are effective in treating both addiction and mental health concerns.

What should I do if TriWest denies my claim for drug treatment?

If TriWest denies your claim for drug treatment, there are several steps and alternatives you can consider:

File an Appeal: Start by appealing the denial. Your treatment center will likely assist in gathering additional information and providing supporting documentation. This can include medical records, letters of medical necessity from your healthcare provider, and other relevant information that strengthens your case. Ensure you follow TriWest’s specific appeals process and meet any submission deadlines.
Request a Review: Contact TriWest directly and request a decision review. Sometimes, denials occur due to administrative errors or missing information. Speaking with a representative can help clarify the reasons for refusal and identify any missing documentation that can be provided to support your claim.
Alternative Coverage Options: Explore other coverage options if the appeal fails. This could include checking if other in-network providers offer the services you need under your current plan or considering supplemental insurance plans that can cover gaps in your primary coverage.
Financial Assistance Programs: Look into your treatment center’s financial assistance programs and payment plans. Many centers have programs to help patients manage out-of-pocket costs. Additionally, community resources and charitable organizations often provide financial support for individuals needing addiction treatment.
Seek Legal Assistance: If you believe your claim was unfairly denied and appeals unsuccessful, don’t hesitate to seek legal advice. This can be a powerful tool in your fight for coverage. Legal resources and patient advocacy groups specialize in helping individuals navigate insurance disputes and obtain the coverage they are entitled to.

By exploring these options, you’re taking proactive steps to increase your chances of getting the necessary coverage for your drug treatment.

Sources

[1] About | TriWest

[2] VCP | TriWest

[3] Community Care Overview

CLINICALLY REVIEWED

Lionel Estrada, LISAC

CLINICAL DIRECTOR

Lionel, our Clinical Director is a Licensed Independent Substance Abuse Counselor (LISAC) with over 4 years at Cornerstone, specializes in addiction and mental health. Trained in EMDR therapy, he employs a trauma-informed, empathetic approach to address the underlying causes of these issues.

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