In addition to
receiving claims from civilian providers, the contractor may also
receive SHCP claims from the DVA. The provisions of the SHCP will
not apply to services provided under any Memorandum of Agreement
(MOA) for sharing between the Department of Defense (DoD) (including the
Army, Air Force, Navy/Marine Corps, and Coast Guard facilities)
and the DVA. Claims for these services will continue to be processed
by the Services. However, any services not included in any MOA described
below shall be paid by the contractor in accordance with the TRICARE
Reimbursement Manual (TRM) to include claims referred for beneficiaries
on the Temporary Disability Retirement List (TDRL).
3.1
Claims
for Care Provided Under the National DoD/DVA MOA for Spinal Cord
Injury (SCI), Traumatic Brain Injury (TBI), Blind Rehabilitation,
and Polytrauma
3.1.1 Effective August 4, 2009, the contractor shall
process DVA submitted claims for Service members’ treated under
the MOA in accordance with this chapter and the following (SCI,
TBI MOA; see
Addendum D for a full text copy of the MOA
for references purposes only).
3.1.2 Claims received from a DVA
health care facility for Service member care shall be processed as
an MOA claim based upon the Defense Health Agency-Great Lakes (DHA-GL)
Specified Authorization Staff (SAS) authorization number. As determined
by SAS, all medical conditions shall be authorized and paid under
this MOA if a condition of TBI, SCI, Blindness, or Polytrauma exists
for the patient. The authorization shall clearly indicate that the
care has been authorized under the SCI, TBI, Blindness, and Polytrauma
MOA. The authorization shall specify type of care (inpatient, outpatient,
etc.) to be given under the referenced MOA and limits of the authorization
(inpatient days, outpatient visits, expiration date, etc.). Suggested
authorization language to possibly include “all care authorized
under the SCI, TBI, Blindness, and Polytrauma MOA” for inpatient,
outpatient and rehabilitative care. SAS shall send authorizations
to the contractor either by fax or by other mutually agreed upon
modality.
3.1.3 The
contractor shall verify whether the DVA-provided care has been authorized
by the SAS. If an authorization is on file, the contractor shall
process the claim to payment. The contractor shall not deny claims
for lack of authorization. If a required authorization is not on
file, the contractor shall place the claim in a pending status and
forward the appropriate documentation to the SAS identifying the claim
as a possible MOA claim for determination (following the procedures
in
Addendum B for the SAS referral and review
procedures). Additionally, any DVA submitted claim for a Service
member with a TBI, SCI, blindness, or polytrauma condition that
does not have a matching authorization number shall be pended to
the SAS for payment determination.
3.1.4 MOA claims shall be reimbursed
as follows:
3.1.4.1 Claims for inpatient care shall be paid using
DVA interagency rates, published in the Federal Register.
The interagency rate is a daily per diem to cover inpatient stays
and includes room and board, nursing, physician, and ancillary care.
These rates will be provided to the contractor by DHA (including
periodic updates as needed). There are three different interagency
rates to be paid for rehabilitation care under the MOA. The Rehabilitation
Medicine rate will apply to TBI care. Blind rehabilitation and SCI
care each have their own separate interagency rate. Additionally,
it is possible that two or more separate rates will apply to one
inpatient stay. All interagency rates except the outpatient interagency
rate in the Office of Management and Budget (OMB) Federal Register
Notice provided by DHA will be applicable. If the DVA-submitted
claim identifies more than one rate (with the appropriate number
of days identified for each separate rate), the contractor shall
pay the claim using the separate rates. (For example, a stay for
SCI may include days paid with the SCI rate and days billed at a
surgery rate.) Contractors shall verify the DVA billed rate on inpatient
claims matches one of the interagency rates provided by DHA. DVA
claims for inpatient care submitted with an applicable interagency
rate shall not be developed any further (i.e., for revenue codes,
diagnosis, etc.) if care has been approved by the DHA/SAS. Claims
without an applicable interagency rate shall be denied and an Explanation
of Benefits (EOB) shall be issued to the DVA, but not the beneficiary.
The claim will need to be resubmitted for payment.
3.1.4.2 Claims
for outpatient and ambulatory surgery professional services shall
be paid at the appropriate TRICARE allowable rate (e.g., CHAMPUS
Maximum Allowable Charge (CMAC)) with a 10% discount applied. For
those services without a TRICARE allowable rate, DVA shall be reimbursed
at billed charges.
3.1.4.3 The following
care services, irrespective of health care delivery setting require authorization
from SAS and are reimbursed at billed charges (actual DVA cost)
separately from DVA inpatient interagency rates, if one exists:
• Transportation
• Prosthetics
• Non-medical rehabilitative
items
• Durable
Equipment (DE) and Durable Medical Equipment (DME)
• Orthotics (including
cognitive devices)
• Routine and adjunctive
dental services
• Optometry
• Lens prescriptions
• Inpatient/outpatient
TBI evaluations
• Special diagnostic
procedures
• Inpatient/outpatient
polytrauma transitional rehabilitation program
• Home care
• Personal care attendants
• Conjoint family
therapy
• Ambulatory
surgeries
• Cognitive
rehabilitation
• Extended care/nursing
home care
3.1.4.4 Effective
August 4, 2009, the contractor shall process all claims received
on or after this date using the guidelines established under the
updated MOA regardless of the date of service. All TRICARE Encounter
Data (TED) records for this care shall include Special Processing
Code (SPC) 17 - DVA medical provider claim.
3.1.4.5 If paid
at per diem rates, the provisions of
Chapter 8, Section 2, paragraph 7.2, apply
when enrollment changes in the middle of an inpatient stay. If enrollment
changes retroactively, prior payments will not be recouped.
3.2 Claims for
Care Provided Under the National DoD/DVA MOA for Payment for Processing Disability
Compensation and Pension Examinations (DCPE) in the Integrated Disability Evaluation
System (IDES)
The contractor shall reimburse
the DVA for services provided under the current national DoD/DVA
MOA for “Processing Payment for Disability Compensation and Pension
Examinations in the Integrated Disability Evaluation System” (IDES
MOA; see
Addendum C for a full text copy of the MOA
for reference purposes only). The contractor shall process claims
with dates of service October 1, 2014, and forward. Claims under
the IDES MOA shall be processed in accordance with this chapter
and the following:
3.2.1 Claims
submitted by any DVA facility/provider for a Service member’s care
with the Current Procedural Terminology (CPT) code of 99456, International
Classification of Diseases, 9th Revision (ICD-9) diagnostic code
of V68.01, or International Classification of Diseases, 10th Revision
(ICD-10) diagnostic code of Z02.71 (Disability Examination) shall
be processed as a IDES MOA claim. IDES MOA claims are SHCP claims.
3.2.2 The
MTF/eMSM will generate a single referral and submit the referral
to the contractor. Although the MTF/eMSM referral shall specify a
particular DVA facility/provider to provide the IDES MOA services,
the contractor shall consider the referral as a blanket authorization
to process claims from any billing DVA facility/provider for authorized/DCPE
exams and associated ancillary services under the IDES MOA. The
MTF/eMSM will complete the referral as described in
Chapter 8, Section 5, paragraph 6.1 including
Note 4. The referral will specify the total number of Compensation
and Pension (C&P) examinations authorized for payment by the
contractor. It is not necessary for the referral to identify the
various specialists who will render the different C&P examinations.
The reason for referral will be entered by the MTF/eMSM as “
DVA
only: Disability Evaluation System (DES) C&P exams for fitness for
duty determination - total __.”
3.2.3 The DVA will list one C&P
examination (CPT code 99456) per the appropriate field of the claim
form and indicate one unit such that there is a separate line item
for each C&P examination. Related ancillary services may be
billed on the same claim form or on a separate claim form identified by
the single diagnosis of ICD-9/ICD-10 diagnostic code, V68.01/Z02.71
(Disability Examination).
3.2.4 If an IDES MOA claim is received
from the DVA (
paragraph 3.2.1) and an authorization to any DVA
provider is on file, the contractor shall process the claim to payment
(see
paragraph 2.2). One C&P examination fee
will be paid for each referred and authorized C&P examination
up to the total number of C&P examinations authorized by the
referring MTF/eMSM.
3.2.5 If
an IDES MOA claim is received from the DVA (
paragraph 3.2.1) and
no
authorization is on file, the contractor shall verify that the claim
contains CPT procedure code 99456 and/or ICD-9/ICD-10 code V68.01/Z02.71,
and process the claim to payment. The contractor shall provide a
monthly report of the number of IDES MOA claims received without
authorization. Details for
reporting are
identified by DD
Form 1423, Contract Data Requirement List (CDRL)
,
located in Section J of the applicable contract.
3.2.6 Claims
for C&P exams shall be paid as SHCP using the pricing provisions
agreed upon in the IDES MOA. CPT procedure code 99456 shall be used
and will be considered to include all parts of each C&P examination,
except ancillary services. Claims for related ancillary services
shall be paid at the appropriate TRICARE allowable rate (e.g., CMAC)
with a 10% discount applied.
Figure 17.2-1 Disability Pay Schedule
|
Effective
Date
|
C&P
Disability Exam (99456)
|
ancillary
services
|
|
01/01/2011
|
$515.00
|
CMAC - 10%
|
3.2.7 All TED records for this care
shall include SPC DC - Compensation and Pension Examinations-DVA,
SPC 17 - VA Medical Provider Claim, and Enrollment
Health Plan Code SR - SHCP-Referred Care.