Military Health System

This Memorandum of Agreement (MOA) establishes policies for medical management within an appropriate care setting and reimbursement between Department of Veterans Affairs (DVA) and Department of Defense (DoD) regarding treatment provided to Service members with Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), blindness, or polytraumatic injuries (more than one injury sustained at the same time that includes either an SCI, TBI, or blindness) at DVA medical facilities. Appendix A provides instructions to implement the provisions of the MOA and is not intended to alter the provisions of this MOA.

There has been a long-standing MOA between DVA and DoD associated with specialized care for Service members sustaining SCI, TBI, and blindness. The Veterans Health Administration (VHA) is known for its integrated system of health care for these conditions. The DVA/DoD Health Executive Council identified the need for referral procedures governing the transfer of Service member inpatients from military or civilian hospitals to DVA medical facilities, and the treatment of Service member inpatients, outpatients, and other related comprehensive services at DVA facilities.

This MOA supersedes all previous DVA/DoD MOAs relating to Service member referrals to DVA facilities for TBI, SCI, and blindness.

DVA and DoD Health Resources Sharing and Emergency Operations Act (38 USC § 8111).

Section 3-105 of the DVA/DoD Health Care Resource Sharing Guidelines of October 31, 2008.

TRICARE Operations Manual 6010.51-M, August 1, 2002.

This MOA applies to DVA facilities with SCI, TBI, and Blindness specialty programs listed in Appendix B, but is not limited to these facilities as Service members covered under this MOA may receive care in any DVA Medical Center (DVAMC).

This MOA does not apply to non-DoD Service members in the Coast Guard, Public Health Service (PHS), and National Oceanic and Atmospheric Administration (NOAA). This MOA does not pertain to the transfer of Service members to DVA facilities for care or treatment related to alcohol or drug abuse in accordance with Title 38 USC § 620A(d)(1). This MOA is separate from existing agreements between the DVA and the Regional TRICARE contractors.

Since this MOA applies only to Service members, the provisions of this MOA will no longer apply to members the day after the member separates or retires from active duty. DoD shall keep the treating DVA facility informed of any pending changes in eligibility of the Service member, including all relevant information such as separation date, type of separation, and the periods of active duty served.

It is the responsibility of the referring Military Treatment Facility (MTF) to ensure that Service members are enrolled in TRICARE Prime or TRICARE Prime Remote (TPR) in all cases prior to transfer of care to a DVA facility. At a minimum, it is preferred that the Service member be enrolled to the referring MTF and assigned to a Primary Care Manager (PCM) at that MTF while the member is receiving inpatient or outpatient services under this MOA unless or until DoD assigns a responsible MTF other than the referring MTF. DoD shall keep the treating DVA facility informed of any pending changes in TRICARE Prime enrollment status of the Service member.

These provisions arc important for ensuring proper authorization for care as well as appropriate billing procedures under the MOA.

DVA and DoD agree to the following provisions:

Care coordination support services will be provided by the TRICARE Management Activity (TMA) in collaboration with the responsible MTF and the treating DVA facility as a joint collaboration appropriate to each individual Service member’s case.

If the Service member being considered for treatment under this MOA is under inpatient or outpatient treatment outside an MTF, and no MTF is involved in the member’s treatment, DoD will assign an MTF to fulfill all responsibilities assigned to responsible MTFs below.

The responsible MTF shall obtain the preferences of the Service member (guardian, conservator, or designee) for DVA facility location. The responsible MTF will identify the appropriate participating DVA facility (listed in Appendix B) and contact the designated facility Program Point of Contact (POC) as early as possible to present the case, gain admission acceptance, and begin the referral process. The responsible MTF will provide sufficient patient medical record documentation to allow the identified DVA health care facility to decide whether to accept the patient for the indicated inpatient or outpatient treatment within the scope of this MOA. The transfer of care from MTF inpatient or outpatient treatment to DVA inpatient or outpatient treatment will involve direct telephone contact between the responsible MTF physician and the accepting DVA physician.

Once a DVA facility has agreed to accept the patient for the indicated inpatient or outpatient treatment within the scope of this MOA. the responsible MTF will complete and submit the appropriate request for preauthorization to TMA. If a request for outpatient, appropriate transitional rehabilitation setting, or other treatment is made immediately following the discharge from inpatient treatment at a DVA facility under this MOA, the treating DVA facility is responsible for submitting the request for authorization to TMA.

Clinical case management of Service members under the MOA will remain the responsibility of the responsible MTF and the accepting DVA facility. Upon receipt of a preauthorization, the responsible DoD MTF case manager will provide the DVA case manager with current clinical information along with the case management plan of care and discharge plan. DoD MTF case managers will update the appropriate patient tracking application(s) and forward necessary information to the DVA case manager to update the appropriate tracking application(s).

Upon receipt of a preauthorization, the responsible MTF and the accepting DVA facility will coordinate the transfer of care for the patient from a DoD treatment setting to DVA treatment along with an agreed upon date and time of transfer to the appropriate healthcare setting, Appendix A lists the criteria for the transfer of care for Service members and the instances in which patients are not to have care transferred. The responsible MTF must notify the DVA facility of any changes in medical status in detail prior to the transfer of care. At MTFs where DVADVA staff is assigned, the DVA Liaison for Health Care will assist with the transfer of care. The responsible MTF must inform TMA of the status of all transfers. Clinical responsibility for the patient en route, during a transition of care setting, rests with DoD. If the Service member being considered for treatment under this MOA is under inpatient or outpatient treatment outside an MTF, the assigned responsible MTF will coordinate with the civilian facility or provider as appropriate.

As part of scheduling the transfer of care, the MTF will arrange for, and DoD will reimburse the transportation of Service members to and from the DVA facility for both inpatient and outpatient care in accordance with applicable DoD policy and procedure. The responsible MTF will arrange with any MTF within a reasonable distance to provide needed transportation. The MTF may involve the Global Patient Movement Requirements Center (GPMRC), particularly for inpatient transfers. (To ensure optimal care, active duty patients may go directly to a DVA medical facility without passing through a transit military hospital if medically indicated.) If the responsible MTF (in coordination with GPMRC) cannot arrange ground transportation from the airfield to the DVA facility, the receiving DVA facility shall obtain appropriate local transportation and will be reimbursed by DoD for costs incurred by DVA.

TMA is the approval authority for all authorizations for DVA services, supplies, and equipment under this MOA. Care authorizations issued by TMA will also include treatment for any co-morbid conditions identified.

TMA will accept requests for preauthorization from responsible MTFs and requests for continued treatment authorization from the treating DVA facility. An inpatient admission is not required for coverage under this MOA. In instances where outpatient, transitional rehabilitation setting, or other treatment immediately follows discharge from inpatient treatment at a DVA facility under this MOA, it shall be considered to be a request for continued treatment and the treating DVA facility is responsible for submitting the request for authorization to TMA.

TMA will consider all information submitted with the request in rendering a determination on the authorization request.

All ongoing outpatient services, supplies, and equipment under the MOA upon discharge from inpatient treatment under this MOA, require prior continued treatment authorization including rehabilitation services. It also includes requests for Durable Medical Equipment (DME) that are not routinely covered under the TRICARE Uniform Benefit that are appropriate for issuance to Service members upon discharge from inpatient treatment at a DVA medical facility.

In order to ensure continuity of care, Service members who are covered under this MOA and have transitioned to an outpatient status, will remain under the program and have their future care needs authorized by TMA regardless of the current diagnosis.

DVA facilities will assist MTFs in selecting the most appropriate participating DVA facility (listed in Appendix B) to provide treatment to prospective Service members under this MOA. Consideration shall be given to selecting a DVA facility closest to the Service member’s home of record or other location requested by the Service member (guardian, conservator, or designee), subject to availability of beds at the facility and approval by TMA. If the preferred/approved DVA facility is unable to accept the patient, DoD, in coordination with DVA, will assist in locating an appropriate DVA facility for placement of the patient.

Note: The Chief Consultant, Rehabilitation Services, or Chief Consultant, SCI&D Services, DVA Central Office, 810 Vermont Avenue, NW, Washington, DC 20420, will assist when necessary.

Upon being identified by a responsible MTF, the identified DVA facility will review patient medical record documentation submitted by the responsible MTF to decide whether to accept the patient for the indicated inpatient or outpatient treatment within the scope of this MOA. Typically, transfers from MTF inpatient treatment to DVA inpatient treatment will involve direct telephone contact between the responsible MTF physician and the accepting DVA physician. Upon receipt of medical records, the DVA facility will respond within three business days with either a request for more information or an acceptance or denial decision.

Upon request. the selected DVA facility will provide patient status information to the assigned responsible MTF in order to assist that MTF with the preparation of the request for preauthorization for submission to TMA.

Clinical case management of Service members under the MOA will remain the responsibility of the responsible MTF and the DVA facility. Upon receipt of a preauthorization. the DVA case manager will accept current clinical information along with the case management plan of care and discharge plan from the responsible DoD) MTF case manager. DoD MTF case managers will update the appropriate patient tracking application(s) and forward necessary information to the DVA case manager.

Upon receipt of a preauthorization, the responsible MTF and the accepting DVA facility will coordinate transfer of care for the patient from DoD treatment to DVA treatment along with an agreed upon date and time of transfer. Appendix A lists the criteria for the transfer of patients and the instances in which patients are not to be transferred. In the case of emergent transfers, DVA facilities will accept inpatient transfers without regard to hour of the day, day of the week, or holidays. All non-emergent or routine inpatient transfers must be transferred within the duty day and time frame coordinated with the treating DVA facility. At MTFs where DVA staff is assigned, the DVA Liaison for Health Care will assist with the transfer of care. If the Service member is receiving treatment in a civilian facility, the DVA facility will participate in coordinating the transfer with the civilian provider along with the MTF as appropriate.

The accepting DVA staff physician will review military transportation arrangements and make recommendations as appropriate. DVA will assist responsible MTFs and GPMRC in coordinating the medically indicated mode of transportation. If the responsible MTF (in coordination with GPMRC) cannot arrange ground transportation from the airfield to the DVA facility, the receiving DVA facility shall obtain appropriate local transportation and will be reimbursed by DoD for costs incurred by DVA.

The treating DVA facility is responsible for completing and submitting requests for continued treatment authorization to TMA. Requirements for the authorization request are specified in Appendix A. If a request for outpatient, transitional rehabilitation setting, or other treatment immediately follows discharge from inpatient treatment tinder this MOA, it shall be considered to be a request for continued treatment and the treating DVA facility is responsible for submitting the request for authorization. if care is to be continued outside of DVA. DVA may assist in finding an acceptable provider if necessary to provide a smooth transition from DVA care setting.

When Service members are a direct admission, the treating DVA facility will notify TMA Defense Health Agency-Great Lakes (DHA-GL) immediately upon admission of a Service member to a DVA facility under this MOA. DVA will assign a case manager to coordinate the full continuum of services for the Service member. The DVA case manager will provide the TMA DHA-GL case manager periodic updates, no less than once a month, depending on the acuity or complexity of the case, until the medical determination or the medical board process is complete or the Service member patient is discharged and returned to an MTF or other military control. This continued coordination is necessary to aid in communication to the DoD PCM, command, other program managers, and medical board personnel.

The treating DVA facility will coordinate the hospital discharge of a Service member with the appropriate MTF and TMA and provide a discharge plan as outlined in Appendix A.

DVA will provide sufficient medical information and documentation for the designated MTF to conduct a medical board for a disability determination.

The treating DVA facility will notify the responsible MTF of any Service members’ absences, while coordinating potential medical discharge, and/or change of location.

Prior to discharge. the treating DVA facility will notify the responsible MTF of the patient’s pending discharge so that the responsible MTF may assist the patient with TRICARE Prime portability enrollments in the region or his/her next or final destination, if desired.

Prescriptions are filled through the TRICARE pharmacy program except for DVA facility emergency room, inpatient and discharge prescriptions that include extended and transitional care settings.

The DVA facilities under the VHA TRICARE Pharmacy Program are authorized to dispense and submit claims for reimbursement of medications. DVA pharmacies will till prescriptions ordered by DVA providers. DVA facilities that have implemented the e-pharmacy solution may become part of the TRICARE pharmacy network when an MOA has been executed between DVA and TMA.

DoD will reimburse DVA facilities CHAMPUS Maximum Allowable Charge (CMAC) minus 10 percent. For those services without a CMAC, DVA will be reimbursed at actual DVA cost. DVA reserves the right to periodically review DVA costs against the CMAC minus 10 percent reimbursement levels for an approval determination of an alternate reimbursement methodology for outpatient care by the DVA/DoD Financial Management Workgroup. At a minimum, the billing will be itemized for each member on Centers for Medicare and Medicaid (CMS) Form 1500 for outpatient services and Universal Billing (UB) Form UB04 for outpatient facility charges.

DoD will reimburse DVA using the DVA’s interagency rates approved by the Office of Management and Budget (OMB) that is periodically updated via a Federal Register Notice. All rates in the OMB Federal Register Notice will be applicable. At a minimum, this will include a UB04 form billed for the appropriate DVA interagency rate(s) for the bed unit(s)/setting(s) of care, which shall be reimbursed at the billed charge by DoD. Multiple DVA interagency rates, as applicable to the bed units/care settings, shall be billed on the same UB04.

The following services, irrespective of health care delivery setting require authorization from TMA. These services are reimbursed separately from DVA inpatient interagency rates, if one exists or actual DVA cost: transportation, prosthetics, non-medical rehabilitative items, DME. orthotics (including cognitive devices), routine and adjunctive dental services, optometry, lens prescriptions. inpatient/outpatient TBI evaluations, special diagnostic procedures (see Appendix A-6), inpatient/outpatient Transitional Rehabilitation program, home care, personal care attendants, conjoint family therapy. cognitive rehabilitation, and extended care/nursing home care. Professional charges will be billed on CMS 1500 and Facility Charges will be billed on UB04, as applicable. The DVA facility will be reimbursed separately for ambulatory surgeries required while in a rehabilitation or transitional rehabilitation program setting. TMA will provide standardized claim processing instructions (i.e., application of revenue codes) to the contractors to enable DVA facilities to bill and receive reimbursement in a consistent manner, per this MOA.

Non-medical rehabilitation items normally required to help achieve maximum medical rehabilitation benefit will be reimbursed by the DoD for Service members at DVA actual cost. Items needed for vocational rehabilitation will be furnished by the DVA and reimbursed at actual cost. The DVA will request preauthorizations for these items from TMA. Professional charges will be billed on CMS 1500 and Facility Charges will be billed on UB04, as applicable. If DVA purchased these items from an outside vendor, the actual bill from the vendor will be submitted for reimbursement of costs to DVA.

This MOA Will remain in force unless terminated at the request of either party after sixty (60) days written notice. In the event this MOA is terminated. DoD shall be liable only for payment in accordance with provisions of this agreement for care provided before the effective termination date. If the agreement is terminated. DoD must expedite coordination of care between DVA and the new provider or medical facility.

This agreement supersedes all local resource sharing agreements.

The appendices to this agreement are used to provide more detailed implementing instructions regarding the MOA. They may be modified at any time, with the concurrence of the VHA and DoD POCs listed below without the requirement for re-signing the MOA.

DVA and TMA/MTF staff will first attempt to resolve authorizations of care and claim issues in collaboration with the TRICARE Contractor. If not resolved, issues will be forwarded to the TMA Director of Healthcare Operations and Director, VHA Medical Sharing Office, who will direct the issues to the stakeholders within DVA and DoD. If necessary, billing and reimbursement issues shall be referred to the DVA/DoD Financial Workgroup for resolution, with inclusion of DVA and DoD General Counsels as necessary. Final resolution of issues resides with the DVA Under Secretary of Health and the Assistant Secretary of Defense (Health Affairs) (ASD(HA)).

The VHA Medical Sharing Office is the DVA POC responsible for documentation of this MOA and its appendices. Through the VHA DVA-DoD Medical Sharing Office designee, the Rehabilitation Services Chief Consultant and the SCI&D Chief Consultant will maintain and update the lists of participating DVA facilities in Appendix B periodically as changes occur.

TMA Policy and Benefit Branch is the DoD POC responsible for documentation of this MOA and its appendices.

This MOA is effective upon the date of approval by the undersigned. Execution of this MOA supersedes and cancels the previous MOA.

August 4, 2009