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I.
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SUBJECT
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Department
of Defense (DoD) TRICARE Contractors are entering into Network Participation Agreements
with the Department of Veterans Affairs (DVA) Veterans Health Administration
(VHA) to provide care for TRICARE/Civilian Health and Medical Program
of the Uniformed Services (CHAMPUS) beneficiaries covered by the
TRICARE Contractors, which include Regional Managed Care Support Contractors,
TRICARE Dual Eligibility Fiscal Intermediary (TDEFIC), and all Overseas
Contractors.
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II.
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Purpose
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This
Memorandum of Understanding (MOU) is to establish general requirements
between VHA and DHA for agreements between a DHA TRICARE contractor
and the DHA under which the TRICARE contractor may include VHA facilities
in the contractor’s network. This agreement replaces the agreement
entitled “Memorandum of Understanding between the Department of
Veterans Affairs and the Department of Defense”, signed in 1995,
with the subject, “Department of Defense (DoD) Managed Care Support
Contractors entering into Agreements with the Department of Veterans
Affairs (DVA) Health Care Facilities to Provide Care for CHAMPUS
Beneficiaries Covered by the Regional Managed Care Support Contracts.”
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III.
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Authority
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This
agreement MOU is supported by, Title 38 United States Code (U.S.C)
Section (Sec.) 8111, and by Title 10 U.S.C. Sec. 1104.
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IV.
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Policy
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a.
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Except
as otherwise provided in this MOU, the Network Participation Agreements
between the TRICARE contractor and the VHA shall conform to requirements
applicable to providers under Title 32 Code of Federal Regulations
(CFR) Part 199.7 and
to network providers under the contract between the TRICARE contractor
and DHA. However, the Secretary of Veterans Affairs is responsible
for the management of VHA facilities pursuant to Title 38 U.S.C.
Sec. 303. Should any requirement conflict with a policy, statute
or regulation governing VA, that conflict shall be brought to the
attention of the DHA TRICARE Contracting Officer for the region
in which the applicable VHA facility or facilities is/are located
to determine if an appropriate resolution is possible.
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b.
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Each
VHA facility covered by a VHA agreement with a DHA TRICARE contractor
shall be established as an authorized participating network provider.
DHA shall accept VHA’s policy and procedures, the parties agree
that VHA providers meeting VHA credentialing requirements including
licensure, and certification, shall be deemed to meet contractor requirements
pertaining to credentialing, licensure and certification for network
provider status. VHA will be exempt from submitting Internal Revenue
Service (IRS) form W9 since VHA facilities are Federal facilities
exempt from taxation.
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c.
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VHA
facilities meeting VHA’s requirements for substance abuse, psychiatric
and rehabilitation hospitals or units shall be deemed to meet TRICARE
requirements for certification and shall be reimbursed in accordance
with the provisions of Title 32 CFR Sec. 199.14, or at 80 percent of VHA’s reasonable
charges, whichever is lower.
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d.
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VHA
is responsible for refunding TRICARE overpayments in a timely fashion.
Upon discovery of an overpayment, the TRICARE contractor will issue
written notice of the basis for the overpayment to the applicable
VHA facility, which will include a request for repayment of an amount
due. The VHA facility will acknowledge receipt within 90 days of
the TRICARE contractor’s notification. In addition, the VHA facility’s
acknowledgment will contain any claim dispute, to include those
regarding the overpayment’s basis or the refund’s calculation. The
VHA facility may also request additional time to investigate potential
disputes. If the VHA facility does not respond or the TRICARE contractor
cannot resolve a claim dispute, the TRICARE contractor will refer
the case to the Chief, Claims Collection at DHA. If the VHA facility does
not submit a claim dispute, VHA will refund the amount due within180
days from the written notification. Upon resolution of claim disputes,
VHA, if appropriate, will issue a refund within 180 days.
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e.
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VHA
shall advise its providers of the applicable dual compensation/conflict
of interest provisions prohibiting VA employees from being authorized
as individual providers capable of billing in their own names for
services provided to TRICARE beneficiaries.
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f.
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DHA
accepts VHA quality assurance standards.
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g.
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VHA
will not be required to supply VHA provider social security numbers
to the TRICARE Contractors. TRICARE Contractors will not conduct
criminal background investigations on VHA providers.
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h.
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Eligible
TRICARE beneficiaries entitled to health care services under this
MOU shall be defined consistent with the TRICARE Program requirements.
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i.
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TRICARE
Beneficiaries shall be subject to copayments consistent with the
TRICARE Uniform Benefit requirements. If a TRICARE for Life (TFL)
beneficiary receives care at a VHA facility for a non-service related
condition, the beneficiary shall be advised by VHA that the maximum payment
by TRICARE will be limited to the co-payment that TRICARE would
have paid had the beneficiary seen a Medicare provider. The beneficiary
shall be advised that in these cases he or she will be personally
liable to the VHA facility for any remaining charges not covered by
other health insurance.
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j.
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With
regard to individuals with dual VA and DoD eligibility (does not
include Reserve Component Service Members on active duty orders
for greater than 30 days), VHA will be responsible for the following
beneficiary care: (a) all care for Veterans for service-connected conditions;
and, (b) care for any Veteran that is a continuation of care for
a condition previously under treatment at the VHA facility. With
regard to Reserve Component Service members serving on orders to
active duty for greater than 30 days (Reserve and National Guard
service members) DoD eligibility will take precedence over VA eligibility
for care and all applicable TRICARE rules (i.e. authorizations,
etc.) will apply.
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k.
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TRICARE
is the primary payer for service members (on active duty greater
than 30 days). Such members cannot use other health insurance. For
all other TRICARE beneficiaries, TRICARE is the secondary payer
to all health benefits and insurance plans, except for Medicaid,
TRICARE supplements, the Indian Health Service, and other programs/plans
as identified by the DHA. The TRICARE contractor will reimburse
VHA for care provided to TRICARE beneficiaries in accordance with
the VHA agreement reimbursement rate schedule. VHA shall make reasonable
efforts to obtain third party health insurance coverage information
from TRICARE beneficiaries other than active duty and will bill
and collect from the third party insurer in accordance with VHA
procedures. Pursuant to TRICARE policy, if VHA is unable to collect
from the third party insurer, TRICARE will pay as primary.
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l.
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Priority
of Care: No service provided under a Network Participation Agreement
between a TRICARE contractor and VHA as determined by the head of
the providing VHA facility, will adversely affect the range of services,
quality of care, or the established priorities for care provided
to the primary/core beneficiaries of the VHA facility providing
services under such agreement.
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V.
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Administrative
Responsibilities
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The Director,
TRICARE Health Plan (J-10) at DHA, in consultation with the VHA
Deputy Under Secretary for Health for Operations and Management,
shall conduct overall program management relating to agreements
between the TRICARE contractors and the VHA under the authorities
of this MOU.
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VI.
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DISPUTE
RESOLUTION
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a.
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Both
parties agree, to the extent possible, to resolve all disputes under
this agreement at the lowest possible level. All disputes will be
submitted in writing to the other party.
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b.
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Final
disposition of the dispute lies within the authority of the Parties’
signatory, or his/her designee, to this Agreement.
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VII.
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MODIFICATION
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Either
VHA or DHA may propose amendments modifying this agreement at any
time. Before any amendment becomes effective, both parties must
agree in writing to the modification. The effective date of any
amendments will be the date agreed upon and specified in the agreement,
or, if no date is specified, the last date upon which representative
officials of both parties have agreed in writing to the amendment.
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VIII.
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EFFECTIVE
DATE
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This
MOU becomes effective upon the last signatory date below for a period
not to exceed five years. Either party may cancel this MOU upon
60 calendar days-written notice.
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___________
// Original Signed//___________
Raquel V. Bono, VADM, MD
Director, Defense Health Agency
Department of Defense
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// Original Signed//___________
David J. Shulkin, MD
Under Secretary for Health
Department of Veterans Affairs
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March 16, 2017 ___________
Date of Signature
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January 04, 2017___________
Date of Signature
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