Military Health System

Provider Network Agreements with the Managed Care Support Contractors (MCSCs) are done at a national level. All DVA/ VHA facilities with signed TRICARE Network Agreements shall be included as network providers. See Chapter 11, Section 2.1, which includes the Memorandum Of Understanding (MOU) for the policy concerning this program. Contractors processing claims submitted from DVA/VHA medical facilities shall continue to use the usual claims processing procedures to include medical necessity, Explanation of Benefits (EOB), Other Health Insurance (OHI) and Third Party Liability (TPL). DVA/VHA medical facilities shall be subject to the same Utilization Management (UM) and Quality Assurance (QA) requirements applicable to other network providers. The contractor shall ensure that all DVA/VHA Health Care Finders, institutional, and individual professional providers are properly trained in and comply with the provisions of TRICARE quality and utilization management programs. The effective date for TRICARE coverage of services provided by a network DVA/VHA medical facility is determined by the agreement between the DVA/VHA and the MCSC. Only services furnished on or after the effective date will be considered for TRICARE payment.

Medical facilities meeting DVA/VHA certification requirements, shall be deemed to meet TRICARE requirements pertaining to certification for network provider status. The contractor shall accept DVA/VHA assertion of licensure and credentials for its providers, as well as facility/program certification and shall not conduct additional validation. The contractor shall assign the DVA/VHA medical facility a Unique Identifier Number (UIN) which will identify the claim as a TRICARE claim, with care rendered in a DVA/VHA medical facility.

Individual providers who meet DVA/VHA credentialing requirements including licensure and certification, shall be deemed to meet TRICARE requirements. The contractor shall accept DVA/VHA assertion of licensure and credentials for its providers, as well as facility/program certification and shall not conduct additional validation. The DVA/VHA medical facility will provide a monthly provider specialty listing to the contractor. The contractor shall create provider records in accordance with the TRICARE Systems Manual (TSM).

All claims will be submitted by the DVA/VHA medical facility and shall be processed as participating claims even if not so indicated on the claim form. Beneficiary submitted claims for care received at the DVA/VHA medical facility shall be denied using the EOB message: “Claims must be filed by the DVA/VHA Medical Facility.”

Reimbursement shall be based on a percentage discount off the CHAMPUS Maximum Allowable Charge (CMAC), the state prevailing, Diagnosis Related Group (DRG), or other methodology such as per diems for all types of services. Cost-shares and deductibles will be withheld prior to payment being made directly to the DVA/VHA medical facility. The contractor shall negotiate reimbursement rates with the DVA/VHA.