In addition to receiving claims
from civilian providers, the contractor may also receive SHCP claims
from the DVA/VHA. 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/VHA.
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
/VHA 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/VHA 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
/VHA-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
/VHA 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/VHA 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/VHA-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/VHA billed
rate on inpatient claims matches one of the interagency rates provided
by DHA. DVA/VHA 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/VHA,
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/VHA 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
/VHA cost) separately from DVA
/VHA 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/VHA 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
/VHA 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/VHA 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
/VHA 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
/VHA 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/VHA only:
Disability Evaluation System (DES) C&P exams for fitness for
duty determination - total __.”
3.2.3 The DVA/VHA 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
/VHA (
paragraph 3.2.1)
and an authorization to any DVA
/VHA 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
/VHA (
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/VHA,
SPC 17 - DVA/VHA Medical
Provider Claim, and Enrollment Health Plan Code SR -
SHCP-Referred Care.