The contractor may, in addition
to receiving claims from civilian providers, 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.
3.2 Claims
for Care Provided Under the National DoD/DVA/VHA MOA for Spinal
Cord Injury (SCI), Traumatic Brain Injury (TBI), Blind Rehabilitation,
and Polytrauma
3.2.1 The
contractor shall process DVA/VHA submitted claims for eligible Service
members’ treated under the MOA in accordance with this chapter (SCI,
TBI MOA; see Addendum C for a full text copy
of the MOA for references purposes only).
3.2.2 The
contractor shall process claims received from a DVA/VHA health care
facility for eligible Service member care as an MOA claim based
upon the Defense Health Agency-Great Lakes (DHA-GL) SAS authorization number.
3.2.2.1 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.
3.2.2.2 The authorization shall clearly
indicate that the care has been authorized under the SCI, TBI, Blindness,
and Polytrauma MOA.
3.2.2.3 The
authorization shall specify type of care (e.g., inpatient, outpatient)
to be given under the referenced MOA and limits of the authorization
(e.g., inpatient days, outpatient visits, expiration date).
3.2.2.4 Suggested authorization language
to possibly include “all care authorized under the SCI, TBI, Blindness,
and Polytrauma MOA” for inpatient, outpatient and rehabilitative
care.
3.2.2.5 SAS
shall send authorizations to the contractor either by fax or by
other mutually agreed upon modality.
3.2.3 The
contractor shall verify whether the DVA/VHA-provided care has been
authorized by the SAS.
3.2.4 The
contractor shall process the claim to payment if an authorization
is on file.
3.2.5 The
contractor shall not deny claims for lack of authorization. If a
required authorization is not on file, the claim will be placed
in a pending status.
3.2.6 The
contractor shall forward the appropriate documentation to the SAS
identifying the claim as a possible MOA claim for determination
(following the procedures in the TRICARE Systems Manual (TSM),
Chapter
1 for the SAS referral and review procedures).
3.2.7 The
contractor shall pend claims to the SAS for payment determination
for any DVA/VHA submitted claim for an eligible Service member with
a TBI, SCI, blindness, or polytrauma condition that does not have
a matching authorization number.
3.2.8 The
contractor shall reimburse MOA claims as follows:
3.2.8.1 The contractor shall pay claims
for inpatient care 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.
3.2.8.1.1 The
contractor shall pay the claim using the separate rates if the DVA/VHA-submitted
claim identifies more than one rate (with the appropriate number
of days identified for each separate rate) (e.g., a stay for SCI
may include days paid with the SCI rate and days billed at a surgery
rate.)
3.2.8.1.2 The
contractor shall verify the DVA/VHA billed rate on inpatient claims
matches one of the interagency rates provided by DHA.
3.2.8.1.2.1 The contractor shall not develop
DVA/VHA claims for inpatient care submitted with an applicable interagency
rate any further (e.g., for revenue codes, diagnosis) if care has
been approved by the DHA/SAS.
3.2.8.1.2.2 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.
3.2.8.2 The contractor shall pay claims
for outpatient and ambulatory surgery professional services at the appropriate
TRICARE allowable rate (e.g., CHAMPUS Maximum Allowable Charge (CMAC))
with a 10% discount applied.
3.2.8.3 The contractor shall pay DVA/VHA
claims at billed charges for services without a TRICARE allowable rate.
3.2.8.4 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 or outpatient TBI
evaluations
• Special diagnostic procedures
• Inpatient or outpatient polytrauma
transitional rehabilitation program
• Home care
• Personal care attendants
• Conjoint family therapy
• Ambulatory surgeries
• Cognitive rehabilitation
• Extended care including nursing
home care
3.2.8.5 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.
3.2.8.6 If paid at per diem rates,
the provisions of Chapter 8, Section 2, apply
when enrollment changes in the middle of an inpatient stay. If enrollment
changes retroactively, prior payments will not be recouped.
3.3 Claims
for Care Provided Under the National DoD/DVA/VHA MOA for Payment
for Processing Disability Compensation and Pension Examinations
(DCPE) in the Integrated Disability Evaluation System (IDES)
3.3.1 The
contractor shall reimburse the DVA/VHA for services provided under
the current national DoD/DVA/VHA MOA for “Processing Payment for
Disability Compensation and Pension Examinations in the Integrated Disability
Evaluation System” (IDES MOA; see Addendum B for
a full text copy of the MOA for reference purposes only).
3.3.2 The
contractor shall process claims under the IDES MOA in accordance
with this chapter and the following:
3.3.2.1 Claims submitted by any DVA/VHA
facility/provider for an eligible 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 an IDES MOA claim. IDES MOA claims are SHCP claims.
3.3.2.2 The contractor shall consider
the referral as a blanket authorization to process claims from any
billing DVA/VHA facility or provider for authorized/DCPE exams and
associated ancillary services under the IDES MOA, although the Market/MTF
referral will specify a particular DVA/VHA facility/provider to
provide the IDES MOA services.
3.3.2.3 The Market/MTF will generate
a single referral and submit the referral to the contractor. The
Market/MTF will complete the referral as described in Chapter
7, Section 5.
3.3.2.4 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 Market/MTF as “DVA/VHA only: Disability Evaluation System
(DES) C&P exams for fitness for duty determination - total.”
3.3.3 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.
3.3.4 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).
3.3.5 The
contractor shall process the claim to payment (refer to
paragraph 2.3)
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). 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 Market/MTF.
3.3.6 The
contractor shall verify that the claim contains CPT code 99456 or
ICD-9/ICD-10 code V68.01/Z02.71, and process the claim to payment,
if an IDES MOA claim is received from the DVA/VHA (
paragraph 3.2.1)
and no authorization is on file.
3.3.7 The
contractor shall process all claims for C&P exams as SHCP using
the pricing provisions agreed upon in the IDES MOA. CPT code 99456
shall be used and will be considered to include all parts of each
C&P examination, except ancillary services.
3.3.8 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 Exam Pay Schedule
|
Effective Date
|
C&P Disability Exam (99456)
|
ancillary services
|
|
01/01/2011
|
$515.00
|
CMAC - 10%
|
3.3.9 The
contractor’s TED records for this care shall include SPC DC (C&P
Examinations-DVA/VHA), SPC 17 (VA Medical Provider
Claim), and Enrollment Health Plan Code SR (SHCP-Market/MTF
Referred Care).