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 The contractor
shall process claims received from a DVA/VHA health
care facility for Service member care as
an MOA claim based upon the Defense Health Agency-Great Lakes (DHA-GL)
Specified Authorization Staff (SAS) authorization number. As determined
by SAS, the contractor shall authorize and pay for all
medical conditions under this MOA if
a condition of TBI, SCI, Blindness, or Polytrauma exists for the
patient. The contractor shall ensure the authorization clearly
indicates that the care has been authorized
under the SCI, TBI, Blindness, and Polytrauma MOA. The contractor
shall ensure authorization specifies 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 The
contractor shall reimburse MOA claims
as
follows:
3.1.4.1 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 contractor
shall apply the Rehabilitation Medicine rate 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. The contractor shall not develop DVA/VHA
claims for inpatient care submitted with an applicable interagency
rate any further (i.e., for revenue
codes, diagnosis, etc.) if care has been approved by the DHA/SAS. The
contractor shall deny claims without an applicable
interagency rate and the
contractor shall issue an Explanation of Benefits
(EOB) to the DVA/VHA, but not the beneficiary.
The claim will need to be resubmitted for payment.
3.1.4.2 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)) and apply a
10% discount. For those services without
a TRICARE allowable rate, the contractor shall reimburse
the DVA/VHA 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.The contractor shall
include Special Processing Code (SPC) 17 - DVA/VHA
medical provider claim, in all TRICARE Encounter Data
(TED) records for this care.
3.1.4.5 If paid at per diem rates,
the
contractor shall apply the provisions
of
Chapter 8, Section 2, paragraph 7.2,
when
enrollment changes in the middle of an inpatient stay. If enrollment
changes retroactively,
the contractor shall not recoup prior
payments
.
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.
The
contractor shall process claims under the IDES MOA
in
accordance with this chapter and the following:
3.2.1 The
contractor shall process 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, Clinical Modification (ICD-9-CM)
diagnostic code of V68.01, or International Classification of Diseases,
10th Revision, Clinical Modification (ICD-10-CM)
diagnostic code of Z02.71 (Disability Examination) as
a IDES MOA claim. IDES MOA claims are SHCP claims.
3.2.2 The
Market/MTF
will
generate a single referral and submit the referral to the contractor. Although
the
Market/MTF
referral
will 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
Market/MTF
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
Market/MTF
will enter
the referral reason 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. The
DVA/VHA may bill related ancillary services on
the same claim form or on a separate claim form identified by the
single diagnosis of ICD-9-CM/ICD-10-CM diagnostic
code, V68.01/Z02.71 (Disability Examination).
3.2.4 If
the contractor
receives an IDES MOA claim
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).
The contractor
shall pay one C&P examination fee
for
each referred and authorized C&P examination up to the total
number of C&P examinations authorized by the referring
Market/MTF
.
3.2.5 If
the
contractor receives an IDES MOA claim
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
or ICD-9
-CM code
V68.01
or ICD-10-CM 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 The
contractor shall pay claims for C&P exams
as
SHCP using the pricing provisions agreed upon in the IDES MOA.
The
contractor shall use CPT procedure code 99456
and
shall consider
the
code to include all parts of each C&P examination,
except ancillary services.
The contractor shall pay
claims for related ancillary services
at
the appropriate TRICARE allowable rate (e.g., CMAC)
and
apply a 10% discount
.
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 The
contractor 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, for all TRICARE Encounter Data
(TED) records for this care.