Military Health System

The Departments of Veterans Affairs (VA) and Defense (DoD) have a shared responsibility to ensure the highest quality of service is delivered efficiently, compassionately, and with minimal inconvenience to our Service Members in the DoD and VA Disability Evaluation System (DES). The Service Member’s experience when participating in the DoD and VA DES will be that the individual is dealing with one Federal health care system or agency. To facilitate these goals, this Memorandum of Agreement (MOA) establishes expected roles, procedures, and outcomes for VA and DoD regarding the processing of Compensation and Pension (C&P) disability examination requests. It also addresses the reimbursement procedures for these examinations.

1) Maintain those components of the VA Compensation and Pension examination system necessary to ensure objective assessment of disabilities of Service Members identified by Military Health System (MHS) personnel as requiring a Medical Evaluation Board (MEB) as part of the DES.

2) Conduct C&P examinations as requested in the DES for both medical conditions to be considered as the basis of fitness for duty determination, and for those claimed by the Service Member.

3) Bill the MHS via the appropriate Regional TRICARE contractors, for those services which are related to medical conditions to be considered as the basis of fitness for duty determination.

1) Identify to VA those Service Members requiring a MEB, and the medical conditions which may render a Service Member unable to fully perform assigned duties or causes them to fall below Service medical retention standards via completion of Section I of the VA Form 21-0819, VA/DoD Joint Disability Evaluation Board Claim.

2) Reimburse VA for C&P services related to DoD-identified medical conditions to be considered as the basis of evaluation for fitness for duty. The services covered will include a C&P General Medical Examination and other C&P examination services related to medical conditions in Section I of the VA Form 21-0819. Additional conditions may be found later in the DES process that may also be used for determination of fitness. Authorization process for conditions identified in Section I of VA Form 21-0819 is discussed in Attachment D.

A.

A DES program oversight contact (POC) will be appointed at each TRICARE Regional Office (TRO), VA Regional Office (VARO), VA Medical Center/Facility and Military Treatment Facility (MTF). The DES oversight official duty may be a collateral duty.

B.

The DoD DES health care provider will determine the conditions that may render the Service Member unable to meet Service medical retention standards or call into question the member’s ability to continue military service. The DoD DES health care provider will annotate these conditions in Section I of VA Form 21-0819 (Attachment A), under “MEDICAL CONDITIONS TO BE CONSIDERED AS THE BASIS OF FITNESS FOR DUTY DETERMINATION.”

C.

The VA Military Services Coordinator (MSC) will coordinate with the Service Member and identify any additional conditions the member may wish to claim for purposes of VA compensation and/or pension. The MSC will annotate these conditions in Section III, Field 8 of the VA Form 21-0819, Additional Conditions. Upon completion of the VA Form 21-0819, the VA MSC will provide the completed form to the local VA medical center billing office.

D.

VA will use the Compensation and Pension Record Interchange (CAPRI) examination request system when possible to transmit data regarding the request, scheduling, completion, and reporting of C&P examinations so that VA and DoD will have notice of C&P examination data and reports. VA and DoD will operate in a provider-to-provider relationship. Transmission of data which cannot be accommodated in CAPRI, such as photocopies of health care documentation, will be resolved on a facility-to-facility basis. All examination requests entered into CAPRI will, at a minimum:

1) State the examination is for a Service member in the DES.

2) Identify specific C&P examination(s) required.

3) Identify specific condition(s) to be evaluated in each C&P examination.

E.

VA will report to the DoD MTF representative the C&P examinations required by the Service Member for evaluation of conditions in Section I of VA Form 21-0819. DoD will use the Military Health System referral management system to transmit an authorization for the VA-reported C&P services to the appropriate Regional TRICARE contractor as outlined in Attachment B. The contractor will in turn transmit the authorization to the appropriate VA medical facility billing office.

F.

Based on findings at the time of the C&P examination and the instructions on the requested Automated Medical Information Exchange (AMIE) worksheet, the Service Member may need to undergo additional examinations. VA will conduct C&P examinations and those other ancillary services needed to complete the C&P examinations for the DES.

G.

DoD and VA will promote the use of approved templates to provide the requested information.

H.

Selected examinations may be conducted using telemedicine technology (a telephonic contact with the Service Member and/or video contact with the Service Member) when clinically and administratively appropriate.

I.

Billing. VA will bill the appropriate regional TRICARE contractor for C&P examination health services related to medical conditions identified in VA Form 21-0819, section I. VA Billing Procedures are contained in Attachment B. Electronic billing is desired and should be used when practical.

J.

Reimbursement. MHS (TRICARE) will reimburse VA for a C&P General Medical Examination, examinations provided for evaluation of medical conditions identified in VA Form 21-0819, Section I, and ancillary services.

K.

VA and DoD, working cooperatively, will make every effort to process claims and resolve issues identified by the other agency in a timely manner. If VA and DoD cannot resolve the issue, it will be forwarded to the Health Executive Committee (HEC) Financial Management Workgroup for final resolution.

A.

Complete C&P examination reports will be available in CAPRI and the Bidirectional Health Information Exchange (BHIE). On average, these reports will be provided by VA and if available, in CAPRI/BHIE, 35 calendar days from the date VA registers as received a properly completed request for examination(s). Complete C&P examination reports include all necessary laboratory and ancillary test results. The C&P examination reports will, at a minimum:

1) Provide the required information from the requested AMIE worksheet(s) and the additional exams identified during the initially ordered C&P examinations.

2) Provide data that will meet DoD/VA DES requirements as documented in the C&P disability examination worksheets, provide results of any additional examinations identified later in the DES process, and adequately address any matters identified in the request for a medical opinion.

B.

Reports. The following reports will be based on the claims submitted to the appropriate Regional TRICARE contractor during the reporting time.

1) On a monthly basis, VA Compensation and Pension Examination Program (CPEP) will prepare C&P timeliness reports listing facility processing times. The C&P timeliness reports will be posted/shared with the MHS and TRO program officials.

2) On a quarterly basis VA will produce a data file of examinations and services provided to Service Members in the DES whose exams have been completed by VA. The file will be shared with the MHS and TRO program officials.

A.

VA will submit a bill to MHS through the TRICARE Managed Care Support (MCS) contracts. VA will bill for C&P examinations and ancillary services associated with the medical conditions which may render a Service Member unable to fully perform assigned duties and/or are to be considered as the basis of fitness for duty determination as listed in Section I of the VA Form 21-0819.

B.

Neither VA nor DoD will bill the Service Member for these C&P examinations and ancillary services as all examinations and services rendered in the DES are authorized and provided by either DoD or VA.

C.

At the present time, the Current Procedural Terminology (CPT) code 99456 does not have a CHAMPUS Maximum Allowable (CMAC) rate. DoD will pay VA the national reasonable charges amount for each exam for CPT code 99456. Ancillary services will be reimbursed based on CMAC less ten percent. Upon agreement of the HEC Financial Management Working Group, and with a minimum two-month advance notification to the contractors, billing procedures may be changed effective annually, on or about 1 January.

D.

VA and DoD will audit services provided and billed quarterly to ensure all C&P examinations and services for which DoD paid were for conditions annotated in Section I of VA Form 21-0819.

E.

C&P examinations and services for conditions claimed in Section III of VA Form 21-0819 will be funded by VA appropriations.

A.

This agreement provides a framework for VA facilities and MTFs to develop local agreements that will address more specific information on operations to implement this program. All local agreements addressing the DoDNA DES shall refer to this MOA.

B.

Requests for modification of this agreement will be submitted in writing from one party to the other, not less than 60 days prior to the desired effective date of such modification.

C.

An annual review of this agreement, including rate structure, will be conducted by both parties to ensure compliance with each Departments’ policies.

D.

This agreement will be renewed automatically on its anniversary date unless either party gives a written 90-day notice of termination or a new agreement is implemented. The provisions are in effect until it is superseded by a new MOA or terminated.

E.

The provisions of this agreement are effective 30 days from the date both approving signatures have been affixed.

Authority: This MOA is entered into under the authority of titles 10 and 38, United States Code (USC), including sections 513 and 8111 of title 38 and chapters 55 and 61 of title 10.

Associated Memoranda of Understandings (MOU): A separate MOU exists and must be consulted regarding processing of Benefits Delivery at Discharge (BDD) exams.

A)

B)

C)

D)

VA Form 21-0819

VA Billing Guidance

CMS -1500 Example

DoD Referral Guidance