Appendix A - Implementing
Instructions
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This appendix provides instructions
to implement the provisions of the Memorandum of Agreement (MOA)
between the Department of Veterans Affairs (DVA) and the Department
of Defense (DoD) for medical treatment provided by Veterans Affairs
Medical Facilities to Service members with a polytrauma injury,
Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), or blindness.
This appendix is not intended to alter the provisions of the MOA.
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1.
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Program Descriptions
and Definitions
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a.
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Traumatic Brain Injury
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TBI is defined as traumatically
induced structural injury and/or physiological disruption of brain function
as a result if an external force that is indicated by any period
of loss of or decreased Level Of Consciousness (LOC), loss of memory
for events immediately before or after the injury (Post-Traumatic
Amnesia [PTA]), alteration in mental state at the time of the injury
(confusion, disorientation, slowed thinking, etc.) (Alteration Of
Consciousness/mental state [AOC]), neurological deficits (weakness,
loss of balance, change in vision, praxis, paresis/plegia, sensory loss,
aphasia, etc.) that may or may not be transient or intracranial
lesion.
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This MOA includes individuals
sustaining a TBI and damage to the central nervous system resulting
from anoxic/hypoxic episodes, related to trauma or exposure to chemical
or environmental toxins that result in brain damage.
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This MOA does not include brain
injuries/insult related to acute/chronic illnesses (i.e., cerebrovascular
accident, aneurysm, hypertension, tumors, diabetes, etc.). Patients
with other acquired brain injuries due to acute/chronic disease
or infectious processes are not covered under this MOA but are eligible
for care in these centers under TRICARE network agreements.
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b.
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Polytrauma
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Polytrauma is defined as two
or more injuries sustained in the same incident that affect multiple body
parts or organ systems and result in physical, cognitive, psychological,
and/or psychosocial impairments and functional disabilities. TBI
frequently occurs as part of the polytrauma spectrum in combination
with other disabling conditions such as amputations, burns, pain, fractures,
auditory and visual impairments, Post-Traumatic Stress Disorder
(PTSD), and other mental health conditions. When present, injury
to the brain is often the impairment that dictates the course of
rehabilitation due to the nature of the cognitive, emotional, and
behavioral deficits related to TBI. Due to the severity and complexity
of these injuries, veterans and Service members with polytrauma
require an extraordinary level of coordination and integration of clinical
and other support services.
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c.
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Polytrauma/TBI System
of Care (PSC)
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Prior to the Operation Enduring
Freedom and Operation Iraqi Freedom (OEF/OIF) conflicts, DVA provided
specialized rehabilitation for Service members with TBI at DVA facilities
designated as TBI Centers and TBI Network sites. Since 2005, DVA
has implemented the PSC consisting of an integrated nationwide network
of over 100 facilities with specialized rehabilitation programs
for veterans and Service members with polytrauma and TBI. Specialized
polytrauma and TBI care is provided at the facility closest to the
patient’s home with the expertise necessary to manage his/her rehabilitation,
medical, surgical, and mental health needs. The components of the
PSC include:
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(1)
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Polytrauma/TBI Rehabilitation
Center (PRC)
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Four regional PRCs provide
medical care for all conditions associated with the injury event. Referral
of Service members with moderate to severe TBI or polytrauma must
be made to an appropriate regional PRC. Each PRC provides the same
level services and programming including an emerging consciousness
program, intensive interdisciplinary inpatient rehabilitation, short
stay admissions for comprehensive evaluations, assistive technology evaluations,
and access to all medical and surgical specialties. (Note: Additional
PRC’s may be constructed).
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(2)
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Polytrauma/TBI Transitional
Rehabilitation Program (PTRP)
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The inpatient PTRP provide
a transition in the continuum of care from acute TBI programs to a
community living setting. PTRPs are offered at the DVA PRCs as a
continuation of rehabilitation setting in a residential, group-based,
interdisciplinary care setting. The goal of transitional rehabilitation
is to return the person to the least restrictive environment including
return to active duty, work and school, or independent living in
the community with meaningful daily activities. The treatment program
focuses on a progressive return to independent living through a
structured program focused on restoring home, community, leisure,
psychosocial, and vocational skills in a controlled, therapeutic
setting.
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(a)
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Polytrauma/TBI Residential
(Inpatient) Transitional Rehabilitation.The residential program
is a time-limited and goal-oriented program designed to improve
the resident’s physical, cognitive retraining and rehabilitation,
communicative, behavioral, psychological and social functioning
with the necessary support and supervision. A dedicated interdisciplinary
team provides treatment and therapeutic activities seven days per
week as well as 24/7 nursing care on the bed unit.
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(b)
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Polytrauma/TBI Day Transitional
Rehabilitation Program. Service members and veterans that
do not require an inpatient setting and have living arrangements
in the community may participate in the PTRP as a day patient. An
individual treatment plan is developed for each patient and typically
includes three to five hours of treatment each day based on clinical
need.
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(3)
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Polytrauma Network Sites
(PNSs)
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PNSs provide post-acute rehabilitation
for veterans and Service members with polytrauma and TBI who reside
within their Veterans Integrated Service Network (VISN) catchment
area. This includes inpatient rehabilitation for those transitioning
closer to home, comprehensive outpatient Tim evaluations, a full
range of outpatient therapy services, evaluations for DME and assistive
technology, access to other consultative specialists, and follow
up evaluations and case management for ongoing rehabilitation needs.
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(4)
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Polytrauma Support Clinic
Teams (PSCTs)
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PSCTs provide interdisciplinary
outpatient rehabilitation services in their catchment areas for veterans
and Service members with mild and/or stable impairments from polytrauma
and TBI. Services include comprehensive TBI evaluations, outpatient
therapy services, management of stable rehabilitation plans referred
from PRCs and PNSs, coordinating access to DVA and non-DVA services,
and follow up evaluations and case management for ongoing rehabilitation
needs.
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(5)
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Polytrauma Point of Contact
(PPOC)
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DVA Medical Centers (DVAMCs)
designated as PPOC sites have the capability of providing some outpatient
rehabilitation therapies and may have the expertise to complete
a TBI evaluation. A designated PPOC ensures that patients with polytrauma
and TBI are referred to a facility and program capable of providing
the level of rehabilitation services required.
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(6)
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Polytrauma/TBI Case Management
and Care Coordination
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Clinical case management and
coordination of care is provided to individuals with polytrauma
and TBI across the PSC and in collaboration with other agencies
and institutions, e.g., Veterans Health Administration (VHA), Veterans
Benefits Administration (VBA), DoD, state, and local agencies. DVA
PSC case managers are knowledgeable of the resources available across
the DVA for specialized care.
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A list of DVA Polytrauma/TBI
Rehabilitation Centers and Network Sites (PNSs) is in Appendix B,
Table 1. This does not include all of the DVA facilities
that serve Service members under this MOA. PRCs and PNSs are familiar
with DVA services available in their VISN and assist with coordination
of referrals.
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d.
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Spinal Cord Injury and
Disorders (SCI&D)
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(1)
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The mission of the Program
within DVA is to promote the health, independence, quality of life,
and productivity of individuals with SCI&D. SCI Centers available
throughout DVA to provide acute rehabilitative services to persons
with new onset SCI are listed in Appendix B, Table 2.
DVA offers a unique system of care through SCI Centers, which includes
a full range of health care for eligible persons who have sustained
injury to their spinal cord or who have other spinal cord lesions.
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(2)
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Persons served in these centers
include those with: stable neurological deficit due to SCI, intraspinal,
non-malignant neoplasms, vascular insult, cauda equina syndrome, inflammatory
disease, spinal cord or cauda equina resulting in non-progressive
neurologic deficit, demyelinating disease limited to the spinal
cord and of a stable nature, and degenerative spine disease.
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e.
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Blind Rehabilitation
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(1)
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Blind Rehabilitation Service
offers a coordinated educational training and health care service delivery
system that provides a continuum of care for veterans with blindness
that extends from their home environment to the local DVA facility,
to the appropriate rehabilitation setting. These services include
adjustment to blindness counseling, patient and family education,
benefits analysis, assistive technology, outpatient programs, and
residential inpatient training. The residential inpatient DVA Blind
Rehabilitation Centers (BRC) arc listed in Appendix B, Table
3.
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(2)
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The mission of each BRC program
is to educate each veteran on all aspects of Blind Rehabilitation
and address the expressed needs of each veteran with blindness so
they may successfully reintegrate hack into their community and
family environment. To accomplish this mission, BRCs offer a comprehensive,
individualized adjustment-training program along with those services
deemed necessary for a person to achieve a realistic level of independence.
BRCs offer a variety of skill courses including: orientation and
mobility, communication skills, activities of daily living, manual
skills, visual skills, leisure skills, and computer access training.
The veteran is also assisted in making an emotional and behavioral adjustment
to blindness through individual counseling sessions and group therapy meetings.
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(3)
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Each DVAMC has a Visual Impairment
Services Team Coordinator who has major responsibility for the coordination
of all services for visually impaired veterans and their families.
Duties include arranging for the provision of appropriate treatment
modalities (e.g., referrals to Blind Rehabilitation Centers and/or
Blind Rehabilitation Outpatient Specialists) and being a resource
for all local service delivery systems in order to enhance the functioning level
of veterans with blindness. Referrals can be directed to the Program
Analyst in the Blind Rehabilitation Program Office in DVA Central
Office at 202-461-7331.
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2.
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Medical Management
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a.
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Transfer Criteria for
Patients with SCI, TBI, Blindness, or Polytrauma
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Prerequisites for transfer
include: identifying an accepting staff physician at the DVA facility, stabilization
of the patient’s injuries, and the acute management of the medical
and physiological conditions associated with the SCI, TBI, blindness,
or polytrauma.
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(1)
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Patients must be stabilized
prior to transfer to the DVA health care facility. Stabilization
is an attempt to prevent additional impairments while focusing on
prevention of complications. The criteria for the transfer of patients
with SCI, TBI, blindness, or polytrauma are:
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• Attention to airway and adequate
oxygenation;
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• Treatment of hemorrhage, no
evidence of active bleeding;
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• Adequate fluid replacement;
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• Maintenance of systolic blood
pressures (>90 mm mercury hydrargyrum (Hg));
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• Foley catheter placement, when
appropriate, with adequate urine output:
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• Use of a nasogastric tube,
if paralytic ileus develops;
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• Maintenance of spinal alignment
by immobilization of the spine, or adequate stabilization to prevent
further neurologic injury (traction, tongs and traction, halo-vest,
hard cervical collar, body jacket, etc.); and
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• Approval by the SCI Center
Chief, TBI/Polytrauma Center Medical Director or Designee, or Blind
Rehabilitation Chief in consultation with other appropriate DVA specialty
care teams.
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(2)
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The responsible Military Treatment
Facility (MTF) must notify the DVA facility of any changes in medical
status in detail prior to transfer and must provide appropriate
medical documentation to ensure the accepting team has all necessary
information to provide seamless care. Every effort should be made
to allow both verbal and written communication between referring
and accepting treatment teams.
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A list of instances in which
patients are not to be transferred is as follows:
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• Deteriorating neurologic function;
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• An inability to stabilize the
spine, especially if the neurologic injury is incomplete;
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• Bradyarrhythmias are present;
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• An inability to maintain systolic
blood pressure >90 mm Hg;
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• Acute respiratory failure is
present; or
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• New onset of fever, infection
and/or change in medical status (e.g., deteriorating physiological
status).
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b.
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MTF Requests for DVA
Facility Treatment
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MTF requests for DVA facility
treatment under the MOA shall include the following information.
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• Reason for referral, list of
all current diagnoses including International Classification of Diseases,
Clinical Modification 9 (ICD-9-CM), and any expectations for treatment;
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• Responsible MTF, MTF physician,
and DoD case manager;
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• Relevant
clinical documentation which shall include history and physical,
narrative summary, diagnostic test results, laboratory findings,
hospital course, progress notes, etc., as applicable.
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Upon acceptance, the DVA facility
accepting the Service member for treatment will provide accepting
physician, POC information for authorization purposes.
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c.
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Preauthorization Requirements
for Initiation of Treatment by VAMC
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(1)
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Requests for preauthorization
include information similar to that specified in paragraph 2.b., plus
the following information:
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• Responsible MTF POC for authorization
coordination, for Medical Evaluation Board (MEB), and other relevant
POCs.
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• Brief statement of planned
treatment and expected length of treatment.
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(2)
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TRICARE Management Activity
(TMA) will either request additional information or issue the determination
to the responsible MTF and the identified DVA facility within two
business days of receipt of request for authorization. If TMA approves
the request, TMA will simultaneously provide the authorization to
the contractor to file in its medical management information system.
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(3)
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Preauthorizations for inpatient
treatment will expire no later than 21 calendar days from admission
date.
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(4)
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Preauthorizations for outpatient
treatment will expire no later than 30 calendar days from the first
outpatient visit.
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d.
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Continued Treatment Authorization
Requirements
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(1)
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Requests for continued treatment
authorization include information similar to those specified in
paragraph 2.b., plus the following information:
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• A master treatment plan that
includes all multidisciplinary, services
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• Anticipated length of stay
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• Prognosis for condition in
which treatment is being provided
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(2)
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The treating DVA facility shall
submit requests for continued inpatient treatment to TMA (with copy
to the MTF authorization POC) no later than five business days before
expiration of the current authorization. TMA will issue determinations
for continued inpatient treatment to the treating DVA facility,
no later than two business days before expiration of the current
authorization. Continued inpatient treatment authorizations shall
not exceed 90 days. TMA will simultaneously provide the authorization
to the treating DVA facility, the responsible MTF and to the contractor,
to file in its medical management information system.
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(3)
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The treating DVA facility shall
submit requests for continuing outpatient treatment (including outpatient
treatment immediately following inpatient treatment authorized under
this MOA) to TMA (with copy to the MTF authorization POC) no later
than five business days before expiration of the current authorization.
TMA will issue determinations for continued outpatient treatment
no later than two business days before expiration of the current
authorization. Continued outpatient treatment authorizations shall
not exceed 90 days. TMA will simultaneously provide the authorization
to the treating DVA facility, the responsible MTF and to the contractor,
to file in its medical management information system.
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e.
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Retroactive Treatment
Authorization Requirements
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If a Service member is admitted
to DVA health care without an authorization, or if the patient was seen
without knowledge of a TBI, SCI, or blindness condition or assessment
need, DVA facilities will request retro-active authorizations from
TMA DHA-GL. If the patient is still an inpatient at the DVA facility,
DHA-GL will issue the authorization retro-active to the date the
admission occurred. if the patient has been discharged from inpatient
care, DVA facilities will bill the contractor for the care, and
the SASs at DHA-GL will review the request.
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f.
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Case Management
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Additionally, care coordination
support services will be provided by TMA in collaboration with the
responsible MTF, and the treating DVA facility as a joint collaboration
appropriate to each individual Service member’s case. Evaluation
for case management under this MOA may involve case management initiatives
of the DoD and the DVA for wounded, ill, and injured Service members.
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If these patients meet the
criteria, DVA Case Managers will notify the Federal Recovery Coordinators
of their admission to a DVA facility.
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g.
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Inpatient Discharge Planning
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Patients identified for discharge
will need an appropriate treatment plan for outpatient care.
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h.
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Home Supplies and Durable
Medical Equipment (DME)
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Home supplies and DME reimbursable
under this MOA require separate authorization from the TMA. It is
recognized that DME requests are often for equipment not routinely
covered under the TRICARE Uniform Benefit, but are appropriate for
issuance to Service members covered by this MOA.
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i.
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Disability Evaluation
System (DES)
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(1)
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The treating DVA facility will
provide clinical information to the military provider for purposes of
MTF completion of MEB forms and provide the clinical information
to that MTF for the board.
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(2)
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It is recognized that the DoD
and the DVA are working collaboratively to update and improve the
DES. Individuals shall not be excluded from any of these initiatives
simply because they are receiving services under this MOA.
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3.
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Additional Reimbursement
and Billing Requirements to the MOA
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a.
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TMA will provide all required
care authorizations for the inpatient Polytrauma/TBI Transitional Rehabilitation
Program with one authorization number each for Inpatient and Outpatient programs
as required. DoD will reimburse DVA using the DVA interagency rate
for inpatient treatment and care, if applicable, CMAC minus 10%
for outpatient care, or DVA’s actual cost.
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b.
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Inpatient and Outpatient TBI
evaluations to determine a diagnosis of TBI will be covered under this
MOA to include comprehensive medical and neuropsychological testing,
assessment and evaluation TBI due to a brain injury caused by an
external physical force resulting in open and closed injuries, and
damage to the central nervous system resulting from anoxic/hypoxic episodes,
related to trauma or exposure to chemical or environmental toxins
that result in brain damage. TMA will provide all required care
authorizations, using one authorization number, relating to care
provided under Appendix A once the member is admitted
to or assigned to a DVA facility. If the Service member is not diagnosed
with a TBI, he/she will be managed as any other Service member TRICARE
patient. Outpatient care may be authorized under the terms of this
MOA for Service members who have not received inpatient treatment
for the covered condition.
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c.
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A DVA facility providing care
under this agreement that is also a TRICARE network provider will be
paid in accordance with this agreement and not the network agreement.
Claims shall be forwarded to the TRICARE contractor for the TRICARE
Region to which the member is enrolled in TRICARE Prime. If the
member is not enrolled, the claim will be paid by the regional TRICARE contractor
where the member resides based on the address on the claim. Prior
to paying a claim, if questions arise, contractors will verify that
the care is payable through TMA. TMA can be reached at 888-647-6676
or by mail at P.O. Box 88699, Great Lakes, IL 60088-6999.
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d.
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The DVA Facility, in collaboration
with DHA-GL or the contractor, will identify an appropriate network
provider, and obtain authorization for all non-DVA care from TMA
if the DVA facility is unable to provide, or retain medical management
of care. If the DVA is transferring medical management to the MTF,
the MTF will coordinate authorizations for care with the Non-DVA provider.
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e.
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DVA facilities shall send claims
for payment to:
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• North Region: North Region
Claims, PGBA, P.O. Box 870140, Surfside Beach, SC 29587-9740.
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• South Region: TRICARE South
Region, Claims Department, P.O. Box 7031, Camden, SC 29020-7031.
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• West Region: WPS/West Region
Claims, P.O. Box 77028, Madison, WI 53707-7028.
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f.
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TRICARE contractors will file
authorizations in their medical management information systems upon
receipt from TMA. They will process claims received from treating
DVA facilities in accordance with authorizations on tile and contract
requirements including referenced TRICARE manuals.
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