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.
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1.
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Roles.
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A.
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VA will:
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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.
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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.
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3) Bill the MHS via the appropriate
TRICARE contractors, for those services which are related to medical conditions
to be considered as the basis of fitness for duty determination.
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B.
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DoD will:
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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.
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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.
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2.
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Procedures.
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A.
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A DES program oversight contact
(POC) will be appointed at each TRICARE Managed Care Support Program
Section (MCSPS), VA Regional Office (VARO), VA Medical Center/Facility
and Military Medical Treatment Facility (MTF). The DES oversight
official duty may be a collateral duty.
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B.
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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.”
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C.
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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.
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D.
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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:
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1) State the examination is
for a Service member in the DES.
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2) Identify specific C&P
examination(s) required.
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3) Identify specific condition(s)
to be evaluated in each C&P examination.
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E.
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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.
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F.
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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.
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G.
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DoD and VA will promote the
use of approved templates to provide the requested information.
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H.
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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.
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I.
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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.
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J.
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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.
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K.
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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.
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3.
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Outcomes.
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A.
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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:
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1) Provide the required information
from the requested AMIE worksheet(s) and the additional exams identified
during the initially ordered C&P examinations.
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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.
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B.
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Reports. The following reports
will be based on the claims submitted to the appropriate Regional
TRICARE contractor during the reporting time.
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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.
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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.
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4.
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Accountability and Funding:
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A.
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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.
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B.
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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.
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C.
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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.
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D.
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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.
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E.
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C&P examinations and services
for conditions claimed in Section III of VA Form 21-0819 will be
funded by VA appropriations.
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5.
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Effective Date, Terms
of Modification and Termination:
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A.
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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 DoD/VA DES shall refer to this
MOA.
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B.
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Requests for modification of
this agreement will be submitted in writing from one party to the
other, not less than 60 calendar days prior to the desired effective
date of such modification.
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C.
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An annual review of this agreement,
including rate structure, will be conducted by both parties to ensure compliance
with each Departments’ policies.
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D.
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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.
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E.
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The provisions of this agreement
are effective 30 calendar days from the date both approving signatures have
been affixed.
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6.
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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.
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7.
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Associated Memoranda
of Understandings (MOU): A separate MOU exists and must be
consulted regarding processing of Benefits Delivery at Discharge
(BDD) exams.
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8.
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Approvals:
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Department of Veterans
Affairs
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Department of Defense
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Attachments:
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A)
B)
C)
D)
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VA Form 21-0819
VA Billing Guidance
CMS -1500 Example
DoD Referral Guidance
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ATTACHMENT A: VA Form
21-0819 (June 2009)
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ATTACHMENT B: VA Billing
Instructions For VA/DoD DES Program Agreement
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1. Registration
of DES Participants:
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STEP 1: Facility
eligibility staff will obtain list of DES participant names based
on daily transmittal of disability examination requests (Form 2507)
to Facility DES POC.
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STEP 2:
Eligibility staff will review each DES Participant’s registration
information to ensure all fields are correct. For additional guidance
on how to register DES participants, refer to the CBO TRICARE Procedure
Guide, Chapter 2: Registration; located at http://www.tricare.mil/dvpco/downloads/OSD%2004851-10.pdf.
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NOTE --- If VA
staff is unable to access the above link, please go to the VHA CBO
Home page, CBO Resources, Policy Procedure Guides, and click on
Series 1601D: Non-Veteran Beneficiaries and the TRICARE Policy Procedure
Guide, click on Chapter 2 as above.
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STEP 3:
Eligibility staff will notify the DES POC and other appropriate
staff that the DES participant’s registration has been reviewed,
and corrected as required.
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2. Billing
related to DES Participants:
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After notification of completion
of exam(s) and ancillary services by DES POC, VA billing staff will
initiate a claim for payment. Notification method and frequency
will be established by local facilities.
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STEP 1:
Facility needs to ensure that the Patient Insurance File contains
the appropriate TRICARE Regional Contractor/Fiscal Intermediary
information, especially the EDI parameters.
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STEP 2:
TRICARE Authorization, along with VA Form 21-0819, will be sent
/ faxed to the VA Billing Supervisor. Please provide appropriate
Billing POC information to the DoD / DHA Government Designated Authority
(GDA). VA staff will use Claims Tracking to document Authorization
number by DES participant.
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STEP 3:
Initiate the claim related to DES Exam (s) using the CMS 1500 (ATTACHMENT
C) for ONLY those exams related to the “Referred” conditions listed
in Section I on VA Form 21-0819.
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Use Rate Type --- “TRICARE,”
this will allow for the funds to be placed in the correct Revenue
Source Code (RSC).
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Some of the information in
Blocks 1-13 should autopopulate based on the registration and insurance
information in the system.
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In Block 1 --- For DES Program,
enter “TRICARE”
In Block 1a --- enter the Service
Member’s (Service Member) SSN
In Block 2 --- enter the Service
Members Name
In Block 3, Block 4, Block
5, Block 7 --- as appropriate
In Block 6 --- enter “Self”
In Block 8 --- enter as appropriate
In Block 9d ---TRICARE
In Block 10a --- enter “Yes”
10b --- enter “No”
10c --- enter “No”
In Block 11 --- enter Service
Members SSN
11a --- enter Service Member
DOB
11b --- leave BLANK
11c --- enter “DoD DES Program”
11d --- enter “No”
In Block 14 --- enter date
of original 2507
In Block 15 --- leave BLANK
In Block 16--- if possible,
enter date of 2507 as date FROM, and Date of exam release as date
TO
In Block
18 --- enter date of original 2507
In Block 19 --- enter “DES”
In Block 21 --- enter “V68,01”
(for Disability Examination)
In Block 23 --- enter the TRICARE
Authorization number
In Block 24a --- enter “Date
exam released”
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24d --- enter “99456” (CPT
Code for “Medical Disability Examination by OTHER than Treating
Physician”);
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NOTE: a
separate line item will be required for each authorized exam performed.
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TEXT: enter the TYPE of DISABILITY
EXAM performed (e.g. PTSD, Audio. Gen Med, etc.)
In Block 24f --- Reasonable
Charges for 99456 will auto-populate (base charge is $382.56 in
FY 2009) NOTE: If your facility has NOT converted
to Reasonable Charges for the TRICARE rate types you will have to
manually enter the national Reasonable Charges base rate above (in
FY09 rate is $382.56); or contact VA Help Desk to assist in establishing
the correct rate to this Rate Type.
In Block 24g --- enter number
of exams completed as unit = 1; Again, a separate line item will
be required for each authorized disability exam performed.
In Block 28 --- total charges
for all procedures (99456) will appear here.
Other Blocks, not otherwise
identified are to be completed as for any other 3rd party
Insurer.
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STEP 4:
Initiate the claim for fees related to DES Exam (s) and ancillary
services using the CMS 1500 for ONLY those items related to the “Referred” conditions
listed in Section I, on VA Form 21-0819.
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Use Rate Type --- “TRICARE,”
this will allow for the funds to be placed in the correct Revenue
Source Code (RSC).
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Using the instructions, as
above for CMS 1500 for DES exams, complete the CMS 1500 for ancillary
services associated with the exams.
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Rates: Reimbursement for ancillary
services will be based on CMAC less 10 percent.
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For additional guidance on
how to bill for DES participants, refer to the CBO TRICARE Procedure
Guide, http://www.tricare.mil/dvpco/downloads/OSD%2004851-10.pdf.
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NOTE --- If VA staff are unable
to access the above link, please go to the CBO Home page, CBO Resources,
Policy Procedure Guides, and click on Series 160 ID: Non-Veteran
Beneficiaries and the TRICARE Policy Procedure Guide, click on Chapter
4B as above.
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Where to
Submit Claims: The appropriate
TRICARE Regional Contractor / Fiscal Intermediary (FI) information, especially
the EDI parameters.
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Disputes: TBD
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CONTACTS: VHA
for Billing Issues - Ms. Felicia A. Lecce, Lead Program Specialist/HSS
CBO, Business Policy Division Ms. Lecce can be reached at 202-461-1588,
or by email at Felicia.Leccegva.gov.
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ATTACHMENT C: CMS 1500
Example
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ATTACHMENT D: Guidance
for DoD Military Medical Treatment Facilities on DoD Referrals
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1. Referrals from the DoD to
VA for Service Members in DoD/VA DES should be generated by a DoD
provider trained on the DES. Based on review of the Service Member’s
medical documentation, DoD providers referring Service Members into
the DoD/VA DES will ensure all “potentially unfitting, or medically
disqualifying conditions” are designated in VA Form 21-0819, Section
I, “Medical Conditions to be Considered as the Basis of Fitness
for Duty Determination,” before referring the DES case to the VA
Military Services Coordinator (MSC).
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2. After VA MSC completes the
VA Form 21-0819 with the Service Member, and requests the Compensation
and Pension (C&P) examinations associated with both the DoD
referred and the Service Member claimed conditions, the DoD will
be provided a completed copy of VA Form 21-0819, VA/DoD Joint Disability
Evaluation Board Claim with the list of requested C&P examinations
for each condition.
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2.1. The DoD will generate
a referral request to the Military Medical Treatment Facility (MTF)
Referral Management section for the conditions listed in Section
I of VA Form 21-0819. The DoD will follow the MTF specific guidance
regarding referral requests.
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2.1.1. AHLTA Generated Referral
Request. Referrals for C&P examinations must be from the FEDB,
FEDC, or FEDD MEPRS for DoD/VA billing and auditing purposes.
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2.1.2. For the DoD/VA DES,
it is not necessary to identify the various specialists who will
be doing the different C&P examinations. Enter only the total
number of DES C&P examinations derived from Section I, “Medical
Conditions to be Considered as the Basis of Fitness for Duty Determination,”
of VA Form 21-0819. In “Reason for request” enter:
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“VA only: DES C&P
exams for fitness for duty determination - total”
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Example:
VA only: DES C&P
exams for fitness for duty determination - total 6.
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3. The MTF Referral Management
Section will forward the information to the contractor who will
provide VA with the applicable referral number for all the DES related
services (e.g.,VA DES C&P exams, necessary laboratory and radiology
studies) for the specific Service Member. C&P examination referrals
should come from the FEDB, FEDC, and FEDD MEPRS for auditing purposes
between DoD and VA.
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