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).