1.0 Description
All DVA/VHA facilities that
have entered in agreements with DoD/DHA shall be included as network
providers. This will enable DoD beneficiaries to use certain DVA/VHA
medical facilities on a space available basis as authorized by 8111
of 38 USC and Title II of Public Law 102-585.
1.1 General
The contractor shall include
all DVA/VHA facilities with signed TRICARE Network Agreements as
network providers. Provider Network Agreements with the Managed
Care Support Contractors (MCSCs) are done at a national level. See
Chapter 11, Section 2.1, which includes the
Memorandum Of Understanding (MOU) for the policy concerning this
program.
1.1.1 The contractor shall process
claims submitted from DVA/VHA medical facilities with the usual
claims processing procedures to include medical necessity, Explanation
of Benefits (EOB), Other Health Insurance (OHI) and Third Party
Liability (TPL). DVA/VHA medical facilities shall be subject to
the same Utilization Management (UM) and Quality Assurance (QA)
requirements applicable to other network providers.
1.1.2 The contractor
shall ensure that all DVA/VHA Health Care Finders (HCFs), institutional,
and individual professional providers are properly trained in and
comply with the provisions of TRICARE quality and utilization management
programs. The effective date for TRICARE coverage of services provided
by a network DVA/VHA medical facility is determined by the agreement
between the DVA/VHA and the MCSC. Only services furnished on or
after the effective date will be considered for TRICARE payment.
1.2 Certification of DVA/VHA Medical
Facilities
Medical
facilities meeting DVA/VHA certification requirements, shall be
deemed to meet TRICARE requirements pertaining to certification
for network provider status.
1.2.1 The contractor
shall accept DVA/VHA assertion of licensure and credentials for
its providers, as well as facility/program certification and shall
not conduct additional validation.
1.2.2 The contractor
shall assign the DVA/VHA medical facility a Unique Identifier Number
(UIN) which will identify the claim as a TRICARE claim, with care
rendered in a DVA/VHA medical facility.
1.3 Certification Of Individual
Professional Providers
Individual
providers who meet DVA/VHA credentialing requirements including
licensure and certification, shall be deemed to meet TRICARE requirements.
1.3.1 The contractor
shall accept DVA/VHA assertion of licensure and credentials for
its providers, as well as facility/program certification and shall
not conduct additional validation. The DVA/VHA medical facility
will provide a monthly provider specialty listing to the contractor.
1.3.2 The contractor
shall create provider records in accordance with the TRICARE Systems
Manual (TSM).
1.4 Claims
Processing
The contractor
shall process all claims submitted by the DVA/VHA medical facility
as participating claims even if not so indicated on the claim form.
Beneficiary submitted claims for care received at the DVA/VHA medical
facility shall be denied using the EOB message: “Claims must be
filed by the DVA/VHA Medical Facility.”
1.5 Reimbursement
The contractor shall negotiate
reimbursement rates with the DVA/VHA. Reimbursement shall be based
on a percentage discount off the CHAMPUS Maximum Allowable Charge
(CMAC), the state prevailing, Diagnosis Related Group (DRG), or
other methodology such as per diems for all types of services. Cost-shares
and deductibles will be withheld prior to payment being made directly
to the DVA/VHA medical facility.
1.6 Pharmacy
Drug Claims
1.6.1 The contractor shall process
pharmacy drug claims in accordance with the guidelines in
Chapter 8, Section 9.1; however, there will
be no discount applied to pharmacy drugs. The DVA/VHA medical facility
will bill for outpatient prescriptions and prescription refills
written for each 30 day supply (or fraction thereof) at DVA/VHA medical
facility’s costs for the prescription items plus a reasonable fee
to cover DVA/VHA medical facility’s dispensing costs.
1.6.2 The contractor shall reimburse
the DVA/VHA medical facility based on:
• The billed charge, or
• The TRICARE allowable charge,
whichever is less.
1.6.3 In addition,
the DVA/VHA medical facility will collect copayments consistent
with TRICARE requirements. The amount of copayment shall be deducted
from the lower of the billed charge or the TRICARE allowable charge.
Note: Inpatient prescriptions, including
those filled at discharge, will be included in the DRG bill and,
as such, are not subject to a separate prescription reimbursement
or copayment.