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, Space Force, and Coast
Guard facilities) and the DVA/VHA. Claims for these services will
continue to be processed by the Uniformed 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,The contractor shall authorize and
pay for all medical conditions shall be authorized
and paid under this MOA if a condition of TBI, SCI,
Blindness, or Polytrauma exists for the patient as determined
by SAS.
3.2.2.2 The contractor shall
ensure the authorization shall clearly indicate that
the care has been authorized under the SCI, TBI, Blindness, and
Polytrauma MOA.
3.2.2.3 The contractor shall
ensure the authorization shall specify specifies
the 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 will 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 contractor shall place 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
contractor shall apply 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 ClaimsThe
contractor shall deny claims without an applicable interagency
rate shall be denied and the
contractor shall issue 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 and
apply 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
contractor shall
obtain authorization from SAS for the following care
services, irrespective of health care delivery setting
require
authorization from SAS and
are reimburse
d these
services 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 The
contractor shall include Special Processing Code (SPC) 17 -
DVA/VHA medical provider claim, in all TRICARE Encounter
Data (TED) records for this care.
3.2.8.6 If paid at per diem rates, the
contractor
shall apply the provisions of
Chapter 8, Section 2,
apply when enrollment
changes in the middle of an inpatient stay. If enrollment changes
retroactively,
the contractor shall not recoup 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 ClaimsThe
contractor shall process 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, Clinical Modification (ICD-9-CM)
Diagnostic code of V68.01, or International Classification of Diseases,
10th Revision, Clinical Modification (ICD-10-CM)
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 will enter
the referral reason 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 RelatedThe
DVA/VHA will bill 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-CM/ICD-10-CM diagnostic
code, V68.01/Z02.71 (Disability Examination).
3.3.5 TheIf
the contractor
shall process the claim
to payment (refer to paragraph 2.3) if receives 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
),
the contractor shall process and pay the claim (see paragraph 2.2).
One The
contractor shall pay 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 TheIf
the contractor receives an IDES MOA claim from DVA/VHA (paragraph 3.2.1)
and no authorization is on file, the contractor shall
verify that the claim contains CPT code 99456 or ICD-9
-CM/ICD-10 code
V68.01
/ or ICD-10-CM 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. The contractor shall use CPT
code 99456 shall be used and will
be shall considered the
code to include all parts of each C&P examination,
except ancillary services.
3.3.8 ClaimsThe
contractor shall pay claims for related ancillary services shall
be paid at the appropriate TRICARE allowable rate
(e.g., CMAC) with and apply 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 (DVA
Medical Provider Claim), and Enrollment Health Plan Code SR (SHCP-Market/MTF
Referred Care), for all TED records for this care.