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Billing

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VA-DoD Resource Sharing: Billing for Inpatient Services

The Departments of Veterans Affairs (VA) and Defense (DoD) recognize a shared responsibility to ensure the highest quality of health care services and resources are delivered efficiently, compassionately, and with minimal inconvenience to our nation’s Service members. The National Defense Authorization Act (NDAA) of 2003:

  • Encouraged VA and DoD joint strategic planning,
  • Established a Joint Executive Council for governance over VA and DoD sharing, and
  • Mandated standardized reimbursement rates for VA-DoD sharing. 

The efforts of the Joint Executive Council resulted in a billing method which uses TRICARE reimbursement rates and an agreed upon methodology to calculate charges.  >>View the Memorandum of Understanding Resource Sharing Reimbursement Methodology. The VA and DoD have agreed to a reimbursement methodology for both the institutional component (i.e. hospital) and non-institutional (e.g.,professional, durable medical equipment, laboratory, pharmacy, anesthesia) elements of inpatient care.

Inpatient Payment Calculator Package

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Calculators and User Guide Now Available on the DHA Launchpad
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The DHA UBO Program Office releases the VA-DoD Sharing Inpatient Payment Calculator package on an annual basis. Use the version of the calculator effective on the patient's date of discharge. There are two versions of the VA-DoD Inpatient Institutional Calculator available on Launchpad include: 

Standard Modified Version

  • For MTFs with standard VA-DoD Direct CareDirect care refers to military hospitals and clinics, also known as “military treatment facilities” and “MTFs.”direct care resource sharing agreements (i.e., charge TRICARE CMAC rates less 10% discount)
  • The 10% discount percentages are pre-populated and cannot be altered in this version. 

Variable Rate Modified Version

  • For MTFs that negotiated discounts other than the standard 10% discount or have specific negotiated reimbursement amounts 
  • The discount percentages are pre-populated at zero and can be changed to reflect the negotiated discount. 

Note: The VA-DoD Inpatient Billing Guide User Guide is a supplemental reference document with step-by-step instructions on how to use the OBG and generate charges to bill the VA for inpatient encounters.

Inpatient MTF Zip Codes & Disposition Status Codes

  • Refer to the official list of Inpatient Zip codes and Disposition Status Codes for use with the calculators.
  • For overseas MTFs, enter "00000"" as the zip code.

VA-DoD Resource Sharing: Billing for Outpatient Services

Outpatient billing guidance is based on the 2003 Memorandum of Agreement (MOA) signed by the Assistant Secretary of Defense for Health Affairs and the Under Secretary for Health, Veterans Health Administration for standardized billing rates. Per the agreement, DoD and VA medical facilities will bill outpatient clinical services provided under direct sharing agreements at CMAC less 10 percent for the appropriate CPT code, unless a waiver is approved. Rates are located on the TRICARE CMAC page. It does not apply to network agreements between VA medical facilities and DoD's managed care support contractors nor to outpatient services rendered under the auspices of the National MOA for Spinal Cord Injury, Traumatic Brain Injury, and Blind Rehabilitation which are billed through the MCSCs. 

VA-DoD Outpatient Billing Guide

The DHA UBO Program Office releases the VA-DoD Outpatient Billing Guide (OBG). The OBG includes an Excel® workbook and the PDF document, "VA-DoD Outpatient Billing Guide User Guide.” The OBG is a guide for MTFs that provide VA-DoD resource sharing agreement care to calculate and document both the institutional and non-institutional (e.g. professional and other non-institutional services) components of an outpatient episode of care.

There are two versions of the VA-DoD Outpatient Billing Guide:

  • MTFs with standard VA-DoD direct care resource sharing agreements (i.e., charge TRICARE CMAC rates less 10% discount) must use the “Standard VA-DoD Outpatient Billing Guide” version. The 10% discount percentages are pre-populated and cannot be altered in this version. 
  • MTFs that have negotiated discounts other than the standard 10% discount or have specific negotiated reimbursement amounts must use the “Variable Rate VA-DoD Outpatient Billing Guide” version. The discount percentages are pre-populated at zero and can be changed to reflect the negotiated discount. 

Billing for Pharmacy Services

The UBO develops pricing estimators to assist the billing office staff and other government organizations with estimating the costs of pharmaceuticals. This estimators, referred to as the VA-DoD Sharing Pharmaceutical Unit Price Estimators, are available for request. To receive a copy of the price estimator:

  • Email the Help Desk
  • Call 1-202-741-1532 and leave a message. 
  • We will respond to your request within one business day. 

Billing the U.S. Coast Guard

Per Interagency Agreement (IAA), the U.S. Coast Guard (USCG) reimburses the Army, Navy and National Capital Region Medical Directorate (NCR MD) annually, and on a prospective basis, for inpatient and outpatient care provided to USCG eligible beneficiaries at their MTFs annually on a prospective basis. Payments are calculated based on actual prior fiscal year encounter data and DHA UBO rates. They are normalized using the appropriate medical inflation factors, force structure adjustments, and other health insurance (OHI) adjustment (a discount). The USCG directly distributes prospective payment amounts (PPAs) to Army, Navy, and NCR MD MTFs based on individual treatment Defense Medical Information System [facility] identifier (DMIS ID) PPA calculations. For more information, see the USCG Billing section in the DHA User Guide. The Memorandum of Understanding between the DoD and the U.S. Coast Guard is available for download on the USCG website. 

Billing NOAA and PHS

The Memorandum of Agreement between DHA, the Defense Health Agency and the Department of Health and Human Services (DHS), US Public Health Service (PHS) Commissioned Corps, and the National Oceanic and Atmospheric Administration (NOAA) Commissioned Officer Corps regarding participation in TRICARE are available for download. 

Multi-Site/Regional Billing

Multi-site billing (sometimes referred to as regional billing) allows one facility to perform claims processing for one or more facilities. The concept of Multi-site billing has been accomplished to various degrees by the Services.  There are some key points, though, involved in any arrangement when a facility or agency is contracted to perform this function for another facility. As a minimum: 

  • A written agreement should be in place between the contracting and contracted facility/agency. This agreement is to be approved by the Service's UBO manager prior to implementation to ensure it meets UBO compliance requirements. 
  • When a service is contracted out, the contracting facility is still ultimately responsible for assuring work is being accomplished within appropriate compliance guidelines. 
  • No military facility performing this service for another MTF should charge anything other than actual cost. The formula for determining the cost of operations is the number of claims divided by the total MEPRS EBH costs. You may need to review your EBH data to ensure it represents your costs. 
  • The facility/agency contracted to perform collections and the contracting facility must have some kind of audit process in place to ensure record documentation supports claims developed. 
  • Accounts receivable processes must separate out claims by facilities against which funds were collected. 
  • The contracting facilities must receive reports on accounts receivable, metrics reports, and have a right to audit the process for accurate accounting and billing processes. 
  • Quarterly metrics reports data is separated out for each facility for which the claims are processed. 
  • The contracting facility has a right to access data from the contracted facility to assess the effectiveness of third party collection operations for their patient population. These requirements should be included in the contractual agreement. 

For further information, please contact your Service UBO Manager.

Billing Medicare

MTFs may bill non-uniformed services Medicare enrollees directly for emergency treatment at the appropriate full inpatient (FRR) or professional/outpatient (FOR) rate based on Service or NCR MD guidance. In the alternative, they may participate in Medicare or elect to enroll as non-participating providers for certain emergency care, and submit claims to Medicare for care provided to these Medicare enrollees. To do so, they must collect and maintain on file the patient’s DD Form 2569. This contains his/her assignment of benefits required to receive Medicare reimbursement. Medicare claims are based on the Interagency Rates (IAR), and payment from Medicare is payment in full. MTFs may not Balance BillThe practice of a provider billing a beneficiary the difference between the TRICARE allowed amount and the billed charges on a claim. Participating providers and network providers may not collect from all sources an amount which exceeds the TRICARE allowed amount. Non-participating providers may not collect an amount which exceeds the balance billing limit (115% of the allowed charge). If the billed charge is less than the balance billing limit, then the billed charge is the maximum amount that can be collected by the non-participating provider. (See the TRICARE Reimbursement Manual (TRM), Chapter 3, Section 1.)balance bill the patient, except for deductibles and copayments. 

Provider Specialty Codes

The table of Provider Specialty Codes is available for download. 

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