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VA-DoD Resource Sharing Billing for Inpatient Services

Background

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 documents below for VA-DoD resource sharing documents.

MOA Resource Sharing Reimbursement Methodology

Charging for Inpatient Services

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.

View the document below for VA-DoD Inpatient Billing Policy Guidance.

VA-DoD Inpatient Billing Policy Guidance

FY14 VA-DoD Sharing Inpatient Payment Calculator Package

The DHA UBO Program Office has released the FY14 VA-DoD Sharing Inpatient Payment Calculator package. The package includes an Excel® workbook with two worksheets (the Inpatient Institutional Calculator and Inpatient Billing Guide) and the PDF document, "FY14 VA-DoD Resource Sharing Inpatient Institutional Billing Modified TRICARE DRG Payment Calculator and Inpatient Billing Guide USER GUIDE."

Summary of FY14 VA-DoD Inpatient Calculator updates:

FY14_ReleaseNotes_updated pdf 333.9 KB

There are two versions of the FY14 VA-DoD Inpatient Institutional Calculator:

  • MTFs with standard VA-DoD direct care resource sharing agreements (i.e., charge TRICARE CMAC rates less 10% discount) must use the “Standard_Modified_VA-DoD_Inp Inst Calculator_FY14” version. The 10 % discount percentages are pre-populated and cannot be altered in this version.
    Standard_Modified_VA-DoD_Inp_Calc_FY14_update xls 1098.5 KB
  • MTFs that have negotiated discounts other than the standard 10% discount or have specific negotiated reimbursement amounts must use the “Variable_Rate_Modified_VA-DoD_Inp Inst Calculator_FY14” version. The discount percentages are pre-populated at zero and can be changed to reflect the negotiated discount.
    Variable_Modified_VA-DoD_Inp_Calc_FY14_updated xls 1093.5 KB

Refer to the official FY14 list of Inpatient MTF ZIP codes and Disposition Status codes for use with the Inpatient Institutional Calculator. Overseas MTFs enter 00000 for their ZIP code.
FY14_Inpatient_MTF_ZIP_codes_and_Disposition_Status_codes xls 45.5 KB

Use the version of the calculator effective on the patient’s date of discharge.

The Inpatient Billing Guide is contained in both the Standard_Modified_VA-DoD_Inp Inst Calculator_FY14 and Variable_Rate_Modified_VA-DoD_Inp Inst Calculator_FY14 workbooks. The Inpatient Billing Guide is a worksheet 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 inpatient episode of care.

The FY14 VA-DoD Resource Sharing Inpatient Institutional Billing Modified TRICARE MS-DRG Payment Calculator and Inpatient Billing Guide USER GUIDE is a supplemental reference document with step-by-step instructions on how to use the IIC and IBG.
FY14 Inp Inst User Guide_updated pdf 1934.4 KB

Past VA-DoD Inpatient Calculators

FY13 VA-DoD Inpatient Calculator Package

FY13 VA-DoD Calculator Release Notes

Standard_Modified_VA-DoD_Inp Inst Calculator_FY13

Variable_Rate_Modified_VA-DoD_Inp Inst Calculator_FY13

ZIP_codes_and_Disposition_Status_codes

FY13 VA-DoD Resource Sharing USER GUIDE

FY12 VA-DoD Inpatient Institutional Calculator

Inpatient Institutional Billing Calculator for FY12

Older VA-DoD resource sharing files and calculators can be found on the Archives page.

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VA-DoD Resource Sharing Billing for Outpatient Services

Background

Outpatient billing guidance is based on the 2003 memorandum of agreement 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. 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.

View the documents below for VA-DoD Outpatient Billing policy and guidance.

MOA Resource Sharing Reimbursement Methodology

VA-DoD Outpatient Billing Guidance

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FY13 VA-DoD Outpatient Billing Guide

The DHA UBO Program Office has released the FY13 VA-DoD Outpatient Billing Guide (OBG). The OBG includes an Excel® workbook and the PDF document, "FY13 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.

Based on feedback from the field, there are two versions of the FY13 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_FY13” version. The 10 % discount percentages are pre-populated and cannot be altered in this version.
    Standard VA-DoD Outpatient Billing Guide xls 276.5 KB
  • 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_FY13” version. The discount percentages are pre-populated at zero and can be changed to reflect the negotiated discount.
    Variable Rate VA-DoD Outpatient Billing Guide xls 308.0 KB

The FY13 VA-DoD Outpatient 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 outpatient encounters.
FY13 VA-DoD Outpatient Billing Guide USER GUIDE pdf 1207.3 KB

VA-DoD Resource Sharing Billing for Pharmacy Services

The UBO developed a pricing estimator to assist the billing office staff and other government organizations with estimating the costs of pharmaceuticals. This estimator, referred to as the VA-DoD Sharing Pharmaceutical Unit Price Estimator, may be downloaded via the links below.

The following VA-DoD Resource Sharing Pharmacy Billing Price Estimator is effective as of
01 September 2013. Both 2007 and 2003 MS Access versions are available.

2013

VA-DoD Sharing Pharmacy Price Estimator v2007 - Sept 2013 zip 3821.6 KB
VA-DoD Sharing Pharmacy Price Estimator v2003 - Sept 2013 zip 3825.0 KB



The following VA-DoD Resource Sharing Pharmacy Billing Price Estimator is effective for
01 September 2012 - 31 August 2013. Both 2007 and 2003 MS Access versions are available.

2012

VA-DoD Sharing Pharmacy Price Estimator v2007- Sept 2012 zip 8008.9 KB
VA-DoD Sharing Pharmacy Price Estimator v2003- Sept 2012 zip 19253.4 KB

Older files can be found on the Archives page.

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Billing the Coast Guard

Per Interagency Agreement (IAA), the U.S. Coast Guard (USCG) reimburses the Army, Navy and National Capital Region (NCR) Medical Directorate (NCR; formerly Joint Task Force National Capital Region Medical, JTF CapMed) 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 Defense Health Agency (DHA) UBO rates. They are normalized using the appropriate medical inflation factors, force structure adjustments, and other health insurance (OHI) adjustment (a discount). The Coast Guard directly distributes prospective payment amounts (PPAs) to Army, Navy, and NCR MTFs based on individual treatment Defense Medical Information System [facility] identifier (DMIS ID) PPA calculations. The Air Force does not participate in the IAA. For more information, see the updated USCG section in the DHA User Guide.

The link below provides the memorandum of understanding between the DoD and the United States Coast Guard regarding participation in TRICARE.
DoD_Coast_Guard Memorandum of Understanding pdf 844.8 KB

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Billing NOAA and PHS

The link below provides the memorandum of understanding between the DoD, the Department of Health and Human Services (DHS) Public Health Service (PHS) Commissioned Corps, and the National Oceanic and Atmospheric Administration (NOAA) Commissioned Corps regarding participation in TRICARE.
DoD_NOAA Memorandum of Understanding pdf 332.2 KB

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Multi-Site Billing

Multi-site billing (sometimes referred to as regional billing) basically 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 that this function 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 basically the number of claims divided by the total MEPRS EBH costs. You may need to review your EBH data to make sure it actually 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.

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Billing Medicare

MTFs may only submit Medicare Parts A (inpatient) and B (outpatient) claims for emergency treatment furnished to non-uniformed services Medicare enrollees. To do so, they must collect and maintain on file the patient’s DD Form 2569 (“THIRD PARTY COLLECTION PROGRAM/MEDICAL SERVICES ACCOUNT/OTHER HEALTH INSURANCE”). This contains his/her assignment of benefits required to receive Medicare reimbursement. MTFs must also enroll as Medicare providers and update/revalidate enrollment in order to receive reimbursement. Claims are based on the Interagency Rates (IAR), and payment from Medicare is payment in full. MTFs may not balance bill the patient, except for deductibles and copayments.

The Medicare online enrollment application and additional guidance is available at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/InternetbasedPECOS.html.
A paper enrollment application process (i.e., CMS Form 855A) is available at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/EnrollmentApplications.html.

For additional claims guidance, see the Centers for Medicare and Medicaid Services (CMS) Medicare Claims Processing Manual available at:
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html?DLPage=1&DLSort=0&DLSortDir=ascending and the DHA UBO User Guide .

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Provider Specialty Codes

Table of the provider specialty codes

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Contact us:

For questions or comments, please e-mail UBO.Helpdesk@altarum.org, or leave a message for the Helpdesk staff at (571) 733-5935. Phone messages will be returned within one business day.

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