TRANSMITTAL #:  126

DATE: 05/09/2011

TRICARE CHANGE #:  N/A

 

CHAMPVA POLICY MANUAL

 

CHAPTER:  3

SECTION:  1.2

TITLE:  CLAIMS PROCESSING - FOREIGN

 

AUTHORITY:  38 CFR 17.270(a) and 17.273-278

 

RELATED AUTHORITY:  32 CFR 199.7(d),199.9 and PPI 98-1

 

 

I. EFFECTIVE DATE(S)

A. For services on or after January 1, 1994, claims must be received within one- year from the date-of-service or one-year from the date-of-discharge from an inpatient facility.

II. DESCRIPTION(S)

A. United States.  For purposes of this policy and payment of inpatient and outpatient services, the term “United States” includes the 50-States, the District of Columbia, American Samoa, Guam, Puerto Rico, Northern Mariana Islands, and the Virgin Islands.  [PPI 98-1, January 22, 1998]

III. POLICY

A. General.  The objective of CHAMPVA claims processing procedures is to ensure that all claims are processed in a timely and consistent manner and that government funds are expended only for those services or supplies authorized by regulation.  All claims reviewed must include sufficient information to determine:

1. Eligibility of the beneficiary.

2. The service/supply is a CHAMPVA benefit.

3. The service/supply is medically necessary.

4. The beneficiary is legally obligated to pay for the service or supply.

B. Itemization.  Requirements for itemization are liberally interpreted for foreign claims and foreign claims will not be rejected for lack of itemization.

C. Claim content.  Claims must contain the following information:

1. A valid, payable diagnosis.

2. The provider name and address.

3. The service/supply/drug/DME (Durable Medical Equipment) ordered, performed or prescribed.

4. Charges for each item.

D. Preauthorization.  The beneficiary and/or provider must ensure advance approval is received from CHAMPVA for the following treatment/services.

1. Dental care (see Chapter 2, Section 5.1, Adjunctive Dental Care).

 

2. DME (see Chapter 2, Section 17.1, DME (Durable Medical Equipment) and Supplies).

 

3. Non-emergent mental health/substance abuse treatment including admission of emotionally disturbed children and adolescents to residential treatment centers (see Chapter 2, Section 18.17.2, Preauthorization for RTC (Residential Treatment Center) Care).

 

4. Admissions to a partial hospitalization program, including alcohol rehabilitation (see Chapter 2, Section 18.18, Psychiatric Partial Hospitalization Programs-Preauthorization and Day Limits).

 

5. Organ transplants (see Chapter 2, Sections 31.2 thru 31.12, Transplants).

 

E. Retroactive authorizations.  When either a claim for CHAMPVA eligibility or claim for benefits has been denied, the denial may be overturned with the submittal of additional information or evidence in support of the claim.  When a retroactive authorization has been made, claims must be received:

1. 180-days following notification to the beneficiary of an approved retroactive authorization date.

2. 180-days following beneficiary notification of the approval of a covered service that had previously been denied.

F. OHI (Other Health Insurance).  CHAMPVA is always the secondary payer of benefits when there is other health insurance.  If OHI is involved, an EOB (Explanation of Benefits) from the OHI must accompany the submission (see Chapter 3, Section 4.1, OHI (Other Health Insurance)).

 

G. CHAMPVA-Foreign claims are paid at 75% of the VA allowable unless the catastrophic cap has been met.

H. Non-Covered Services.  Services and/or supplies that are not covered by CHAMPVA are the responsibility of the beneficiary.

I. Payment of benefits.  Payment will be made to the beneficiary or provider based on the evidence submitted.  In either case, there must be clear evidence submitted as to whether payment has or has not already been made by the beneficiary to the provider.

J Payment under $1.00.  If the CHAMPVA benefit payment is under $1.00, payment will not be issued although the catastrophic cap and deductible will be credited.

K. Claim disposition.  Upon completion of claim processing, an EOB will be sent to the beneficiary and the provider if benefits were assigned.  For claims resulting in a payment, a check, or EFT (Electronic Funds Transfer) will be issued by the U.S. Treasury.

1. An EOB will be issued whether or not an actual payment is involved.

2. Procedure codes for claims involving abortion, AIDS, alcoholism, drug abuse, psychosexual dysfunction or venereal disease will not be included on CHAMPVA EOB’s.

L. Reopened claims.  A claim may be reopened based on new information or a finding of administrative error.  A reopened claim may result in increased or decreased allowable charges.

1. The new or relevant information will be appended to the original claim.

2. The reopened claim will be computed using the payment methodology applicable on the date-of-service.

3. If there was an underpayment, the claim will be reprocessed for additional payment through regular procedures.

4. If there was an overpayment, medical cost recovery will be pursed through our DCU (Debt Collection Unit).

M. Fraud.  Falsifying information, such as providing an incorrect residence address, modifying claim forms, billing for services not provided, is considered fraud.

N. Timely Filing:

1. Prior to January 1, 1994, claims were required to be received no later than December 31st following the year in which the services/supplies were provided.

 

2. For services on or after January 1, 1994, claims must be received within one-year from the date-of-service or one-year from the date-of-discharge from an inpatient facility.

 

3. The provider cannot seek payment from the beneficiary when the provider fails to meet the timely filing requirements and a waiver is not granted.

 

4. Exceptions to timely filing requirements may be granted when:

a. Retroactive Determinations.  Only the HAC may determine retroactive eligibility.  In any case where a retroactive “preauthorization” determination is made to cover such services as surgical procedures, the timely filing requirement will be waived back to the effective date of the retroactive authorization.  Claims which are past the filing deadline must, however, be filed not more that 180 days after the date of issue of the retroactive determination.

 

b. Administrative Error.  An administrative error is when the beneficiary has been prevented from timely filing due to misrepresentation, mistake or other accountable action of a HAC (Health Administration Center) employee acting within the scope of that individual’s authority.  Necessary evidence must include:

 

(1) A written statement describing how the error caused failure to file within the usual time limit.

 

(2) Copy of an agency letter or written notice reflecting the error.

 

c. Inability to Communicate and Mental Incompetency.  A physician’s statement, which includes dates, diagnosis and treatment, attesting to the beneficiary’s mental incompetency shall accompany each claim submitted. The statement must present reasonable likelihood that mental incompetency prevented the person from timely filing.

 

(1) The beneficiary did not have a legal guardian.  If the charges were paid by someone else, that is, spouse or parent, evidence must be presented that the claim was paid and by whom.  Upon receipt, payment may be made to the signer of the claim.

 

(2) If a legal guardian was appointed prior to the timely filing deadline and the claim filing deadline was not met, an exception cannot be granted due to incompetency of the beneficiary.

 

d. OHI (Other Health Insurance).  The claimant submitted the claim to a primary health insurer and the primary insurer delayed adjudication past the CHAMPVA deadline.  In this case, the following must be established:

 

(1) The claim was originally sent to the primary health insurer prior to the CHAMPVA claim filing deadline or must have been filed with CHAMPVA prior to the deadline but returned or denied pending processing by the other health insurer.

 

(2) The claimant must submit with the claim a statement indicating the original date of submission to the other health insurer, the date of adjudication, and any relevant correspondence and an EOB.

 

(3) The claimant must have filed the claim with CHAMPVA within 90 calendar days from the date of OHI adjudication.

 

e. TRICARE Claims.  An exception may be considered on a case-by-case basis when evidence reflects the provider inappropriately billed TRICARE for medical services or supplies when the beneficiary has CHAMPVA coverage.  The provider will show that the initial claim was filed with TRICARE within one year of the service.  The provider will also be required to submit their claim for reimbursement to CHAMPVA within 90 calendar days of TRICARE’s notification.

 

(2) The claimant must submit with the claim a statement indicating the original date of submission to the other health insurer, the date of adjudication, and any relevant correspondence and an EOB.

 

O. Foreign conversion rates.  Effective June 15, 2009, if the billing is in foreign currency, the billed amount will be converted to the US currency equivalent based on conversion rates in effect on the date of service or date of discharge from inpatient care utilizing conversion rates referenced under www.oanda.com.

 

P. The Treasury Department maintains a list of countries to which Treasury checks may not be sent since there is no reasonable assurance the payee will actually receive and be able to negotiate a check for full value.  Therefore, reimbursement cannot be made in countries where the issuance of US Dept of Treasury checks and travel by US citizens is restricted or prohibited.

 

Q. Development of missing information will be kept to a minimum.

 

R. Policy Considerations A - F in Chapter 3, Section 1.1, Claims Processing-General, are applicable to foreign claims.

 

S. If the billing is submitted in a foreign language, it will first be sent to the HAC foreign-language contractor for translation.

 

*END OF POLICY*