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VHA Office of Community Care

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Provider Payments

Checking Claims Status | Emergency Care Claims and Payments
Audit for Recovery of Community Care Overpayments | Community Care Claims Process | Filing Claims

On January 3, 2018, VA announced a series of immediate actions to improve the timeliness of payments to community providers. The actions will address the issue of delayed payments to create sustainable fixes that solve ongoing payment issues which affect Veterans, community providers and other VA partners.

VA will create rapid response teams to work with the following list of Top 20 providers to reach financial settlement within the next 90 days. VA will continue to work closely with other important partners that have been participating in ongoing claims resolution meetings.

Providers can email questions or inquiries to provider.response@va.gov. Providing the following information may help to expedite your request:

  • Provider name
  • Provider address
  • Email address
  • Phone number
  • Claim number(s), if available
  • Desired resolution date, if required
  • Taxpayer Identification Number (TIN)
  • National Provider Identifier (NPI) number
  • Points of contact
  • Brief description of the issue
  • Have you contacted VA, Health Net or TriWest about this issue before? If yes, when?
  • Is this an issue with the Veterans Choice Program (VCP)*, VA Community Care (VACC)**, or a Provider Agreement**?

*If VCP, you would be receiving authorizations and sending claims to TriWest or Health Net.

**If VACC and/or Provider Agreements, you would be receiving authorizations and sending claims directly to your local VA medical center (VAMC).


PROVIDERSTATE
Top 20 Providers with High Dollar Value of Unpaid Claims
HCA Florida; Texas; Louisiana; Colorado; South Carolina
Adventist Health System  Florida
UF Health Florida
Orlando Health  Florida
Ohio Health Ohio
Health First Florida
Dignity Health California; Arizona; Texas
Bay Care Health System Florida
Cape Fear Valley Health System North Carolina
Tenet Health California; Texas
Centracare Health Minnesota
Carolinas Healthcare System North Carolina
University of Cincinnati Health Ohio
Sanford North Dakota; South Dakota
Universal Health Services Florida; District of Columbia
University of Colorado Health Colorado
Wake Health North Carolina
Mount Carmel Health Ohio
Lee Health Florida
Vanderbilt Health Tennessee

Frequently Asked Questions

  1. How were the Top 20 providers determined?
    The Top 20 providers were identified by extracting a list based on the total volume of claims pending as determined by total billed charges, however, VA does not imply reimbursement will be based on billed charges. Providers will be reimbursed according to current regulatory guidance associated with the authorization for care. In addition to the identification of the Top 20 providers, VA is actively working with several large provider networks not listed in the Top 20, but who are national provider networks with independent healthcare providers within their coverage area.
  2. I have submitted many claims that have been rejected. Why am I not on the Top 20 provider list?
    The list of Top 20 providers was based on total claims pending according to billed charges. VA intends on working with all providers to assist with reconciling their accounts receivable associated with traditional referrals, Choice provider agreements, and Third Party Administrator (TPA) Choice claims status. Once VA works through the Top 20 provider list, VA will continue to work with additional providers.
  3. Why does it matter if care is authorized by VA?
    All care must be authorized by VA for payment to be made, to include emergency care. A phone call to schedule an appointment is not considered as preauthorization at this time. Each community provider will receive a written authorization for care authorized by VA.
  4. How will providers be notified that a rapid response team will be working with us?
    VA will reach out to providers and establish a meeting or phone call to discuss the steps necessary to reconcile their accounts receivable and claims status with VA and the Choice Third Party Administrators (TPAs). VA will also provide a timeline on the review process as well as provider education to include differentiation of claim types and authorities.
  5. What will the rapid response teams accomplish?
    The intent of the rapid response team is to expedite assistance with reconciling the provider accounts receivable status, claims status, and provider education on VA referrals, authorizations, and regulatory authorities to provide care in the community.
  6. What if we can’t reach a financial settlement within 90 days?
    VA intends to reconcile a provider’s accounts receivable status within 90 days. However, due to volume of claims outstanding and the issues associated with the claims status, VA and the provider will discuss the reasons for a delay in resolution and will develop a plan with an expected timeline to resolve any outstanding claims issues.

Checking Claims Status

VA has established multiple ways for providers to check the status of their VA claims, including using the VA Vendor Inquiry System (VIS) located at https://www.vis.fsc.va.gov. You can also read about VIS in the Vendor Inquiry System Fact Sheet.

To check the status of claims with PC3/Choice vendors, TriWest or Health Net, click on the following links:

Emergency Care Claims and Payments

Beginning January 9, 2018, in accordance with an amended regulation (Title 38 CFR 17.1005), VA will begin processing claims for reimbursement for reasonable costs that were only partially paid by the Veteran’s other health insurance (OHI). Those costs may include hospital charges, professional fees and emergency transportation such as ambulances.

The amended regulation, published in a Federal Register notice, establishes the methodology VA will use to process and pay these claims. VA will apply the updated regulations to claims pending with the VA on or after April 8, 2016, and to new claims.

Effective immediately, VA will reject claims pending with VA on or after April 8, 2016, and will contact community providers to obtain any additional information needed to review and process the claim. There will be no need to resubmit claims unless a specific request is received from VA.

Claims for emergency treatment, or travel, related to a non-service connected condition provided on or after January 9, 2018, must be submitted within 90 days of the latest: date of discharge; the date of death (if death occurred during treatment or transportation); or the date that all efforts to obtain payment or reimbursement from a third party have been exhausted. The results do not fully eliminate the Veteran’s liability for the emergency treatment or transportation.

VA payment is the lesser of the amount for which the Veteran is personally liable or 70 percent of the applicable Medicare fee schedule amount, excluding copayment, cost share or deductible associated with the Veteran’s OHI. By law, VA cannot reimburse remaining costs such as copayments, cost shares or deductibles associated with a Veteran’s other health insurance.

For additional information, please reach out to the VA Medical Center responsible for processing the claims.


Audit for Recovery of Community Care Overpayments

As part of Federal efforts to reduce the number and amount of overpayments, VA is required by law (38 U.S.C. 1703) to award a contract to audit VA community care claims and payments and to initiate the recovery of any overpayments.

During this process, it’s important that community providers know their full rights and responsibilities with respect to the audit. As a result, VA is currently working to send additional information to community providers affected by the audit findings, and is holding on pursuing Treasury offsets on identified debts. If you have a question or concern about the audit, please contact VHAOCC.RecoveryAudit@va.gov. VA is committed to working with community providers throughout the audit process.

Fact Sheet: Audit Contract for Recovery of Community Care Overpayments
Describes the audit process for recovery of community care overpayments.

Community Care Claims Process


Community Care Claims Process — Published October 6, 2017

Filing Claims Directly with VA

For programs that file claims directly with VA, instructions and helpful information are listed below:

  • Billing Fact Sheet for VA Community Care Programs
    A tool to help community providers deliver care through the Veterans Choice Program (VCP), VCP Provider Agreements, Patient-Centered Community Care (PC3), or traditional VA Community Care to submit claims and get paid faster.
  • How to File a Claim–Instructions for Providers
    Details about the information and documentation needed when filing paper claims, including helpful claim-filing hints. You will also find information for CHAMPVA claims filing and authorization requirements.
  • Electronic Claims Information
    Contains information about ICD-10, VHA Office of Community Care's National Provider Identifier (NPI) requirements, electronic pharmacy claims and how to register and/or submit an EDI claim to your local VA health care facility.
  • Claims Payment Information
    Instructions for customers who would like to apply for payment via Electronic Funds Transfer (EFT), information on file changes and updates for current EFT vendors as well as requirements for electronic payments for non-VA community providers.
  • Rejected Claims–Explanation of Codes
    A list of the top 10 reasons claims are rejected/denied along with additional explanations for the rejections and what a beneficiary/provider needs to do to get the claim processed correctly.