Third Party Payers
One of the important ways that the Department of Veterans Affairs (VA) supports quality healthcare for Veterans is by working closely with private health insurance companies also known as third party payers or TPPs. Many Veterans have private health insurance coverage in addition to Veterans Affairs (VA) health care benefits. Under federal law, VA bills eligible Veterans private health insurance companies for non-service connected conditions. Veterans can use these insurance benefits to help offset copayments that VA may charge for these services.
TPPs must pay VA billed charges, or an amount comparable to what is paid, for similar services to commercial providers in the same geographic area (defined as a 3-digit postal zip code). If third party payers pay billed charges, they will not be subject to rate verification. For more details, read 38 CFR § 17.101, Collection or Recovery by VA for Medical Care or Services Provided or Furnished to a Veteran for a Nonservice-Connected Disability.
Average Administrative Cost for Prescriptions
VA updates the average national administrative cost used for billing third party pharmacy prescription drugs every calendar year (CY) for nonservice-connected disabilities. Average national administrative costs for CY2014 through CY2017 can be viewed at Average Administrative Cost for Prescriptions.
Payer Rates and Charges
Review Payer Rates and Charges for reasonable charges rules, notices and the Federal Register, as well as data tables, data sources and facility locations for VA medical rates.
Prescription Billing Methodology Rule Change
For information on the VA prescription billing methodology rule change, please review the following resources: