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 has established rapid response teams to work with the following list of Top 20 providers to assist with account receivable reconciliation and provider training. VA continues to work closely with other important community partners and small providers that have been participating in ongoing claims resolution meetings.
List of Top 20 providers Frequently Asked Questions about the Top 20 List
Community Care Claims Process
Community Care Claims Process — Published October 6, 2017
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 Federal Register, Vol. 83, No. 6, 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.
Title 38 CFR 17.1005 Federal Register notice
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 nonservice-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.
Fact Sheet: VA Expands Eligibility for Emergency Treatment
For more information, providers should call the local VA medical facility responsible for processing emergency care community care claims. The VA Facility Locator can assist in finding a facility and key staff information.
For programs that file claims directly with VA, instructions and helpful information are listed below:
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.
How to File a Claim–Instructions for Providers
Electronic Claims Information
Contains information about National Provider Identifier (NPI) requirements and electronic payments as well as instructions on how to apply for payment via Electronic Funds Transfer (EFT) and information on file changes and updates for current EFT vendors.
Electronic Claims Information
A list of the top 10 reasons claims are rejected/denied along with additional explanations for the rejection codes and what a beneficiary/provider needs to do to get the claim processed correctly.
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). VIS is an external web application that allows community providers and registered vendors to research the status of claims received by VA. Community providers may register on VIS to find specialized training and receive special user access to view VA Treasury payment information. You can learn more about VIS from the Vendor Inquiry System fact sheet below.
Vendor Inquiry System Fact Sheet: Vendor Inquiry System
To check the status of claims with the Patient-Centered Community Care (PC3)/Veteran Choice Program (VCP) vendor TriWest, visit the Billing and Claims area on the TriWest Provider Portal. Providers who have questions for all claims filed with the PC3/VCP vendor Health Net prior to September 30, 2018, are to call Health Net directly.
TriWest Provider Portal: Billing and Claims
Health Net Federal Services: 844-728-1914
The U.S. Department of Treasury published a final rule on Electronic Funds Transfer (31 C.F.R. 208) on Dec. 21, 2010. This rule requires that all federal payments be made electronically. This requirement includes payments made to community medical and dental providers. Community care providers have two options to meet this requirement: Electronic Funds Transfer (EFT) or the VA SmartPay Purchase Card Program.
Electronic Funds Transfer (EFT)
If you would like to apply for payment via EFT, complete the "Payee/Vendor Information" and "EFT/ACH" sections of the VA-FSC Vendor File Request Form, Form VA 10091. Fax the signed, completed form to the VA Financial Services Center (FSC), Vendor Support Section.
VA Form 10091–Fillable PDF
You, the enrolling health care provider, will need to contact your financial institution to arrange for the delivery of the CORE-required Minimum CCD+ Data Elements necessary for successful reassociation of the EFT payment with the ERA remittance advice. For questions on EFT enrollment, please contact the FSC, Vendor Support Section.
If you are currently enrolled in or receiving EFT payments from any federal program (Medicare, Medicaid, Tricare, etc), please read the section below.
VA Financial Services Center
FSC, Vendor Support Section
Updates and File Changes to EFT
Health care providers already receiving EFT payments from the federal government can submit file changes/updates by selecting the box marked "Update" on VA Form 10091. You can obtain a copy of the current VA Form 10091 and instructions for completing the form by emailing the VA-FSC. Complete Form VA 10091 with the desired updates, and fax the completed, signed form to Financial Service Center Nationwide Vendor File.
Financial Service Center Nationwide Vendor File
For questions regarding updates to EFT information on file, please contact the VA-FSC, Vendor Support Section at the phone or email listed above.
The VA SmartPay Purchase Card Program offers rapid electronic claims payments for community care vendors. The VA will pay your community care claims using their SmartPay Purchase Card. These payments will be made electronically to your bank account. You can track and manage your community care payments using your Internet browser. To access your new account, click on the link below for the SmartPay login and follow the instructions to login or to create a new account.SmartPay Login Page
VA is committed to maintaining a strong relationship with community providers, who are critical to ensuring Veterans receive timely, high-quality care, while also ensuring proper stewardship of public funds.
As required by federal law, in 2016 VA awarded a contract to perform an audit of community care payments to identify potential overpayments and recover funds. The audit, much like recovery audit contracts with Medicare or commercial insurances, is a review of claims and supporting medical documentation. VA subsequently became aware that certain claims were not being processed in accordance with VA’s payment regulations, resulting in overpayments; these claims were included in the recovery audit contract. Through the recovery audit contract, the VA recouped approximately $36M in overpayments for fiscal years 2013 and 2014, the majority of which was returned to VA Medical Centers to support Veteran care.
VA takes our relationships with community providers very seriously and, after listening to concerns raised by providers and evaluating VA’s internal processes and federal financial requirements, VA has decided that the current audit will cease. As a result, VA is temporarily suspending debt collections for Community Care payments through a third-party auditor while we pursue additional approaches that will take into account individual community provider circumstances and alternative payment options while also ensuring proper stewardship of public funds.
If you have a question or concern about the audit, please contact VHAOCC.RecoveryAudit@va.gov.