fee provider brochure

8/12/2019 Fee Provider Brochure

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How To File

A Claim For

Non-VA

Provided

Care

Information

for the Provider



I. Claim Filing Instructions for

Preauthorized Care*Claims submitted for payment

consideration of costs of preauthorized

medical services provided to veteransmust include a completed CMS 1500

and/or UB-04 billing forms to include,

at a minimum, the following patient andprovider information:

• Patient Name (include middle initial)

• Patient Address (include zip code)

• Patient Full Social Security Number

• Provider Name

• National Provider Identier (NPI

Number)• Provider taxonomy code(s), if known



• Submit all medical records, reports,

treatment documents, etc.• Please reference the table provided on

the opposite side for a list of required

documents.* VA reserves the right to return a claim

with a request for additional information.

III. Filing Deadlines

VA Fee programs have different claims

ling deadlines depending on how the claimis being considered for payment. The table

on the opposite side shows the timelines for

those programs.IV. Electronic Claims

VA accepts electronic health care claims

that satisfy criteria established in the Health

Insurance Portability and Accountability



If you are not sure if VA authorized

payment of care in advance, you maysubmit health care claims to the nearest

VA Medical Facility Fee Ofce. This link

may assist in locating the nearest VAMedical Facility:

http://www1.va.gov/directory/guide/

home.aspVI. Additional Information

Additional information for non-VA

providers about ling Fee claims may be

found at: http://www.nonvacare.va.gov

You may also contact your local VAMedical Facility Fee Ofce for additional

information and assistance in ling claims

for the health care services provided tothe veteran.

Your local VA Medical Facility Fee

http://www1.va.gov/directory/guide/home.asp






If the care is: And the service is: Submit claim: Documents should include:

Preauthorized

Facility Charges

(Inpatient andOutpatient)

As soon aspossible afterthe care is

completed

- 837 EDI claim or UB-04 anditemized statement of charges

- Hospital Discharge Summary orOutpatient Treatment Records/

Progress Notes

Preauthorized

Physician Charges& Other ProfessionalServices, Including

Ambulance

(Inpatient or

Outpatient)

As soon aspossible afterthe care iscompleted

- 837 EDI claim, UB-04 or CMS1500 and itemized statement ofcharges

- Outpatient Hospital EmergencyTreatment Records/

Progress NotesNotPreauthorized(ServiceConnectedCondition)

Emergency MedicalCare FacilityCharges


As soon aspossible butno later than 2years from dateof service

- 837 EDI claim or UB-04, anditemized statement of charges

- Hospital Discharge Summary orOutpatient Treatment Records/Progress Notes

NotPreauthorized(ServiceConnectedCondition)


Ambulance

(Inpatient orOutpatient)

As soon aspossible butno later than 2years from dateof service

- 837 EDI claim or CMS 1500 anditemized statement of charges


NotPreauthorized(Non-ServiceConnectedCondition)

Emergency MedicalCare FacilityCharges


Within 90 daysafter the mostrecent of thefollowing:

• Date of

discharge; or • Date of

Veteran’sdeath; or

• Date all thirdparty liabilityis exhausted

withoutsuccess

- 837 EDI claim or UB-04 anditemized statement of charges


- Certication of no other Payerfor the services billed

NotPreauthorized(Non-ServiceConnected

Condition)


Ambulance

(Inpatient orOutpatient)

- 837 EDI claim or CMS 1500 anditemized statement of charges


- Certication of no other Payerfor the services billed

2500907