**§17.903 Payment.**

\(a\) (1) Payment for services or benefits under §§17.900 through 17.905
will be determined utilizing the same payment methodologies as provided
for under the Civilian Health and Medical Program of the Department of
Veterans Affairs (CHAMPVA) (see §17.270).

\(2\) As a condition of payment, the services must have occurred:

\(i\) For spina bifida, on or after October 1, 1997, and must have
occurred on or after the date the child was determined eligible for
benefits under §3.814 of this title.

\(ii\) For covered birth defects, on or after December 1, 2001, and must
have occurred on or after the date the child was determined eligible for
benefits under §3.815 of this title.

\(3\) Claims from approved health care providers must be filed with the
Health Administration Center in writing (facsimile, mail, hand delivery,
or electronically) no later than:

\(i\) One year after the date of service; or

\(ii\) In the case of inpatient care, one year after the date of
discharge; or

\(iii\) In the case of retroactive approval for health care, 180 days
following beneficiary notification of eligibility.

\(4\) Claims for health care provided under the provisions of §§17.900
through 17.905 must contain, as appropriate, the information set forth
in paragraphs (a)(4)(i) through (a)(4)(v) of this section.

\(i\) Patient identification information:

\(A\) Full name,

\(B\) Address,

\(C\) Date of birth, and

\(D\) Social Security number.

\(ii\) Provider identification information (inpatient and outpatient
services):

> \(A\) Full name and address (such as hospital or physician),
>
> \(B\) Remittance address,
>
> \(C\) Address where services were rendered,
>
> \(D\) Individual provider's professional status (M.D., Ph.D., R.N.,
> etc.), and
>
> \(E\) Provider tax identification number (TIN) or Social Security
> number.

\(iii\) Patient treatment information (long-term care or institutional
services):

> \(A\) Dates of service (specific and inclusive),
>
> \(B\) Summary level itemization (by revenue code),
>
> \(C\) Dates of service for all absences from a hospital or other
> approved institution during a period for which inpatient benefits are
> being claimed,
>
> \(D\) Principal diagnosis established, after study, to be chiefly
> responsible for causing the patient's hospitalization,
>
> \(E\) All secondary diagnoses,
>
> \(F\) All procedures performed,
>
> \(G\) Discharge status of the patient, and
>
> \(H\) Institution's Medicare provider number.

\(iv\) Patient treatment information for all other health care providers
and ancillary outpatient services such as durable medical equipment,
medical requisites, and independent laboratories:

> \(A\) Diagnosis,
>
> \(B\) Procedure code for each procedure, service, or supply for each
> date of service, and
>
> \(C\) Individual billed charge for each procedure, service, or supply
> for each date of service.

\(v\) Prescription drugs and medicines and pharmacy supplies:

> \(A\) Name and address of pharmacy where drug was dispensed,
>
> \(B\) Name of drug,
>
> \(C\) National Drug Code (NDC) for drug provided,
>
> \(D\) Strength,
>
> \(E\) Quantity,
>
> \(F\) Date dispensed,
>
> \(G\) Pharmacy receipt for each drug dispensed (including billed
> charge), and
>
> \(H\) Diagnosis for which each drug is prescribed.

\(b\) Health care payment will be provided in accordance with the
provisions of §§17.900 through 17.905. However, the following are
specifically excluded from payment:

\(1\) Care as part of a grant study or research program,

\(2\) Care considered experimental or investigational,

\(3\) Drugs not approved by the U.S. Food and Drug Administration for
commercial marketing,

\(4\) Services, procedures, or supplies for which the beneficiary has no
legal obligation to pay, such as services obtained at a health fair,

\(5\) Services provided outside the scope of the provider's license or
certification, and

\(6\) Services rendered by providers suspended or sanctioned by a
Federal agency.

\(c\) Payments made in accordance with the provisions of §§17.900
through 17.905 shall constitute payment in full. Accordingly, the health
care provider or agent for the health care provider may not impose any
additional charge for any services for which payment is made by VA.

\(d\) *Explanation of benefits (EOB).*

\(1\) When a claim under the provisions of §§17.900 through 17.905 is
adjudicated, an EOB will be sent to the beneficiary or guardian and the
provider. The EOB provides, at a minimum, the following information:

\(i\) Name and address of recipient,

\(ii\) Description of services and/or supplies provided,

\(iii\) Dates of services or supplies provided,

\(iv\) Amount billed,

\(v\) Determined allowable amount,

\(vi\) To whom payment, if any, was made, and

\(vii\) Reasons for denial (if applicable).

\(2\) \[Reserved\] (Authority: 38 U.S.C. 101(2), 1802-1803, 1811-1813,
1821)

(The Office of Management and Budget has approved the information
collection requirements in this section under control number 2900-0578.)

\[62 FR 51284, Sept. 30, 1997, as amended at 65 FR 35283, June 2, 2000;
68 FR 1010, Jan. 8, 2003\]

**Supplement *Highlights* reference**: 13(1)