(Current law permits the VA to collect appropriate Medicare coinsurance and deductible amounts from supplemental insurers for claims for supplies and services ordinarily covered by Medicare but furnished:)

Medicare Claims Processing Manual  Chapter 37 - Department of Veterans Affairs (VA) Claims Adjudication Services Project   Table of Contents  (Rev. 11427, 05- 20-22)  Transmittals for Chapter 37   1 - Background on the VA Claims Adjudication Services Project  1.1 - Requirements for Processing VA  Institutional and Professional  Claims                  1.1.2  Requirements for Processing VA Durable Medical Equipment            Prosthetics Orthotics and Supplies (DMEPOS) Claims  1.2 - Department of VA Claims Adjudication: Coinsurance and Deductible  1.3 - Generating Unsolicited Responses to the VA  1.4 - Use of Legacy Provider Numbers After National Provider Ident ifiers (NPIs ) Are Fully Implemented  1 - Background on the VA Claims Adjudication Services Project  (Rev. 1454, Issued: 02- 22-08, Effective: 04 -01-08, Implementation: 04- 07-08)  Current law permits the VA to collect appro priate Medicare coinsurance and deductible amounts from supplemental insurers for claims for supplies and services ordinarily covered by Medicare but furnished:    At VA facilities; and   For veterans eligible to receive both VA health and Medicare benefits and also having Medicare supplemental insurance.   To facilitate this process, the Centers for Medicare & Medicaid Services (CMS) entered into an interagency agreement with the VA whereby CMS will help the VA work with the designated CMS MAC to adjudicate cl aims for these services to produce remittance advices equivalent to those ordinarily produced for Medicare claims.  Medicare does not pay these claims, but the remittance advices show how much Medicare would have paid had the claims been payable by Medicar e along with the applicable deductibles and coinsurance.  In adjudicating a claim and generating these remittance advice notices, the CMS MAC must verify that the services provided are covered benefits, certify admission where appropriate, conduct prepayme nt utilization screening, and authorize payment.  CMS has a single A/B MAC (A) and (B) to process these claims.  The remittance advices, sent by the VA to the supplemental insurers, will help the insurers determine payment amounts they owe to the VA.   The VA funds all of the work on this project, including systems changes.   1.1 - Requirements for Processing VA Institutional and Professional Claims (Rev.  4023, Issued: 04- 20-18, Effective: 07 - 20-18, Implementation: 07- 20- 18)  Veterans typically see more than one physician at a VA facility on a given day.  The A/B MAC (B) -defined provider number will contain a V in the first position and specialty codes.  Including specialty codes permits the VA to have multiple provider numbers to accommodate various pr ofessional services furnished at a given facility on the same day for the same beneficiary -veteran.  CWF will edit to ensure that only claims having all three of the following conditions will be processed according to the special VA claims adjudication procedures of this project:   1. A demo number of 31 is present;   2. A V is present in the first position of the A/B MAC (B) defined provider number field (HUBC Field 83 Provider Number, Positions 440- 449); and   3. The VA A/B MAC (B) number is present   If only two of these conditions are present, then CWF will reject the claim.  If only the demo code of 31 is present, CWF will also reject the claim.   The VA will use the ASC X12 837 professional claim format for A/B MAC (B) equivalent claims.   To process VA claims from various localities, the VA A/B MAC (A) and (B) has established a database for the Medicare physician fee schedule to include pricing information for all of the States.   The VA will use the following bill types for A/B MAC (A) equivalent claims: 11x, (Hospi tal Inpatient, Part A), 12x (Hospital Inpatient, Part B), 13x (Hospital Outpatient), 14x (Hospital Other, Part B), 18x (Hospital Swing Beds), 21x (SNF inpatient), and 23x (SNF outpatient).  These claims are submitted using the ASC X12 837 institutional cla im format.   The SNF VA provider numbering scheme is as follows:   a 2 digit numeric state code, followed by a 5, followed by a 1 digit one up number, followed by with a V, ending with a single position alpha numeric .  1.1.2  Requirements for Processing VA Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) Claims  (Rev. 11427; Issued: 05- 20-22; Effective: 01 -01-23; Implementation: 01- 03-23)  NOTE:  CMS seeks to reduce burden and modernize processes to ensure a reduction in improper payments and an increase in customer satisfaction. The Certificate of Medical Necessity (CMN) form and DME Information Form (DIF) were originally required to help document the medical necessity and other coverage criteria for selected Durable Medi cal Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items. In the past, a supplier received a signed CMN from the treating physician or created and signed a DIF to submit with the claim. Due to improvements in claims processing and medical records  management, the information found on CMNs or DIFs is available either on the claim or in the medical record and is redundant. Therefore, to reduce burden and increase customer satisfaction, providers and suppliers no longer need to submit these forms for services rendered after January 1, 2023.  For claims with dates of service on or after January 1, 2023  providers and suppliers no longer need to submit CMNs or DIFs with claims. Due to electronic filing requirements, claims received with these forms attached will be rejected and returned to the provider or supplier.  For claims with dates of service prior  to January 1, 2023  processes will not change and if the CMN or DIF is required, it will still need to be submitted with the claim, or be on file with a previous claim. This statement applies throughout the Program Integrity Manual wherever CMNs and DIFs  are mentioned.   The process of receiving VA DMEPOS claims for a no- pay Electronic Medicare Remittance Advice (e- MRA) is effective on April 1, 2018.  The processing of these claims, as with the Part A and Part B claims, allows for a CMS no -pay e -MRA to be generated for all DMEPOS claims submitted to CMS by the VA.  VA DMEPOS claims are processed by a single DME MAC.  For VA DMEPOS claims the e- MRA displays the amount that Medicare would have paid for the claim using the same fee schedule payments as DMEPOS Medicare claims wouldve paid and are based on the beneficiarys state of residence. The same deductible and coinsurance rules applicable to Medicare are applied to the VA claims and are provided on the e -MRA.   The VA submits DMEPOS claims via the ANSI X12  837P electronic format. The VA claims will be processed through the Medicare DME MAC Common Electronic Data Interchange (CEDI) front end system, DMEPOS claims processing system (VMS) and the common working file (CWF).   In addition to following the ANSI X 12 837P standards for claims submissions the following criteria applies:   The VA's submitter of record is the approved biller and submits all VA electronic claims to CEDI.   The VA supplies CMS, the VA DME MAC and CEDI with the VA facility NPI list. Validation of the NPI is done at the CMS front end contractor.   VA claims are processed as mandatory assigned claims, no beneficiary submitted claims will be processed.   VA DMEPOS submitted claims must be for beneficiaries that reside in the US and its territories.   The VA must submit claims for Medicare approved HCPCS provided on the DMEPOS jurisdiction list which can be found at https://www.cms.gov/Center/Provider -Type/Durable -Medical -Equipment -DME -Center.html.   The VA DMEPOS claims are subject to the Medicare timely  filing rules. Claims will be accepted for processing with dates of service one year prior to the date of receipt.   The VA will submit paper CMNs for DMEPOS items that require a CMN per Medicare rules. The CMNs will be faxed (until the time VA has the ability to submit CMNs electronically) to the DME MAC. Claims requiring a CMN may be held for up to 2 weeks to allow for receipt of the CMN. Claims will be denied if a CMN is not received within 2 weeks.   The CWF edits to ensure the same three conditions stated above for A/B claims are applicable and must be present for adjudication on the DMEPOS claims.  In addition, MSP claims are accepted from the VA and the CWF will apply MSP editing to VA DMEPOS claims.   Finalized claims will be included in the VA e -MRA an d produced in the CMS flat file format.  CEDI will translate the VA e -MRA flat file to the ANSI X12 835 format and make the file(s) available for the VAs submitter of record to retrieve.    Adjustments to claims submitted by the VA can be made only for redeterminations or cancels.  This applies to all DMEPOS claims submitted by the VA for VA facilities and for independent suppliers.  1.2 - Department of VA Claims Adjudication: Coinsurance and Deductible  (Rev. 1454, Issued: 02- 22-08, Effective: 04 -01-08, Implementation: 04 -07-08)  Part of this process involves the calculation of the deductible applicable to the Medicare -equivalent VA claims.  The CWF calculates the deductible based on true Medicare claims, i.e., for Medicare services rendered by Medicare p roviders to Medicare beneficiaries, and sends this information back to the shared system maintainers for this project.  The MCS and FISS further adjust the deductible information received from CWF with the deductible amounts that apply to the Medicare -equivalent VA claims.  This arrangement results in a calculation of the deductible for the VA's equivalent of Part A and B claims.   In addition, effective January 1, 2005, CWF began to calculate the Part B -equivalent deductible for Medicare claims taking into consideration the VA equivalents of both Medicare outpatient and professional claims as well as true Medicare claims.   To confirm that CMS has made no payment on the VA claim, the remittance advice will include message MA118 Coinsurance and or deductible  amounts apply to a claim for services or supplies furnished to a Medicare Eligible veteran through a facility of the Department of Veterans Affairs. No Medicare payment issued".  Existing claim adjustment reason codes 1 (deductible) and/or 2 (coinsurance) will be used to report those amounts on these remittance advice transactions.  As necessary, CWF expands the VA claim auxiliary file within CWF so that the history of VA Part A -equivalent no- pay claims, adjudicated for the MRA Project, contai n sufficient information about the VA claims and Medicare -equivalent Part A deductible and coinsurance amounts applied so that an unsolicited response can be generated.  The auxiliary file contains sufficient information so that there can be one such unsol icited response for each VA claim affected.   The VA auxiliary file within CWF also provides a claims history for VA Part B equivalent claims.  The auxiliary contains the information about VA claims necessary to show Medicare- equivalent Part B deductibles s atisfied by the VA claims.  National Claims History is not updated with the VA deductible information, and these changes have no effect on Medicare claims.  CWF sends the Part B deductible information to the A/B MACs (A) and (B) for this project.  This aff ects claims with dates of service of January 1, 2004, and after and will use deductible amounts for calendar years 2004 and after.  1.3 - Generating Unsolicited Responses to the VA  (Rev. 1454, Issued: 02- 22-08, Effective: 04 -01-08, Implementation: 04- 07-08)