Billing

Billing Medicare Part A When VA-Eligible Medicare Beneficiaries Receive Services in Non VA Facilities

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Billing Medicare Part A When VA-Eligible Medicare Beneficiaries Receive Services in Non VA Facilities

Outlined below are instructions on how Medicare Part A providers (non VA facilities) must bill for services rendered to VA-eligible Medicare beneficiaries. To prevent claims from being RTP, please make your billing staff aware of these instructions.

Each time a Medicare beneficiary, who is also eligible for VA benefits, receives services in a non VA facility, the beneficiary may choose to use Medicare as the primary payer or their VA benefits as the primary payer for the services (the latter requires authorization from and payment by the VA).

How Medicare is billed depends on whether the beneficiary chooses to use Medicare or their VA benefits as the primary payer for the services, whether the VA has/has not paid for the services, whether the VA paid in part or in full, and whether the services are inpatient or outpatient. There is also claim editing in our system to consider.

When billing Medicare for services to VA-eligible Medicare beneficiaries, you may need to report condition code (CC) 26 on your claims. CC 26 means a VA-eligible beneficiary chose to receive services in a Medicare-certified facility instead of a VA facility. The instructions below include guidance on whether or not to report CC 26 on your claims and we have taken the current claim editing in our system into account.

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Beneficiary Chooses to Use Medicare

If a VA-eligible beneficiary chooses to use Medicare as the primary payer for their services in a non VA facility, the non VA facility may bill Medicare as primary. Reporting CC 26 is optional. Because current claim editing in our system causes claims submitted with CC 26 to suspend or RTP, we recommend you do not report CC 26 on these claims at this time. Note: On/after 5/23/2017, you may choose to report CC 26 on outpatient claims but not on inpatient claims. In addition, do not report value code (VC) 42 or the VA as a payer on such outpatient or inpatient claims.

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Beneficiary Chooses to Use VA but VA Does Not Make Payment

If a VA-eligible beneficiary chooses to use their VA benefits as the primary payer for their services in a non VA facility, the non VA facility seeks authorization from and payment by the VA. If the VA will not authorize and/or make payment for the services (no payment for any services), the non VA facility may bill Medicare as primary. Because current claim editing in our system causes claims submitted with CC 26 to suspend or RTP, we recommend you do not report CC 26 on these claims at this time. Note: Beginning 5/23/2017, you may then choose to report CC 26 on outpatient claims but not on inpatient claims. In addition, do not report VC 42 or the VA as a payer on such outpatient or inpatient claims.

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Beneficiary Chooses to Use VA and VA Makes Payment

If a VA-eligible beneficiary chooses to use their VA benefits as the primary payer for their services in a non VA facility, the non VA facility seeks authorization from and payment by the VA. If the VA authorizes/makes payment for the services, the non VA facility bills Medicare as follows, depending on the type of services (inpatient or outpatient), the facility type and whether the VA’s payment was made in part or in full:

  • Inpatient hospital claims partially paid by the VA: Hospitals bill admit to discharge claims; therefore, do not split bill stays based on which portion the VA paid for and which portion they did not. When the VA pays for only a portion of an inpatient hospital stay, bill admit to discharge claims as usual and per the instructions in CMSMLN Matters MM9818. We will determine if any Medicare payment is due. These claims look like MSP claims in terms of the coding you enter but are not considered MSP claims since no MSP record in the CWF is needed. Per MM9818, timeliness can be overridden. On these claims, report:
    • CC 26
    • VC 42 with dollar amount of the partial payment from the VA for that stay
    • VA as the primary payer’s name (payer code “I” if using FISS DDE)
    • Medicare as the secondary payer
    • All services/charges for the stay including those the VA paid and those they did not
  • Inpatient SNF claims partially paid by the VA: SNFS bill monthly claims; therefore, do not split bill monthly claims based on which portion the VA paid for and which portion they did not. When the VA pays for only a portion of an inpatient SNF monthly claim, bill monthly claims as usual and per the instructions in CMS’ MLN Matters MM9818. We will determine if any Medicare payment is due. These claims look like MSP claims in terms of the coding you enter but are not considered MSP claims since no MSP record in the CWF is needed. Per MM9818, timeliness can be overridden. On these claims, report:
    • CC 26
    • VC 42 with dollar amount of the partial payment from the VA for that month
    • VA as the primary payer’s name (payer code “I” if using FISS DDE)
    • Medicare as the secondary payer
    • All services/charges for that month including those the VA paid and those they did not
  • Outpatient claims partially paid by the VA: Bill us as Medicare primary. On these claims, report: :
    • Services/charges the VA did not pay (do not include those the VA paid).
    • Do not report CC 26, VC 42 or the VA as a payer on the claims. Note: Beginning 5/23/2017, you may then choose to report CC 26 on these claims going forward.
  • Inpatient claims fully paid by the VA (admit to discharge claims for hospitals or monthly claims for SNFs): Bill us noncovered claims per MLN Matters SE1517. SE1517 references the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 60 with regard to billing statutorily excluded services.
    • Do not report CC 26, VC 42 or the VA as a payer on the claims.
  • Outpatient claims fully paid by the VA: You may choose to bill us or not to bill us. If you bill us, bill noncovered claims per MLN Matters SE1517. SE1517 references the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 60 with regard to billing statutorily excluded services.
    • Do not report CC 26, VC 42 or the VA as a payer on the claims. Beginning 5/23/2017, you may then choose to report CC 26 on these claims going forward.

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