Common use of Claim Submission and Payment Clause in Contracts

Claim Submission and Payment. A. Claims for reimbursement should be submitted to VA electronically unless not feasible. If electronic submission is not feasible, claims submitted in paper form shall comply with the format required for the submission of claims under title XVIII of the Social Security Act. For example, claims submitted in paper may be printed on forms such as a CMS 1450, ADA, CMS 1500, or NCPDP. Claims submitted electronically shall comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) standards for electronic transactions. B. Payment to each IHS operated Service Unit will be made upon receipt and processing of the claim, through industry standards. Adjustments to a claim will be provided to IHS via industry standard Explanation of Benefits (EOB). Any disputes will be jointly reviewed by VA and IHS staff to resolve. C. Payment to each Tribally-operated Service Unit will be made upon receipt and processing of the claim, through industry standards. Adjustments to a claim will be provided to Tribal health program via industry standard Explanation of Benefits (EOB). Any disputes will be jointly reviewed by VA and Tribal staff to resolve. D. In accordance with 25 U.S.C. § 1621f, all reimbursements received under this Agreement shall be credited to the IHS or Tribal Service Unit by or through which such services were provided and shall be used as provided in 25 U.S.C. § 1641. E. IHS and participating Tribal health programs may, consistent with applicable privacy laws, provide VA copies of medical records to support the claims submitted for reimbursement upon request from VA. The request from VA for medical records to support the claims does not need to be in writing and can be made verbally or through other agreed upon methods. Upon disclosure, copies of medical records exchanged under the agreement shall belong to the recipient agency, which will bear responsibility for information security and breach response with regard to those records. F. If IHS or a Tribal health program seeks reimbursement under this agreement, and VA provides reimbursement for the Direct Care Services provided to an Eligible AI/AN Veteran, IHS or the Tribal health program may not seek reimbursement for such care from entities other than VA. VA shall retain the right to ▇▇▇▇ an Eligible AI/AN Veteran’s third party insurer to the extent permitted by 38 U.S.C. 1729. When an Eligible AI/AN Veteran is treated by IHS or a Tribal health program under this agreement, IHS or such Tribal health program shall, consistent with applicable privacy laws, provide VA with any applicable information on each Eligible AI/AN Veterans’ private insurance, Workers’ Compensation coverage, Medicare Supplemental Insurance information, and information with respect to third-party tortfeasor cases arising under the Federal Medical Care Recovery Act (FMCRA), 42 U.S.C. 2651. If IHS or a Tribal health program seeks reimbursement under the terms of this agreement for Direct Care provided to eligible AI/AN Veterans with third party insurance who are being treated for HIV, sickle cell anemia, drug or alcohol abuse, IHS or the Tribal health program shall seek to obtain from the Eligible AI/AN Veteran and provide to VA a fully executed VA Form 10-5345, “Request For and Authorization To Release Medical Records or Health Information” so that VA may pursue reimbursement for medical care for any claims arising under 38 U.S.C. 1729. If IHS or a Tribal health program seeks reimbursement under the terms of this agreement for Direct Care provided to eligible AI/AN Veterans that IHS or the Tribal health program have determined have been injured due to the negligence of a third party under the Federal Medical Care Recovery Act (FMCRA), 42 U.S.C. 2651, IHS or the Tribal health program shall seek to obtain from the Eligible AI/AN Veteran and provide to VA a fully executed VA Form 4763, Power of Attorney and Assignment, and VA Form 10-5345, “Request For and Authorization To Release Medical Records or Health Information” so that VA may pursue reimbursement. G. Payment to IHS or the Tribal health program will be made by VA only after the AI/AN Veteran for which payment is sought, is determined by VA to be an Eligible AI/AN Veteran and only to the extent authorized for that Eligible AI/AN Veteran under VA statutes and regulations. This agreement governs payment for only those Direct Care Services provided to Eligible AI/AN Veterans after the effective date of this agreement. For an individual who applies for enrollment in VA’s system of patient enrollment and is subsequently determined to be an eligible AI/AN Veteran, VA will reimburse for Direct Care services provided back to the date of the individual’s application for enrollment, but for only those Direct Care Services provided to the Eligible AI/AN Veteran after the effective date of this agreement. When IHS or the Tribal health program identifies Veterans who do not wish to enroll in VA’s system of patient enrollment, VA and IHS or the Tribal health program will establish a process to determine eligibility.

Claim Submission and Payment. A. Claims ▇. ▇▇▇▇▇▇ for reimbursement should be submitted to VA electronically unless not feasible. If electronic submission is not feasible, claims submitted in paper form shall comply with the format required for the submission of claims under title XVIII of the Social Security Act. For example, claims submitted in paper may be printed on forms such as a CMS 1450, ADA, CMS 1500, or NCPDP. Claims submitted electronically shall comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) standards for electronic transactions. B. Payment to each IHS operated Service Unit will be made upon receipt and processing of the claim, through industry standards. Adjustments to a claim will be provided to IHS via industry standard Explanation of Benefits (EOB). Any disputes will be jointly reviewed by VA and IHS staff to resolve. C. Payment to each Tribally-operated Service Unit will be made upon receipt and processing of the claim, through industry standards. Adjustments to a claim will be provided to Tribal health program via industry standard Explanation of Benefits (EOB). Any disputes will be jointly reviewed by VA and Tribal staff to resolve. D. In accordance with 25 U.S.C. § 1621f, all reimbursements received under this Agreement shall be credited to the IHS or Tribal Service Unit by or through which such services were provided and shall be used as provided in 25 U.S.C. § 1641. E. IHS and participating Tribal health programs may, consistent with applicable privacy laws, provide VA copies of medical records to support the claims submitted for reimbursement upon request from VA. The request from VA for medical records to support the claims does not need to be in writing and can be made verbally or through other agreed upon methods. Upon disclosure, copies of medical records exchanged under the agreement shall belong to the recipient agency, which will bear responsibility for information security and breach response with regard to those records. F. If IHS or a Tribal health program seeks reimbursement under this agreement, and VA provides reimbursement for the Direct Care Services provided to an Eligible AI/AN Veteran, IHS or the Tribal health program may not seek reimbursement for such care from entities other than VA. VA shall retain the right to ▇▇▇▇ bill an Eligible AI/AN Veteran’s third party insurer to the extent permitted by 38 U.S.C. 1729. When an Eligible AI/AN Veteran is treated by IHS or a Tribal health program under this agreement, IHS or such Tribal health program shall, consistent with applicable privacy laws, provide VA with any applicable information on each Eligible AI/AN Veterans’ private insurance, Workers’ Compensation coverage, Medicare Supplemental Insurance information, and information with respect to third-party tortfeasor cases arising under the Federal Medical Care Recovery Act (FMCRA), 42 U.S.C. 2651. If IHS or a Tribal health program seeks reimbursement under the terms of this agreement for Direct Care provided to eligible AI/AN Veterans with third party insurance who are being treated for HIV, sickle cell anemia, drug or alcohol abuse, IHS or the Tribal health program shall seek to obtain from the Eligible AI/AN Veteran and provide to VA a fully executed VA Form 10-5345, “Request For and Authorization To Release Medical Records or Health Information” so that VA may pursue reimbursement for medical care for any claims arising under 38 U.S.C. 1729. If IHS or a Tribal health program seeks reimbursement under the terms of this agreement for Direct Care provided to eligible AI/AN Veterans that IHS or the Tribal health program have determined have been injured due to the negligence of a third party under the Federal Medical Care Recovery Act (FMCRA), 42 U.S.C. 2651, IHS or the Tribal health program shall seek to obtain from the Eligible AI/AN Veteran and provide to VA a fully executed VA Form 4763, Power of Attorney and Assignment, and VA Form 10-5345, “Request For and Authorization To Release Medical Records or Health Information” so that VA may pursue reimbursement. G. Payment to IHS or the Tribal health program will be made by VA only after the AI/AN Veteran for which payment is sought, is determined by VA to be an Eligible AI/AN Veteran and only to the extent authorized for that Eligible AI/AN Veteran under VA statutes and regulations. This agreement governs payment for only those Direct Care Services provided to Eligible AI/AN Veterans after the effective date of this agreement. For an individual who applies for enrollment in VA’s system of patient enrollment and is subsequently determined to be an eligible AI/AN Veteran, VA will reimburse for Direct Care services provided back to the date of the individual’s application for enrollment, but for only those Direct Care Services provided to the Eligible AI/AN Veteran after the effective date of this agreement. When IHS or the Tribal health program identifies Veterans who do not wish to enroll in VA’s system of patient enrollment, VA and IHS or the Tribal health program will establish a process to determine eligibility.