Direct Care Services Reimbursement Agreement

Between

Department of Veterans Affairs [Insert VA Healthcare System Name]

And

[Insert Urban Indian Organization Provider Name]

PURPOSE

This Reimbursement Agreement (Agreement) is intended to facilitate reimbursement of Urban Indian Organizations (UIO) by Department of Veterans Affairs (VA) for certain health care services, specifically Direct Care Services (as defined herein) provided by the UIO to eligible Veterans who are American Indian/Alaska Native (AI/AN).

VA and UIO are entering into this agreement to improve access to direct care services for eligible AI/AN Veterans. This agreement establishes the basic underlying terms for reimbursement that will be carried out between the UIO and the local VA Medical Center (VAMC).

AUTHORITIES

25 U.S.C. § 1645(c) and 38 U.S.C. § 8153

PARTIES

Department of Veterans Affairs, [Insert VA Healthcare System Name, FILL IN ADDRESS]

[NAME Urban Indian Organization facility], [FILL IN ADDRESS] (Include List of All Included Facilities, if applicable)

DEFINITIONS

“Eligible American Indian/Alaska Native (AI/AN) Veteran” means an AI/AN Veteran who is (1) eligible for services from IHS, THP, or UIO in accordance with 42 C.F.R. Part 136 and (2) meets the definition of “Eligible Veteran” in section 4.5. 6224221 (UIO may insert additional applicable legal authorities if needed. If no insertion, delete this guidance.)

“Claim” means a written demand or assertion by one of the parties seeking, as legal right, the payment of money, adjustment or interpretation of agreement terms, or other relief, arising or relating to this Agreement.

“Days” in this Agreement refers to calendar days unless otherwise specified herein.

“Direct Care Services” means any health service that is provided directly by a UIO, including services delivered through telehealth. “Direct care services” does not include care or service provided by a UIO through the Purchased/Referred Care program for care provided outside of the facility. This term does not include travel expenses incurred by eligible veterans.

“Eligible Service” means any health care service that is reimbursable under Paragraph 6.1.

“Eligible Veteran” means a Veteran who is enrolled in VA’s system of patient enrollment in accordance with 38 U.S.C. § 1705 and 38 C.F.R. § 17.36 or is otherwise eligible for hospital care and medical services under 38 U.S.C. § 1705(c)(2) and 38 C.F.R. 17.37(a)-(c) notwithstanding the Veteran’s failure to enroll in VA’s system of patient enrollment.

“Telehealth” means clinical interactions between the patient and the physician or practitioner at a distant site using synchronous telehealth (i.e., video and/or audio only communications). VA reimbursement includes Medicare defined telehealth codes and does not include other types of telemedicine (e.g., virtual Check-Ins and E-visits). This term does not include travel expenses incurred by Veterans.

“Urban Indian Organization” has the meaning given that term in 25 U.S.C. § 1603(29). The term “Urban Indian organization” means a nonprofit corporate body situated in an urban center, governed by an urban Indian controlled board of directors, and providing for the maximum participation of all interested Indian groups and individuals, which body is capable of legally cooperating with other public and private entities for the purpose of performing the activities described in section 1653(a) of this title. (UIO may insert additional applicable legal authorities if needed. If no insertion, delete this guidance.)

DETERMINATION OF ENROLLMENT FOR ELIGIBLITY

VA is responsible for determining whether an individual qualifies to be enrolled in its patient health care system or otherwise meets the definition of an Eligible Veteran for purposes of this Agreement.

UIO may assist a Veteran in submitting an application for enrollment. If a Veteran who is eligible for services under 38 U.S.C. § 1705(c)(2) and does not choose to enroll in VA’s system of patient enrollment, a UIO may submit identifying information to the VA Healthcare System so that VA may determine whether the Veteran meets the definition of an Eligible Veteran in accordance with this Agreement despite the Veteran’s failure to enroll.

The UIO is responsible for determining whether an individual qualifies as Native or otherwise meets the definition of an Eligible Native for purposes of this Agreement. The UIO will provide information concerning determination for services as requested.

ELIGIBILITY AND REIMBURSEMENT

Reimbursable Services. VA shall reimburse UIO only for direct care services provided in the VA Medical Benefits Package available in accordance with 38 C.F.R. § 17.38 or otherwise available under statute or regulation to Eligible Veterans from VA. VA shall not reimburse for any direct care services that are excluded from the Medical Benefits Package or for which the Eligible AI/AN Veteran does not meet qualifying criteria (e.g., the requirement that the Eligible AI/AN Veteran needs the care as determined in accordance with 38 C.F.R. § 17.38(b)). This agreement does not include outpatient Durable Medical Equipment (DME).

Preauthorization. Preauthorization by VA is not required for Eligible AI/AN Veterans receiving direct care services from a UIO. Preauthorization is required for reimbursement of pharmaceuticals not on VA’s formulary.

Determination of Eligible Services. UIO may seek information from VA before delivering any direct care service as to whether the Eligible AI/AN Veteran is eligible for the specific services proposed to be provided by submitting a request for verification for eligibility. UIO may verify eligibility (and any special conditions that may apply) by contacting the VA Health and Eligibility office within their local VA Healthcare System. In particular, VA recommends that UIO verify eligibility of Eligible AI/AN Veteran for the following services, which have restricted eligibility requirements: dental, prosthetics (such as hearing aids), long-term care (including nursing home care), and transplant services.

Applicability of Agreement. This Agreement governs payment for only those direct care services provided by the UIO, including applicable pharmaceuticals, provided to an Eligible AI/AN Veteran after the effective date of this Agreement.

Reimbursement Rates.

Generally. Except as otherwise provided herein, VA shall reimburse at rates based on Medicare payment methodologies for Eligible Services provided to Eligible AI/AN Veterans. If there are not Medicare rates (to included dental), VA will reimburse the lesser of billed charges or VA’s local fee schedule.

Inpatient Hospital Services. Except to the extent inconsistent with the rate methodology explained herein, VA shall reimburse at rates based on Medicare payment methodologies for services provided to Eligible AI/AN Veterans. The payment methodology under this section applies to all inpatient services furnished by the UIO whether provided by part of a department, subunit, distinct part, or other component of a hospital (including services furnished directly by the hospital or under arrangements with contract providers who provide direct care services onsite in a UIO facility). Residential Treatment is not considered inpatient hospital services, and the residential portion is not covered under these agreements.

Payment for inpatient hospital services that the Medicare program would pay under a prospective payment system (PPS) will be based on the applicable PPS. For example, payment for inpatient hospital services shall be made per discharge based on the applicable PPS used by the Medicare program to pay for similar inpatient hospital services under 42 C.F.R. Part 412.

For hospitals that furnish inpatient services but are exempt from PPS and receive reimbursement based on reasonable costs (for example, critical access hospitals (CAHs)), including provider subunits exempt from PPS, payment shall be made per discharge based on the reasonable cost methods established under 42 C.F.R. Part 413, except that the interim payment rate under 42 C.F.R. Part 413.70, shall constitute payment in full.

The inpatient rates set forth above do not include inpatient physician services and practitioner services. The inpatient physician and other practitioner services shall be billed based on the Medicare fee schedule.

Outpatient Hospital Services and Freestanding Clinic Services. VA shall pay for outpatient and free-standing clinics services provided to Eligible AI/AN Veterans at Medicare rates (to include any other applicable rates).

Ambulatory Surgical Services. VA shall reimburse for services provided to Eligible AI/AN Veterans at established Medicare rates for freestanding Ambulatory Surgery Centers.

Outpatient Pharmacy Services. To the extent pharmaceuticals are reimbursable under this Agreement, VA shall reimburse UIO as follows:

Formulary. VA shall reimburse UIO only for pharmaceutical drugs on the formulary used by VA in accordance with National VHA and Veterans Integrated Service Network (VISN) policy for medication orders. The Pharmacy Benefits Management Services (http://www.pbm.va.gov/nationalformulary.asp) webpage contains the VA National Formulary. Requests for reimbursement of pharmaceutical drugs not on the VA formulary shall be submitted by UIO for approval by VA in advance of the request for reimbursement to VA Pharmacy and processed in accordance with VA policy on non-formulary drugs. If UIO is requesting reimbursement for a VA Non-Formulary pharmaceutical, UIO must attach the approval documentation with the submitted pharmacy claims.

Outpatient Pharmacy Services rate. Wholesale Acquisition Cost (WAC), updated monthly, plus dispensing fee of $1.00 per pharmaceutical dispensed by the UIO facility to eligible AI/AN Veterans. VA currently uses WAC published by MediSpan, subject to change.

Co-Payments. Pursuant to 25 U.S.C. § 1645(c), VA copayments do not apply to direct care services provided by UIO to Eligible AI/AN Veterans under this agreement.

Invoice Submission and Processing.

Basic Requirements.
Claims for reimbursement should be submitted to VA electronically unless not feasible. All claims submitted for reimbursement must be billed in accordance with Medicare’s National Correct Coding Initiative (NCCI) and must include DRG codes. 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.

Timely Filing. Invoices for direct care services provided after the effective date of this Agreement, not submitted to VA within 12 months from the date of service, shall not be reimbursed by VA.

Other Reimbursement.

Pursuant to 25 U.S.C. 1645(c), the UIO will seek payment from all other liable payers before seeking reimbursement from VA for services provided to an Eligible AI/AN Veteran under this agreement. The UIO shall provide VA copies of Other Health Insurance (OHI) Explanation of Benefits (EOB) with claim submission. VA is responsible for only the balance remaining up to the VA allowed amount after other third-party reimbursements; except for when the third-party payer is a federal entity, VA will not pay the balance remaining on claims already partially paid by another federal entity.

Information Sharing.

VA retains the right to bill an Eligible AI/AN Veteran’s Other Health Insurance (OHI) to the extent permitted by 38 U.S.C. § 1729. When an Eligible AI/AN Veteran is treated by UIO under this Agreement, UIO shall, consistent with applicable privacy laws, provide VA with any applicable information regarding the 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 UIO seeks reimbursement under the terms of this Agreement for direct care services provided to Eligible AI/AN Veterans with Other Health Insurance (OHI) who are being treated for HIV, sickle cell anemia, drug or alcohol abuse, UIO 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 UIO seeks reimbursement under the terms of this Agreement for direct care services provided to an Eligible AI/AN Veteran who UIO has determined to have been injured due to the negligence of a third party, UIO 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 under the Federal Medical Care Recovery Act (FMCRA), 42 U.S.C. § 2651.

Denied Invoices. Nothing in this Agreement prohibits UIO from seeking reimbursement from any other payer, including the Veteran (if consistent with UIO’s policies) for direct care services provided to a Veteran for which VA is not responsible due to the patient not being an Eligible Veteran or the services not being Eligible Services or for which VA denies payment for any other reason.

Denial, Reconsideration and Appeal

Denial. VA may deny an invoice or a portion of an invoice for direct care services provided by UIO under the following conditions:

The Veteran is not an Eligible Veteran as defined in the Agreement;

the care or services provided are not direct care services;

the care or services provided are not otherwise reimbursable under the terms of this Agreement;

the invoice was not submitted as required under Section 6.7 of this Agreement;

the claim was not submitted with proper OHI Explanation of Benefits (EOB) or,

the information needed to adjudicate the invoice, consistent with the information contained on the electronic Health Care Financing Administration (HCFA) and Universal Billing (UB) forms (or other applicable form), is not provided.

Notice and Request for Reconsideration. If VA denies reimbursement for an invoice, VA shall notify UIO of the denial in writing together with a statement of the reason for the denial. The notice shall advise that UIO may obtain a reconsideration of the denial by submitting a request for reconsideration or appeal in writing, within 90-days of the notice, setting forth the grounds supporting the request or appeal, including any documentation requested by VA for reconsideration. VA shall issue a decision on the request for reconsideration in writing within 30 days. In the event that UIO disputes VA’s request for reconsideration decision, UIO may avail itself of the Disputes process in Paragraph 9.

QUALITY OF CARE

Information Exchange. VA and UIO shall develop a process to share patient records through the Nation-Wide Health Information Network consistent with relevant privacy laws and will continue activities to share data electronically.

Agree to meet CMS promoting Operability requirements for electronic health records (EHR).

Certification and Accreditation. In order to receive reimbursement, each UIO must meet conditions and requirements for participation in Medicare or Medicaid, as demonstrated by enrollment or certification in Medicaid or Medicare, or by maintaining accreditation with an organization recognized by the Centers for Medicare and Medicaid Services (CMS), such as the Joint Commission or Accreditation Association for Ambulatory Heath Care (AAAHC), or the Commission on Accreditation for Rehabilitation Facilities (CARF). Each UIO shall submit enrollment/certification or accreditation information to VA upon request during the effective period of this agreement and notify VA within 15 days of any disenrollment or loss of certification or accreditation.

Medical Quality Assurance Activities. UIO agrees to:

Develop a patient advocacy process to address patient grievances and complaints that are not resolved at the local VA or UIO level, collaborating with VA as needed.

Convene ad hoc meetings or an annual meeting, to discuss program-specific quality issues or concerns.

Share information with VA regarding its medical quality assurance activities.

Promote care coordination between VA and IHS by utilizing VA’s authorization and referral systems when care is referred to VA.

GENERAL PROVISIONS

Veteran’s Choice of Provider. Nothing in this Agreement affects the right of AI/AN Eligible Veterans to choose whether they receive health care services in VA or UIO facilities.

Privacy Standards.

Generally. VA and UIO will comply with all applicable Federal laws and regulations regarding the confidentiality of health information.

UIO Records. Medical, health and billing records of UIO patients are subject to some or all of the following laws: the Privacy Act, 5 U.S.C. § 552a; the Freedom of Information Act, 5 U.S.C. § 552; the Drug Abuse Prevention, Treatment, and Rehabilitation Act, 21 U.S.C. § 1101, the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act, 42 U.S.C. § 4541, the Administrative Simplification requirements of HIPAA, 45 C.F.R. Parts 160 and 164; Confidentiality of Medical Quality Assurance Records, 25 U.S.C. § 1675, the Patient Safety and Quality Improvement Act of 2005, and Federal regulations promulgated to implement those acts. Pursuant to the Indian Self-Determination and Education Assistance Act, as amended, UIO’s patient records may not be considered Federal records for the purposes of chapter 5 of title 5 of the United States Code (including the Privacy Act and the Freedom of Information Act) or may be considered Federal records for only limited purposes under those provisions. (UIO may insert additional applicable legal authorities if needed. If no insertion, delete this guidance.)

VA Records. Records of VA payment for direct care services are subject to some or all of the following laws: the Privacy Act, 5 U.S.C. § 552a; the Freedom of Information Act, 5 U.S.C. § 552; Confidentiality of Certain Medical Records, 38 U.S.C. § 7332; Confidential Nature of Claims, 38 U.S.C. § 5701; the Administrative Simplification requirements of HIPAA, 45 C.F.R. Parts 160 and 164; Medical Quality Assurance Records Confidentiality, 38 U.S.C. § 5705; the Patient Safety and Quality Improvement Act of 2005, and Federal regulations promulgated to implement those acts. All requirements of HIPAA will be met before there is any sharing of identifiable patient information.

Exchange of Medical Records. UIO shall 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 means. Copies of medical records exchanged under the Agreement shall belong to the recipient party, which will bear responsibility for information security and breach response with regard to those records.

Medical Malpractice. UIO has medical malpractice insurance under the Federal Tort Claims Act (“FTCA”) and, possibly other professional liability coverage that covers direct care services provided under this Agreement. VA will bear no responsibility for claims arising from health care provided to a Veteran under this Agreement. If VA receives a medical malpractice claim directly from a Veteran that primarily involves medical care rendered by UIO, VA will promptly notify UIO. Where VA is identified as an involved party in a claim submitted to UIO, UIO will provide a copy of the claim and documents effecting resolution or disposition of the claim to the VA Office of the General Counsel (021B), 810 Vermont Avenue, NW, Washington DC 20420.

Rights of Veterans. Nothing in this Agreement restricts the right(s) of a Veteran to challenge or dispute, pursuant to Federal law or regulation, an eligibility determination made by VA.

DISPUTES.

The Parties shall utilize all reasonable efforts to resolve any dispute at the lowest administrative level possible. In the event that either Party determines that further efforts are not conducive to resolving a dispute, the dispute shall be presented to the VA Contracting Officer for consideration; the VA Contracting Officer shall furnish a written reply on the dispute or claim to the UIO within 90 days. The UIO shall comply with any decision of the VA Contracting Officer pending final resolution of the matter.

In the event the Parties cannot amicably resolve the matter upon the decision of the VA Contracting Officer, a dispute or claim arising out of or relating to this Agreement, or breach thereof, shall be settled by mediation. The neutral mediator shall be assigned from the Administrative Judges of the U.S. Civilian Board of Contract Appeals, with each Party bearing an equal share of any cost. The U.S. Civilian Board of Contract Appeals may furnish a neutral at no cost.

Any claim by either Party against the other must be presented no later than 1 year after the effective date of cancellation or final expiration of this Agreement otherwise the party forfeits its right(s) to relief.

SURVIVAL OF TERMS. The rights and obligations of the parties under Paragraphs 6 (eligibility and reimbursement), 8.2 (privacy standards), 8.3 (medical malpractice), and 9 (disputes) shall survive expiration or cancellation of this Agreement. All other rights and obligations arising solely from this Agreement shall cease upon expiration or cancellation of the Agreement, provided expiration or cancellation of the Agreement shall have no effect on statutory rights or responsibilities of the parties.

EFFECTIVE DATE, TERM, TERMINATION, AND AMENDMENT.

Effective Date. This Agreement shall become effective upon the date when signed by all parties. The only official authorized to legally bind VA is the VA Contracting Officer. {UIO FILL IN EQUIVALENT INFORMATION.}

Term. This Agreement shall be effective through June 30, 2024. VA obligations under this Direct Care Services Reimbursement Agreement shall be subject to the availability of appropriated funds.

Amendment. Except for Cancellation, this Agreement may be revised or amended only by mutual written agreement signed by the signatories (or their authorized representatives) to this Agreement.

Cancellation. Either party may cancel this Agreement at any time by providing a 60-day written notice of the intent to cancel the Agreement to the signatories (or their authorized representatives). Cancellation shall take effect at the end of the 60-day period established by the written notice.

SIGNATURE BLOCKS.

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(Name of UIO Authority)	Date

(Title)

(Name of UIO)

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Department of Veterans Affairs	Date

Contracting Officer

VISN XX Network Contracting