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 by the Department of Veterans Affairs (VA) to Urban Indian Organizations (UIO) for health care and related services provided by the UIO to Eligible American Indian/Alaska Native (AI/AN) Veterans as defined herein.

This Agreement establishes the basic underlying terms for reimbursement from VA to the UIO.

This Agreement is a continuation of the agreement between the Parties for reimbursement of direct health care services in 2022, with terms that supersede the provisions of that earlier agreement.

PARTIES

Department of Veterans Affairs, NAME VA Healthcare System, FILL IN ADDRESS

NAME Urban Indian Organization facility, FILL IN ADDRESS. (List all included facilities, if applicable)

AUTHORITY

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

DEFINITIONS

Direct Care Services: means any health service that is provided directly by a UIO, including services delivered through telemedicine. The scope of direct care services covered by VA is determined by the VA medical benefits package, and may include dental, Long-Term Care, and mental health services, depending on the Veteran’s eligibility to receive such services. “Direct care services” does not include care or services provided by a UIO through the Purchased/Referred Care (PRC) program for care provided outside of the UIO facility by non-UIO providers.

Eligible American Indian/Alaska Native (AI/AN) Veteran: means an American Indian/Alaska Native Veteran who is (1) eligible for services from the UIO in accordance with 42 C.F.R. Part 136 and (2) is enrolled in VA’s system of patient enrollment in accordance with 38 U.S.C. § 1705 and 38 C.F.R.17.36, is 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 Eligible American Indian/Alaska Native Veteran’s failure to enroll in VA’s system of patient enrollment, or is otherwise eligible for services provided or paid for by VA. VA and the UIO are responsible for determining eligibility for health care services within their respective programs.

Telemedicine: means the exchange of medical information from one site to another through electronic communication to improve a patient’s health. Examples of telemedicine include health care services delivered through videoconferencing, store-and-forward imaging, on-line patient portals, and/or audio communications.

Urban Indian Organization (UIO): 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.

REIMBURSABLE SERVICES

Direct Care Services. VA shall reimburse UIO for direct care services provided to Eligible American Indian/Alaska Native Veterans, at the rates set forth in Section VI, when: (1) the UIO provided the Direct Care Services by or through UIO-operated facilities/programs; and (2) at the time of care, VA had the authority to provide or pay for the care through any means. This Agreement does not cover care provided by VA providers, or care referred to the UIO under a separate agreement with VA. VA providers cannot order any care or services from UIOs without a separate agreement for VA purchased care. No services provided at the request of a VA provider are reimbursable under this Agreement.

Outpatient Pharmacy Services. VA shall reimburse for outpatient medications on the VA formulary associated with the provision of Direct Care Services provided to an Eligible American Indian/Alaska Native Veteran. VA will not reimburse for the following: (1) compounded medications; (2) medications that are not approved by the Food and Drug Administration (FDA); (3) medications that are considered experimental.

Preauthorization. Preauthorization by VA is not required for any of the reimbursable services within the scope of this Agreement, but VA may require the UIO to provide additional justification. Preauthorization is required for reimbursement of pharmaceuticals not on VA’s formulary.

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

REIMBURSEMENT RATES FOR DIRECT CARE SERVICES

Generally: Except to the extent inconsistent with the rate methodology explained herein, VA shall reimburse the UIO for Direct Care services at rates based on Medicare payment methodologies. In the absence of Medicare rates and otherwise agreed upon rates specified herein, VA will pay the lesser of the local VA Fee Schedule amount or billed charges.

Outpatient Hospital Services and Freestanding Clinic Services: VA shall reimburse the UIO for outpatient hospital services and free-standing clinic services provided to Eligible American Indian/Alaska Native Veterans based on Medicare payment methodologies, to include any other applicable Medicare rates including Federally Qualified Health Centers (FQHC) rates.

Dental Services: VA shall reimburse the UIO at the lesser of VA’s local dental fee schedule or billed charges for dental care services provided to Eligible American Indian/Alaska Native Veterans.

Durable Medical Equipment, Prosthetics/Orthotics & Supplies (DMEPOS): VA shall reimburse the UIO at established Medicare rates for DMEPOS provided to Eligible American Indian/Alaska Native Veterans.

Home Health: VA shall reimburse the UIO at established Medicare Home Health prospective payment system (PPS) rates for Direct Care Home Health Services provided to Eligible American Indian/Alaska Native Veterans.

Outpatient Pharmacy Services: VA shall reimburse the UIO for Outpatient Pharmacy Services at the lesser of reasonable billed charges or the Wholesale Acquisition Cost (WAC) plus a $2.50 dispensing fee per pharmaceutical (not including supplies). VA Payment Operations will complete audits on the Outpatient Pharmacy.

Ambulatory Surgical Service Centers: VA shall reimburse the UIO for services provided to Eligible American Indian/Alaska Native Veterans at established Medicare rates for freestanding Ambulatory Surgical Service Centers.

Inpatient Hospital Services: The reimbursement 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.

Payment for inpatient hospital services will be based upon the applicable PPS. For example, reimbursement 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. This methodology will be used under this Agreement to reimburse inpatient hospital services regardless of whether the UIO hospital participates in the Medicare program or is otherwise exempt from the PPS (e.g., Critical Access Hospitals (CAHs)).

For hospitals that furnish inpatient services but are exempt from PPS and receive reimbursement based on reasonable costs, 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, subpart E 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 reimbursed based on the Medicare physician fee schedule.

CLAIMS SUBMISSION AND PAYMENT

Generally: The UIO and VA agree to follow National Correct Coding Initiative (NCCI) standards for health care claims submission and adjudication.

Direct Care Services: Claims for Direct Care Services 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 or recognized under section 1175 of such Act. All direct care claims submitted for reimbursement must be billed in accordance with Medicare’s National Correct Coding Initiative (NCCI) and must include DRG codes. Claims submitted electronically shall comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) standards for electronic transactions.

Required Program Identifier (All Claim Types): All claims under this Agreement must be submitted using the following program identifier(s), unless otherwise indicated by VA: UIO.

Outpatient Pharmacy Claims:

Required Coding: All pharmacy claims should be coded using the Healthcare Common Procedure Coding System (HCPCS) code J3490.

Required Claim Information:

Program Identifier

Social Security Numbers (SSNs) (must be 9 digits with no dashes or other characters)

Provider Tax IDs (must be 9 digits with no extra characters)

HCPCS code J3490

Date of fill

Number of day’s supply

Quantity of drug

Pharmacy name

Doctor and address

Drug name (generic name) and strength

Amount paid by the other health plan or retail price for the pharmacy

National Drug Code (NDC) and Description

NDC Unit/basis of measurements

Timely Filing Limitation: Claims and invoices shall be submitted to VA within 36 months from the date of service, unless there is good cause for delay or unless specified otherwise in this Agreement.

Liable Payers for Direct Care: The UIO shall seek payment from all other liable payers for Direct Care Services, to the extent feasible and as permissible by law, before seeking reimbursement from VA for Direct Care Services provided to an Eligible American Indian/Alaska Native Veteran under this Agreement. The UIO shall provide VA with copies of Other Health Insurance (OHI), Explanation of Benefits (EOB), Explanation of Payment (EOP), or similar documentation when the UIO receives payment from other liable payers and a balance remains. When UIO receives payment from other liable payers, VA is responsible for only the balance remaining, up to the agreed-upon rates.

Timely Payment for Direct Care: VA will process claims for payment submitted electronically within 30 days of receipt and within 45 days of receipt for claims submitted in paper form. An EOB that satisfies industry standards will be provided by VA to the UIO.

No cost-sharing, co-payments, or other deductions may be subtracted from the reimbursements, charged to the Eligible American Indian/Alaska Native Veteran, or otherwise counted against any caps for the Eligible American Indian/Alaska Native Veteran.

DENIAL, RECONSIDERATION, AND APPEAL

VA may only deny an invoice/claim or a portion thereof for services provided when:

The American Indian/Alaska Native Veteran is ineligible for VA services, or;

VA lacks the authority to provide or pay for the care or related services, or;

The information needed to adjudicate the invoice/claim is not provided, but only if VA has provided both notice to the UIO of the missing information and a reasonable opportunity to provide such information to VA.

Notice and Request for Reconsideration. If VA denies reimbursement for a claim, VA shall notify the 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 one year of the denial notice. The UIO’s written request for reconsideration or appeal shall set forth the grounds supporting the request for appeal and include any documentation requested by VA for reconsideration.

VA shall review and respond to a request for reconsideration or appeal. If the original decision is affirmed on reconsideration, the Service Unit shall be so notified in writing and advised that a notice of disagreement (NOD) may be submitted to VA within one year of the notice of the reconsidered decision. The NOD shall be in writing and shall set forth the grounds supporting the appeal.

GENERAL PROVISIONS

Nothing in this Agreement shall be construed to shift the ultimate responsibility of any patient care from the Government, its physicians, and its other healthcare professionals. It is further understood the Agreement shall not impair the priority access of VA or UIO beneficiaries to health care provided through their respective agencies; the quantity or range of quality of health care services provided to VA or UIO beneficiaries by the respective health care programs; or the eligibility of VA or UIO beneficiaries to receive health care through their respective agencies. The terms of the Agreement shall not in any way alter or affect Congressional mandates imposed on the parties as governed by applicable law, regulation, or policy. Moreover, the intent of this Agreement is to expand the ability of each party to better and more efficiently meet its obligations to its respective beneficiaries.

Veteran’s Choice of Provider. Nothing in this Agreement affects the right of Eligible American Indian/Alaska Native Veterans to choose whether they receive direct care services at VA or UIO facilities.

VA and UIO will comply with all applicable Federal laws and regulations regarding the confidentiality of health information. 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. Records of VA payment for direct care services within the scope of this Agreement 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 HIPAA Privacy Rule, 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. Medical records created or maintained by UIO programs in the performance of providing Direct Care Services are not subject to VA confidentiality statutes. Records created or maintained by VA in the performance of reimbursing the UIO for health care and related services are not subject to UIO statutes.

For audit and examination purposes and to the extent permitted by Federal law, VA or any of its duly authorized representatives or agents shall have access to all books, documents, papers, and records of the UIO that are related or pertinent to this Agreement or any claim paid pursuant to this Agreement. To the extent permitted by Federal law and when consistent with records retention schedules, said books, documents, papers, and records shall be made available until the expiration of five years after submission of any claim paid pursuant to this Agreement.

Exchange of Medical Records. To the extent permitted by Federal law, 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 shall be made through agreed upon means, to the extent permitted by Federal law. 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.

If VA and the UIO are unable to agree about a material aspect of this Agreement or the resolution of invoice/claim denials, the Parties agree to engage in an effort to reach mutual agreement in the proper interpretation of this Agreement, including amendment of the Agreement, as necessary, by escalating the dispute within their respective organizations.

To the extent an Eligible American Indian/Alaska Native Veteran is eligible for VA hospital care and medical services but not enrolled, the UIO shall take steps to collaborate with VA to assist the Eligible American Indian/Alaska Native Veteran in enrolling in VA’s system of patient enrollment.

Medical Malpractice. All medical malpractice claims arising under the Federal Tort Claims Act (FTCA) for incidents occurring under this Agreement shall be the responsibility of the UIO in accordance with applicable law and regulation and are not the responsibility of VA. Nothing in this paragraph shall be construed to expand the circumstances under which the FTCA applies. 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, Torts Law Group (021A), 810 Vermont Avenue, NW, Washington DC 20420.

DISPUTES

The Parties shall utilize all reasonable efforts to resolve any dispute at the lowest administrative level possible with Payment Operations. 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 and the VA Contracting Officer shall furnish a written reply on the dispute or claim to the UIO within 90 days.

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 referred to a non-binding mediation before the initiation of any legal adjudicative action or proceeding before any court or tribunal. To initiate mediation, either Party shall give written notice to the other of the intent to mediate an anticipated or alleged actual dispute.

Within a reasonable timeframe thereafter, but not to exceed 90 calendar days, the Parties, directly or through their designated representative(s) agree to select a mutually agreeable mediator who can mediate the dispute on a date acceptable by both Parties. If agreed to, a neutral mediator may 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 mediator at no cost.

The Parties agree that mediation shall be confidential in all respects. The Parties further agree that documents exchanged, statements prepared and provided, and settlement offers and counteroffers made during mediation shall be inadmissible in any resolution action or proceedings.

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.

EFFECTIVE DATE, TRANSITION, AND AMENDMENT

Effective Date. This Agreement becomes effective the date that the last signatory signs the Agreement.

Transition. VA continues to be responsible for any reimbursements due to the UIO under any prior agreement between the Parties consistent with the terms of that Agreement.

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) to this Agreement.

Funding. VA’s obligations under this Agreement shall be subject to the availability of appropriated funds.

SIGNATURE BLOCKS.

Name of UIO Authority	Date

Title

Name of UIO

Department of Veterans Affairs	Date

Name of VA Authority

Executive Director, Regional Procurement Office West

Head of Contracting Activity (HCA)