IHS/THP/UIO Reimbursement Agreements Program (RAP)–Information for Providers about Direct Care

Direct Care Claims

Health Care Claims

VA will reimburse participating tribes for direct care services provided to eligible American Indian and Alaska Native (AI/AN) Veterans. VA prefers to receive EDI claims but also accepts paper claims.

Unique VA Requirements:
Generally, VA follows National Correct Coding Initiative (NCII) standard submission processes; however, VA does require specific identifiers to be added to claims for proper program routing:

• EDI Claims – VA payer IDs

• VA Program Identifier

• Agreement Number

Additional details and samples regarding direct care services can be found in the IHS/THP/UIO RAP Provider Guide listed in the Resources section below.

Pharmacy Claims

VA will reimburse facilities for outpatient pharmaceutical on the Indian Health Services/Tribal Health Programs (IHS/THP) formulary. For Urban Indian Organizations (UIO), VA will only reimburse facilities for pharmaceutical drugs listed on the VA National Formulary.

VA accepts paper and EDI pharmacy claims and follows the direct care services claim submission process. VA does not accept CMS Standard pharmacy claims submission. Facilities submit pharmacy claims on CMS medical claim forms (i.e. EDI 837 and CMS 1500).

Refer to the "Pharmacy Claims Submission" section of the IHS/THP/UIO RAP Provider Guide for detailed information on how to submit pharmacy claims.

Resources

IHS/THP/UIO Reimbursement Agreements Provider Guide

VA National Formulary

Direct Care Claim Submission Process

Electronic billing (Electronic Data Interchange)

Electronic 837 claim and 275 supporting documentation submissions can be completed through the VA clearinghouse or through another clearinghouse of your choice. Billing staff should ensure “IHS,” “THP” or “UIO” is added to the SBR03 segment of the 837 for proper routing.

VA payer IDs are:

12115 for medical claim submissions
12116 for dental claims
00231 for any inquiry transaction

Change Healthcare Customer Support:
866-371-9066
Mon.–Fri., 8 a.m.–4 p.m. Central Time (CT)

Change Healthcare Customer Resources–Payer Lists

Paper Claims

VA has a centralized claims processing center for paper claims.
NOTE: IHS must submit paper claims to the following address via Certified Mail (per the Social Security Number Fraud Prevention Act of 2017):

VHA Office of Finance
P.O. Box 30780
Tampa FL 33630-3780

Community Care