 VA is committed to maintaining a strong relationship with community providers, who are critical to ensuring Veterans receive timely, high-quality care, while also ensuring proper stewardship of public funds.
As required by federal law, in 2016 VA awarded a contract to perform an audit of community care payments to identify potential overpayments and recover funds. The audit, much like recovery audit contracts with Medicare or commercial insurances, is a review of claims and supporting medical documentation. VA subsequently became aware that certain claims were not being processed in accordance with VA’s payment regulations, resulting in overpayments; these claims were included in the recovery audit contract. Through the recovery audit contract, the VA recouped approximately $36M in overpayments for fiscal years 2013 and 2014, the majority of which was returned to VA Medical Centers to support Veteran care.
VA takes our relationships with community providers very seriously and, after listening to concerns raised by providers and evaluating VA’s internal processes and federal financial requirements, VA has decided that the current audit will cease. As a result, VA is temporarily suspending debt collections for Community Care payments through a third-party auditor while we pursue additional approaches that will take into account individual community provider circumstances and alternative payment options while also ensuring proper stewardship of public funds.
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 November 15, 2018: VHA Office of Community Care Overview, provides an overview of Community Care programs and policies, focuses on how to file clean claims, and goes into other topics such as eligibility, referral, top rejection reasons and other provider issues. Register for the webinar.
November 29, 2018: Understanding the Context of Military Culture in Treating Veterans, describes how military culture affects veterans seeking healthy, how help-seeking Veterans are affected by healthcare providers who are not familiar with military culture and much more. Registration is available for VA employess via VA’s Talent Management System (TMS) ID 37063 and VHA TrainingFinder Real-time Affiliate Integrated Network (TRAIN) for non-VA attendees, a direct link to be posted soon . Both VA TMS and VHA TRAIN require attendees to have accounts prior to registering for the webinar.
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HealthShare Referral Manager (HSRM) is a commercial off-the-shelf solution that VA has selected to accelerate and better manage community care referrals and authorizations. HSRM streamlines referral and authorization management, and improves information-sharing between VA and community providers. These improvements allow more timely access to care for Veterans and greater coordination between community providers and VA.
To review the key benefits community providers will see with the use of HealthShare Referral Manager read this HealthShare Referral Manager Information Sheet.
 Did you know VA offers 24/7 online access to claim status and VA Treasury payment information via the Vendor Inquiry System (VIS)? VIS is a web application that allows community providers and registered vendors to research the status of claims received by VA. Visit VA FSC VIS to find specialized training, create and account and access claim status information.
VA will now require a referral/authorization number to be submitted on all EDI and paper claim submissions that are pre-approved. The compliance date for this is Janaury 2019, so please begin adjusting processes and systems now. This additional claim data will enable faster claims processing for authorized care. For paper claims, include this information in field 23 on an HCFA 1500, or field 63 on a UB-04. For EDI 837, Referral Number is Loop = 2300, Segment = REF*9F, Position = FEF02, or Prior Authorization, Loop = 2300, Segment = REF*G1, Position = REF02.
 As mentioned in the September edition of the Community Provider Monthly Updates Newsletter, the VHA Office of Community Care (OCC) is implementing a new initiative to transition Veteran paper claims to an electronic format. This initiative consolidates the receipt location of eligible paper claim submissions to a central location, where they are converted to an electronic format known as Electronic Data Interchange (EDI) transactions for processing.
During the current transition phase, providers should continue to submit claims using the normal process. However, beginning in what is currently scheduled for early-to-mid 2019, community providers will begin mailing paper claims submissions for Veterans directly to the new location, the address of which will be shared upon national release.
The new intake system automatically scans claims for compliance based on national standards, which should reduce the need to correct non-compliant form fields throughout claims processing. Community providers should be aware, however, that this scan may cause an increase in rejections at the beginning of claims processing.
While this new mailing and scanning process improves timeliness for paper claims, we continue to encourage providers and their billing services to file EDI claims directly through VHA’s EDI clearinghouse, Change Healthcare, when possible. Community providers can work with Change Healthcare to submit electronic claims to VA by contacting 888-545-6127.
Both EDI submissions and a new, single mailing location for paper claims scanning and EDI conversion are important solutions for reducing the community care claims backlog and provide timely and accurate payments to community health care providers.
For more information about the transition from paper to electronic claims, please visit the “Paper to Electronic Claims” page on the VHA Office of Community Care website. Here you will find general guidance on the new paper claims submission process as well as details about how to prevent the most common paper claims rejections. Click here to view a list of the most common claims rejections.
Please continue to check this and other communications for more information such as the new address as it becomes available in the coming months. Finally, if you have questions or comments related to the transition from paper to electronic claims initiative, please email P2EInquiries@va.gov.
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