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VA Community Care (VACC) claims reimbursed through the Electronic Claims Adjudication Management System (eCAMS), Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) reimbursed through ClaimsXM and Spina Bifida (SB) Program of the Department of Veterans Affairs reimbursed through ClaimsXM for Fiscal Years (FY) 2022 and 2023.
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Cotiviti will review paid claims for VA Community Care Non-Network Claims (CCCNNC) paid by VA through the Electronic Claims Adjudication Management System (eCAMS), paid claims for the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) paid by VA through ClaimsXM and paid claims for the Spina Bifida (SB) Program of the Department of Veterans Affairs paid by VA through ClaimsXM.
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Cotiviti will review claims paid by VA in Fiscal Year 2022 (10/1/2021-09/30/2022), and Fiscal Year 2023 (10/01/2022-09/30/2023).
The review will include claims paid under the following authorities:
CCCNNC
38 U.S.C. § 1703 (authorized care)
38 U.S.C. § 1728 (service-connected unauthorized care)
38 U.S.C. § 1725 (non-service connected emergency care)
CHAMPVA
38 U.S.C. § 1781 (Medical Care for survivors and dependents of certain veterans)
38 C.F.R § 17.270-17.278 (Civilian Health and Medical Program of the Department of Veterans Affairs)
SB
38 C.F.R § 17.900-17.905 (Health Care Benefits for Certain Children of Vietnam Veterans and Veterans with Covered Service in Korea—Spina Bifida and Covered Birth Defects)
Criteria for this audit is based on the following questions:
1. Was the care rendered under § 1703 in compliance with the authorization/referral?
2. Was the care rendered under 38 U.S.C. § 1781 and 38 C.F.R § 17.270-17.278 in compliance with the authorization/referral?
3. Was the care rendered under 38 C.F.R § 17.900-17.905 in compliance with the authorization/referral?
4. Was the appropriate rate reimbursed based on the methodology under applicable VA authorities?
5. Do the medical records support the billed services?
Information from the following sources will be used to determine the accuracy of each payment:
1. Authorization/referral for services.
2. Paid claim data.
3. Medical records.
The following assumption will apply to this audit:
Payment by the VA for the reviewed claims is determinative of the Veteran’s eligibility for the care; therefore, Cotiviti will not review Veteran eligibility.
Exclusions:
1. This audit will not include FY22, FY23 claims rendered under the Patient Centered Community Care (PC3)/CHOICE or Community Care Network (CCN) contracts.
2. Claims specifically excluded from the scope of the contract:
a. Claims paid to the Department of Defense
b. Claims paid by VA for care furnished outside of the United States and its territories
c. Claims paid for State Home Per Diem Program
d. Claims paid related to domiciliary care
f. Claims paid for dental
g. Claims paid for adult day healthcare
h. Claims paid for bowel and bladder care
i. Claims currently under investigation by the VA for potential fraud, waste, and abuse
j. Claims included in equitable relief
k. Claims in prepayment review
l. Claims paid directly to Veterans
m. Any claim or claim type specifically sequestered by the VA
n. Claims paid directly to a beneficiary
o. Claims where CHAMPVA was secondary payer
p. Claims for travel other than ambulance associated with medical care
q. Pharmacy claims including "Meds by Mail"
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03/08/2024
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05/03/2024
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