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VA Community Care (VACC) Claims Reimbursed Through the Electronic Claims Adjudication Management System (eCAMS), 2024 - 2029.
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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).
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Cotiviti will review claims paid by VA in the following FY's:
-FY 2024 (10/01/2023 - 09/30/2024)
-FY 2025 (10/01/2024 - 09/30/2025)
-FY 2026 (10/01/2025 - 09/30/2026)
-FY 2027 (10/01/2026 - 09/30/2027)
-FY 2028 (10/01/2027 - 09/30/2028)
-FY 2029 (10/01/2028- 09/30/2029)
The review will include claims paid under the following authorities:
CCCNNC
38 U.S.C. § 1703 (Preauthorized Claims)
38 U.S.C. § 1728 (Emergency Care for Service-Connected Veterans)
38 U.S.C. § 1725 (Emergency Care for Non-Service Connected Veterans)
38 U.S.C. § 1720J (Emergency Care for Acute Suicidal Crisis)
Criteria for this audit is based on the following questions:
1. Was the appropriate rate reimbursed based on the methodology under 38 U.S.C § 1703?
2. Was the appropriate rate reimbursed based on the methodology under 38 U.S.C. § 1725?
3. Was the appropriate rate reimbursed based on the methodology under 38 U.S.C. § 1728?
4. Was the appropriate rate reimbursed based on the mehtodology under 38 U.S.C. § 1720J?
5. Do the medical records support the billed services?
Information from the following sources may be used to determine the accuracy of each payment:
1. Paid claim data.
2. 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 FY24 - FY29 claims rendered under the Patient Centered Community Care (PC3)/CHOICE or Community Care Network (CCN) contracts.
2. Claims paid to Department of Defense (DoD)
3. Claims paid to Indian Health and Tribal Health providers
4. Claims paid by VA for care furnished outside of the United States and its territories
5. Claims paid for State Home Per Diem Program
6. Claims paid related to domiciliary
7. Claims paid for contract nursing homes care
8. Claims paid for bowel and bladder care
9. Claims currently under investigation by the VA for potential Fraud Waste and Abuse
(FWA)
10. Claims included in equitable relief
11. Claims in pre-payment review
12. Claims previously identified in previous audit activities
13. Claims paid directly to Veterans
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03/30/2026
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