- Outpatient Institutional Providers Reimbursed Under MPFS: When to Split Claims for Updated Rates
- Outpatient Services for Registered Inpatients
- Allergen Immunotherapy Preparation (95144-95165)
- Ambulatory Surgical Center Approved HCPCS Codes and Payment Rates
- Billing for FQHC MAO Plan Supplemental Payment (PPS Providers)
- Billing for Services Not Included in the FQHC Benefit
- Attention all OPPS Providers: Provider-Based Department Edits Being Implemented on/after 8/1/2023
- Billing for Drug Wastage: JW and JZ Modifier
- Billing Medicare for a Denial - Condition Code 21
- URGENT: Billing Reminders for OPPS Providers with Multiple Service Locations
- Billing Medicare Part A When Veteran’s Administration Eligible Medicare Beneficiaries Receive Services in Non-VA Facilities
- Condition Code G0 Reminder
- CPT Code 15830: Excision, Excess Skin and Subcutaneous Tissue; Abdomen, Infraumbilical Panniculectomy
- Medicare Part B Electronic Claims that Exceed the Threshold for Charges and Units of Service
- ESRD Facilities: Clarification for Providing Dialysis Services to Patients Acute Kidney Injury
- Federally Qualified Health Centers Behavioral Health Claims Job Aid
- Federally Qualified Health Centers Contracting with Medicare Advantage Plans
- Fee-For-Time Compensation Arrangement and Reciprocal Billing Job Aid
- Answers to Common Fee-for-Time Compensation Arrangements Questions
- FQHC and Group Therapy Services Job Aid
- Long-Term Care Hospitals: How to Request Adjustments of Claims Paid at the Site Neutral Rate
- Inhalation Treatment CPT 94640 – Billing Errors
- Immunization Roster Billing
- Nonphysician Practitioners Billing for Surgical Procedures
- Professional Services During a Patient Hospice Election
- Professional Services During a Patient Hospice Election
- Proper Billing for Finger and Toe Procedures
- Proper Submission of Fee-For-Time Compensation Arrangements and Reciprocal Billing Arrangements
- Proper Use of Taxonomy Codes
- A/B Rebilling Facts
- Common Reciprocal Billing Questions and Answers
- Reminder for Avoiding Claim Denials for Positron Emission Tomography Scans
- Reminder on Deleting Revenue Code Line(s) in the Fiscal Intermediary Standard System Direct Data Entry System
- Repetitive Outpatient Services for Providers Submitting Institutional Outpatient Claims
- Reporting Multiple Qualifying Visits on the Same Date of Service for FQHC Reimbursement
- Unlisted and Not Otherwise Classified Procedure Codes
- What All Facilities Need to Know About the Long-Term Care Hospital Three-Day or Less Interrupted Stay Policy
- Fiscal Year/Calendar Year Claim Split
Billing Medicare Part A When Veteran’s Administration Eligible Medicare Beneficiaries Receive Services in Non-VA Facilities
- Background
- Beneficiary Chooses to Use Medicare
- Beneficiary Chooses to Use VA Benefits
- Related Content
Background
Each time a Medicare beneficiary, who is also eligible for VA benefits, receives services in a non-VA facility, the beneficiary may choose to use their Medicare or their VA benefits to pay for the services. How a non-VA facility submits your claim(s) depends on whether the
- Beneficiary chooses to use their Medicare or VA benefits
- VA authorizes/pays or does not authorize/pay the claim (when the beneficiary chose to use their VA benefits)
- VA pays in part or in full (when the beneficiary chose to use their VA benefits and the VA pays)
- Services are inpatient or outpatient
When billing us for services your non-VA facility rendered to VA-eligible beneficiaries, report CC 26 as instructed below (optional in some cases). The CC 26 indicates a VA-eligible beneficiary chose to receive services in a Medicare-certified facility rather than a VA facility.
Beneficiary Chooses to Use Medicare
If a VA-eligible Medicare beneficiary chooses to use Medicare as the payer for the services in your non-VA facility, submit a Medicare primary claim to us. You may report CC 26 on the outpatient but not on the inpatient claims.
Beneficiary Chooses to Use VA Benefits
If a VA-eligible beneficiary chooses to use their VA benefits as the payer for services in your non-VA facility, seek authorization from and payment by the VA. The beneficiary may seek such authorization rather than the non-VA facility.
If the VA does not authorize and/or pay for the services in your non-VA facility, submit a Medicare primary (not conditional) claim to us. You may report CC 26 on the outpatient but not on the inpatient claims.
If the VA authorizes and pays for the services in your non-VA facility, submit the claim(s) as follows:
-
VA Paid in Part for Inpatient Services
- If the VA pays part of an inpatient hospital or SNF stay, submit your inpatient claim(s) to us as usual (hospitals submit admission to discharge claims and SNFs submit monthly claims) and we will determine if a secondary payment is due per the MSPPAY module. Do not split your claims during your billing period based on the date on which the VA started/stopped paying. On your claim, report:
- CC 26
- VC 42 with the amount of the VA’s partial payment
- VA as the primary payer (if using FISS DDE, use code ID = “I” for VA)
- Medicare as the secondary payer
- All Medicare-covered services/charges including those the VA paid
- If the VA pays part of an inpatient hospital or SNF stay, submit your inpatient claim(s) to us as usual (hospitals submit admission to discharge claims and SNFs submit monthly claims) and we will determine if a secondary payment is due per the MSPPAY module. Do not split your claims during your billing period based on the date on which the VA started/stopped paying. On your claim, report:
-
VA Paid in Part for Outpatient Services
- If the VA pays part of the outpatient services, submit a claim to us for only the Medicare-covered services/charges the VA did not pay. You may report CC 26 (optional).
-
VA Paid in Full for Inpatient Services
- If the VA pays all of an inpatient hospital or SNF stay, the services are statutorily excluded from Medicare payment. Medicare cannot pay for the same services the VA paid. Submit a noncovered inpatient claim(s) to us per the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 60.
-
VA Paid in Full for Outpatient Services
- If the VA pays all of the outpatient services, the services are statutorily excluded from Medicare payment. Medicare cannot pay for the same services the VA paid. You may submit a noncovered outpatient claim to us per the CMS IOM Publication 100-04,Medicare Claims Processing Manual, Chapter 1, Section 60. You may report CC 26 (optional).
Related Content
- CMS IOM Publication 100-02,Medicare Benefit Policy Manual, Chapter 16, Section 50.1
- CMS IOM Publication 100-04,Medicare Claims Processing Manual, Chapter 1, Section 60
- CR 9818, “Instructions to Process Services Not Authorized by the Veterans Administration (VA) in a Non-VA Facility Reported With Value Code (VC) 42”
Revised 11/4/2024