Community Care

IHS/THP Reimbursement Agreements Program–Information for Providers

Listed below are several resources for initiating agreements and implementing the reimbursement agreement.

• Eligibility and Enrollment Verification
• IHS/THP Initiation and Implementation
• Submitting Claims
• Claims Status Check
• Care Coordination
• Training
• Operational Updates
• Contacts and Resources

Eligibility and Enrollment Verification

Eligibility and Enrollment Verification explains ways in which IHS/THP facilities can verify American Indian/Alaska Native (AI/AN) Veteran eligibility.

Initiation and Implementation

IHS/THP Initiation and Implementation outlines the process for starting and implementing the IHS/THP reimbursement agreement. While working through the agreement process, the VA encourages IHS/THP facility staff to ensure Veterans are enrolled in the VA health system.

Submitting Claims

Tribal facility staff may submit claims electronically or on paper:

Electronic billing (Electronic Data Interchange)

Facilities submitting electronic/Electronic Data Interchange (EDI) claims will need to register with Change Healthcare (formerly Emdeon) by phone or web:

Once registered, billing staff should ensure that “THP” is added to the SBR03 segment of the 837 for proper routing through the VA. The VA payer IDs are:

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

Where to Mail Paper Claims

VA has a centralized claims processing center for paper claims. Send paper claims to:

Third Party Billing

IHS/THP will bill all third-party payers, prior to billing VA so that VA is responsible only for the balance remaining after other third-party reimbursements. IHS/ THP providers are responsible for submitting healthcare claims to the other health insurance prior to billing VA. VA does not reimburse co-pays, deductibles, or participate in balance billing; in addition to what other Federal organizations (i.e., Medicare or Medicaid) have already paid. VA will not pay services that the Veteran has Medicare/Medicaid coverage for.

Coronavirus-related Billing

The 2020 VA–IHS and THP Reimbursement Agreement Modification will allow VA pay for direct care or Purchased Referred Care (PRC) related to COVID-19 healthcare services as defined in the section 11.5. Other PRC services are not reimbursable, as healthcare services must be provided directly by your facility per the agreement.

For VA to pay for direct care or PRC treatment due to COVID 19, the diagnosis and CPT code must follow Medicare guidance for COVID-19 billing and as such must be identified as COVID-19 in the claims. Outpatient or inpatient claims submissions must follow industry standard guidelines. Current VA billing process or requirements is not changing except for use of COVID-19 specific codes.

Refer to the Medicare.gov Medicare & Coronavirus webpage for further information.

Claims Status Check

To check the status of the IHS or THP submitted claims.

VA THP Claims Payment Processing Center
877-881-7618, Monday–Friday, 6:05 a.m. to 4:45 p.m., MT.
Do not enter your facility zip code, instead use the Region 5 NW POM zip code: 98661.

VA Customer Engagement Portal (CEP)
Registered IHS/THP providers can research the status of claims received by VA.

VA Provider Profile
Registered IHS/THP providers can research paid claims and the Explanation of Payment (EOP). IHS/THP providers may register this weblink.

Care Coordination

When AI/AN Veterans need care that is not available within IHS/THP-participating Reimbursement Agreement Program (RAP) facilities, care must be referred to non-IHS/THP providers to provide such care. For eligible Veterans, this includes referrals to VA health care facilities where VA may provide the care directly, or referral to a community care provider which requires enhanced care coordination and associated collaboration between VHA and IHS and/or THPs.

To ensure enhanced care coordination, VHA Office of Community Care (OCC) established the Healthcare Coordination Advisory Board (HCAB) with participation from IHS and tribes to assist VA in developing standardized processes for care coordination of eligible AI/AN Veterans, including referrals from IHS/THP facilities to the respective VA medical centers (VAMCs) to receive care not available within the IHS/THP health care facilities. The HCAB convened to develop a draft care coordination approach which ensures Veterans are at the center of the process. VA hosted additional events to gain stakeholder input including a February 2020 listening session to begin formal stakeholder discussions on care coordination and a tribal consultation in August 2020 to introduce the draft care coordination approach and receive further feedback.

Training

Native Cultural Awareness

Cultural awareness is an essential component of Veteran-centered care. Providers who do not regularly work with AI/AN patients may lack awareness of specific cultural aspects of care. To boost cultural awareness of this group, VA has identified material that could benefit both clinical and administrative staff. They are:

• SAMHSA Native Culture Card–a guide to build cultural awareness, American Indian and Alaska Native, is intended to serve as a general briefing to enhance cultural competence while providing services to American Indian and Alaska Native communities.
• IHS Gold Book–a four-part publication in which IHS reviews progress from the agency’s first 50 years of operation, including lessons learned regarding culturally acceptable public health services.

Operational Updates

In September 2020, Veterans Health Administration (VHA) announced an amendment to the Indian Health Service/Tribal Health Programs (IHS/THP) Reimbursement Agreement program for direct care services for eligible American Indian and Alaska Native (AI/AN) Veterans. The agreement allows eligible Veterans to receive direct care services at their local tribal facility, and in turn, the tribal facility will be reimbursed by VA for that care per the terms of the agreement.

The amendment:

• Expands reimbursement to include services provided through telehealth, at the outpatient all-inclusive rate, by clarifying the definition of the term “direct care services.”
  This excludes the Alaska THP agreements as telehealth was previously included.
• Expands reimbursement to include COVID-19 related testing and care provided by contracts established by the IHS/THPs (i.e., purchased referred care program) for health care provided outside of the facility during the COVID-19 emergency period that meet certain conditions.
• Clarifies language in the quality section of the agreement relating to certification and accreditation requirements.
• Extends the terms of agreement to June 30, 2024; an additional two years beyond the existing term.

To view the Tribal Leader Letter issued on the amendment, please visit the Indian Health Service newsroom.

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