Background on the VA Claims Adjudication Services Project

1 - Background on the VA Claims Adjudication Services Project (Rev. 1454, Issued: 02-22-08, Effective: 04-01-08, Implementation: 04-07-08) Current law permits the VA to collect appropriate Medicare coinsurance and deductible amounts from supplemental insurers for claims for supplies and services ordinarily covered by Medicare but furnished: • At VA facilities; and • For veterans eligible to receive both VA health and Medicare benefits and also having Medicare supplemental insurance. To facilitate this process, the Centers for Medicare & Medicaid Services (CMS) entered into an interagency agreement with the VA whereby CMS will help the VA work with the designated CMS MAC to adjudicate claims for these services to produce remittance advices equivalent to those ordinarily produced for Medicare claims. Medicare does not pay these claims, but the remittance advices show how much Medicare would have paid had the claims been payable by Medicare along with the applicable deductibles and coinsurance. In adjudicating a claim and generating these remittance advice notices, the CMS MAC must verify that the services provided are covered benefits, certify admission where appropriate, conduct prepayment utilization screening, and authorize payment. CMS has a single A/B MAC (A) and (B) to process these claims. The remittance advices, sent by the VA to the supplemental insurers, will help the insurers determine payment amounts they owe to the VA. The VA funds all of the work on this project, including systems changes.