Department of VA Claims Adjudication: Coinsurance and

1.2 - Department of VA Claims Adjudication: Coinsurance and Deductible (Rev. 1454, Issued: 02-22-08, Effective: 04-01-08, Implementation: 04-07-08) Part of this process involves the calculation of the deductible applicable to the Medicare- equivalent VA claims. The CWF calculates the deductible based on true Medicare claims, i.e., for Medicare services rendered by Medicare providers to Medicare beneficiaries, and sends this information back to the shared system maintainers for this project. The MCS and FISS further adjust the deductible information received from CWF with the deductible amounts that apply to the Medicare-equivalent VA claims. This arrangement results in a calculation of the deductible for the VA's equivalent of Part A and B claims. In addition, effective January 1, 2005, CWF began to calculate the Part B-equivalent deductible for Medicare claims taking into consideration the VA equivalents of both Medicare outpatient and professional claims as well as true Medicare claims. To confirm that CMS has made no payment on the VA claim, the remittance advice will include message MA118 –“Coinsurance and or deductible amounts apply to a claim for services or supplies furnished to a Medicare Eligible veteran through a facility of the Department of Veterans Affairs. No Medicare payment issued". Existing claim adjustment reason codes 1 (deductible) and/or 2 (coinsurance) will be used to report those amounts on these remittance advice transactions. As necessary, CWF expands the VA claim auxiliary file within CWF so that the history of VA Part A-equivalent no-pay claims, adjudicated for the MRA Project, contain sufficient information about the VA claims and Medicare-equivalent Part A deductible and coinsurance amounts applied so that an unsolicited response can be generated. The auxiliary file contains sufficient information so that there can be one such unsolicited response for each VA claim affected. The VA auxiliary file within CWF also provides a claims history for VA Part B equivalent claims. The auxiliary contains the information about VA claims necessary to show Medicare-equivalent Part B deductibles satisfied by the VA claims. National Claims History is not updated with the VA deductible information, and these changes have no effect on Medicare claims. CWF sends the Part B deductible information to the A/B MACs (A) and (B) for this project. This affects claims with dates of service of January 1, 2004, and after and will use deductible amounts for calendar years 2004 and after.