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Notes

§17.903. Payment.

Cited by 12 provisions

38 C.F.R. § 17.903

(a)
(1)
Payment for services or benefits under §§ 17.900 through 17.905 will be determined utilizing the same payment methodologies as provided for under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) (see § 17.270). For those services or benefits covered by §§ 17.900 through 17.905 but not covered by CHAMPVA we will use payment methodologies the same or similar to those used for equivalent services or benefits provided to veterans.
(2)
As a condition of payment, the services must have occurred:
(i)
For spina bifida, on or after October 1, 1997, and must have occurred on or after the date the child was determined eligible for benefits under § 3.814 of this title.
(ii)
For covered birth defects, on or after December 1, 2001, and must have occurred on or after the date the child was determined eligible for benefits under § 3.815 of this title.
(3)
Claims from approved health care providers must be filed with the Health Administration Center in writing (facsimile, mail, hand delivery, or electronically) no later than:
(i)
One year after the date of service; or
(ii)
In the case of inpatient care, one year after the date of discharge; or
(iii)
In the case of retroactive approval for health care, 180 days following beneficiary notification of eligibility.
(4)
Claims for health care provided under the provisions of §§ 17.900 through 17.905 must contain, as appropriate, the information set forth in paragraphs (a)(4)(i) through (a)(4)(v) of this section.
(i)
Patient identification information—
(A)
Full name,
(B)
Address,
(C)
Date of birth, and
(D)
Social Security number.
(ii)
Provider identification information (inpatient and outpatient services)—
(A)
Full name and address (such as hospital or physician),
(B)
Remittance address,
(C)
Address where services were rendered,
(D)
Individual provider's professional status (M.D., Ph.D., R.N., etc.), and
(E)
Provider tax identification number (TIN) or Social Security number.
(iii)
Patient treatment information (long-term care or institutional services)—
(A)
Dates of service (specific and inclusive),
(B)
Summary level itemization (by revenue code),
(C)
Dates of service for all absences from a hospital or other approved institution during a period for which inpatient benefits are being claimed,
(D)
Principal diagnosis established, after study, to be chiefly responsible for causing the patient's hospitalization,
(E)
All secondary diagnoses,
(F)
All procedures performed,
(G)
Discharge status of the patient, and
(H)
Institution's Medicare provider number.
(iv)
Patient treatment information for all other health care providers and ancillary outpatient services such as durable medical equipment, medical requisites, and independent laboratories:
(A)
Diagnosis,
(B)
Procedure code for each procedure, service, or supply for each date of service, and
(C)
Individual billed charge for each procedure, service, or supply for each date of service.
(v)
Prescription drugs and medicines and pharmacy supplies—
(A)
Name and address of pharmacy where drug was dispensed,
(B)
Name of drug,
(C)
National Drug Code (NDC) for drug provided,
(D)
Strength,
(E)
Quantity,
(F)
Date dispensed,
(G)
Pharmacy receipt for each drug dispensed (including billed charge), and
(H)
Diagnosis for which each drug is prescribed.
(b)
Health care payment will be provided in accordance with the provisions of §§ 17.900 through 17.905. However, the following are specifically excluded from payment:
(1)
Care as part of a grant study or research program,
(2)
Care considered experimental or investigational,
(3)
Drugs not approved by the U.S. Food and Drug Administration for commercial marketing,
(4)
Services, procedures, or supplies for which the beneficiary has no legal obligation to pay, such as services obtained at a health fair,
(5)
Services provided outside the scope of the provider's license or certification, and
(6)
Services rendered by providers suspended or sanctioned by a Federal agency.
(c)
Payments made in accordance with the provisions of §§ 17.900 through 17.905 shall constitute payment in full. Accordingly, the health care provider or agent for the health care provider may not impose any additional charge for any services for which payment is made by VA.
(d)
Explanation of benefits (EOB)—
(1)
When a claim under the provisions of §§ 17.900 through 17.905 is adjudicated, an EOB will be sent to the beneficiary or guardian and the provider. The EOB provides, at a minimum, the following information:
(i)
Name and address of recipient,
(ii)
Description of services and/or supplies provided,
(iii)
Dates of services or supplies provided,
(iv)
Amount billed,
(v)
Determined allowable amount,
(vi)
To whom payment, if any, was made, and
(vii)
Reasons for denial (if applicable).
(2)
[Reserved]
Notes, amendments, and revision history

Amendments

[68 FR 1010, Jan. 8, 2003, as amended at 76 FR 4249, Jan. 25, 2011; 81 FR 19890, Apr. 6, 2016]

Source

Source: 68 FR 1010, Jan. 8, 2003, unless otherwise noted.

Authority

Authority: 38 U.S.C. 501, and as noted in specific sections. Section 17.30 also issued under 38 U.S.C. 1701. Section 17.32 also issued under 38 U.S.C. 7331-7334. Section 17.35 is also issued under 38 U.S.C. 1724. Section 17.37 is also issued under 38 U.S.C. 101, 1701, 1705, 1710, 1720J, 1721, 1722. Section 17.38 is also issued under 38 U.S.C. 1701 and 1703. Section 17.43 also issued under 38 U.S.C. 109, 1784, 8111, and 8153. Section 17.44 also issued under E.O. 10122, 15 FR 2173, 3 CFR, 1949-1953 Comp., p. 313, E.O. 10400, 17 FR 8648, 3 CFR, 1949-1953 Comp., p. 900, and E.O. 11733, 38 FR 20431, 3 CFR, 1971-1975 Comp., p. 792. Section 17.46 is also issued under 38 U.S.C. 1710. Section 17.47 is also issued under 38 U.S.C. 1701, 1710, 1721, 1722, 1729, 3104(a)(9), 7333, Pub. L. 99-272; 42 U.S.C. 1396 et seq. Section 17.52 is also issued under 38 U.S.C. 1701, 1703, 1710, 1712, and 3104. Section 17.55 is also issued under 38 U.S.C. 513, 1703, and 1728. Section 17.56 is also issued under 38 U.S.C. 1703 and 1728. Sections 17.61 through 17.74 are also issued under 38 U.S.C. 1730. Section 17.86 also issued under 38 U.S.C. 1785. Section 17.101 is also issued under 38 U.S.C. 101, 1701, 1705, 1710, 1721, 1722, 1729. Section 17.102 also issued under 38 U.S.C. 109, 1711, 1729, 1784, 1784A, 1785, 8111, 8153. Section 17.105 is also issued under 38 U.S.C. 501, 1721, 1722A, 1724, and 1725A. Section 17.108 is also issued under 38 U.S.C. 501, 1703, 1710, 1725A, 1720J, and 1730A. Section 17.110 is also issued under 38 U.S.C. 501, 1703, 1710, 1720D, 1720J, 1722A, and 1730A. Section 17.111 is also issued under 38 U.S.C. 101(28), 501, 1701(7), 1703, 1710, 1710B, 1720B, 1720D, 1722A, and 1730A. Section 17.125 is also issued under 38 U.S.C. 7304. Sections 17.156 and 17.157 are also issued under 38 U.S.C. 3901 and 3902. Section 17.158 is also issued under 38 U.S.C. 3902 and 3903. Section 17.169 is also issued under 38 U.S.C. 1712C. Sections 17.243 through 17.248 are also issued under 38 U.S.C. 7302 note. Sections 17.270, and 17.272 through 17.277 are also issued under 38 U.S.C. 1781. Section 17.271 is also issued under 38 U.S.C. 1720G(a)(7)(A) and 1781. Section 17.278 is also issued under 38 U.S.C. 1781 and 42 U.S.C. 2651. Section 17.279 is also issued under 5 U.S.C. 552 and 552a; 38 U.S.C. 1781, 5701, and 7332. Sections 17.380, 17.390 and 17.412 are also issued under sec. 260, Pub. L. 114-223, 130 Stat. 857, and sec. 236, Public Law 115-141, 132 Stat. 348, and sec. 236, div. J, Pub. L 115-141, 132 Stat. 348. Section 17.395 is also issued under 38 U.S.C. 1788. Section 17.410 is also issued under 38 U.S.C. 1787. Section 17.415 is also issued under 38 U.S.C. 7301, 7304, 7402, and 7403. Section 17.417 also issued under 38 U.S.C. 1701 (note), 1709A, 1712A (note), 1722B, 1730C, 7301, 7306, 7330A, 7331, 7401-7403, 7405, 7406, 7408. Section 17.419 also issued under 38 U.S.C. 1701 (note), 7301, 7306, 7330A, 7401-7403, 7405, 7406, 7408). Section 17.450 is also issued under 38 U.S.C. 1703E. Sections 17.525 through 17.531 are also issued under 38 U.S.C. 7691 through 7697. Sections 17.545 through 17.553 are also issued under 38 U.S.C. 7698, 7699, 7699A, and 7699B. Sections 17.600 through 17.612 are also issued under 38 U.S.C. 7601-7619, 7633, 7634, 7636, and sec. 104(a), div. V, Public Law 117-328. Sections 17.613 through 17.618 are also issued under Pub. L. 115-182, sec. 304. Sections 17.640 and 17.647 are also issued under sec. 4, Pub. L. 114-2, 129 Stat. 30. Sections 17.641 through 17.646 are also issued under 38 U.S.C. 501(a) and sec. 4, Pub. L. 114-2, 129 Stat. 30. Section 17.655 also issued under 38 U.S.C. 501(a), 7304, 7405. Sections 17.1200 through 17.1230 are also issued under 38 U.S.C. 1720J. Section 17.3200 also issued under 38 U.S.C. 1162, 1701, 1707, 1710, 1714, 1717, 3901. Section 17.3210 also issued under 38 U.S.C. 1701, 1710. Section 17.3220 also issued under 38 U.S.C. 1701(6)(F), 1710. Section 17.3230 also issued under 38 U.S.C. 1701(6)(F), 1710, 1714(a). Section 17.3250 also issued under 38 U.S.C. 1701, 1710, 1725, 1728. Section 17.3500 is also issued under Pub. L. 102-139 sec. 101. Sections 17.4000 through 17.4040 also issued under 38 U.S.C. 1703, 1703B, and 1703C. Section 17.4100 et seq. is also issued under 38 U.S.C. 1703A. Section 17.4600 is also issued under 38 U.S.C. 1725A and 1730A.

Amendments

[68 FR 1010, Jan. 8, 2003, as amended at 76 FR 4249, Jan. 25, 2011; 81 FR 19890, Apr. 6, 2016]