Awareness : Newsletter Articles

Processing Services Not Authorized by the Veterans Administration in a Non-VA Facility

For inpatient claims where the Veterans Administration (VA) is the payer, the covered services are exclusions to the Medicare program per Section 1862 of the Social Security Act. Change request (CR) 9818 provides clarification to address the following:

  • When a VA- eligible patient chooses to receive services in a Medicare certified facility for which the VA has not authorized, the facility shall use condition code 26 to indicate the patient is a VA-eligible patient and chooses to receive services in a Medicare certified provider instead of a VA facility. The facility will also use value code 42 with the amount of the VA payment for the authorized days.
  • Medicare administrative contractors will accept value code ‘42’ on inpatient claims with type of bill codes 11x, 18x, 21x, 41x, and 51x. MACs will calculate the Medicare payment for an inpatient claim when condition code ‘26’ and value code ‘42’ are present on a claim. However, MACs will return the claim to the provider if CC ‘26’ is present without VC ‘42’ or vice versa.