The following resources provide payment information related to TRICARE and Veterans' Affairs payment.
For additional assistance with payment and reimbursement issues, contact APTA's Payment Policy & Advocacy department at 800/999-2782, ext. 8511 or firstname.lastname@example.org.
Information on Veterans' Care By Non-VA Providers
Medical care provided to eligible Veterans outside of VA when VA facilities are not available. Non-VA Care is used when VA medical facilities are not "feasibly available." The local VA medical facility has criteria to determine whether Non-VA Care may be used. If a Veteran is eligible for certain medical care, the VA hospital or clinic should provide it as the first option. If they can't - due to a lack of available specialists, long wait times, or extraordinary distances from the Veteran's home - the VA may consider Non-VA Care in the Veteran's community.
For Non-VA Care Provider Information
Once Purchased Care (non-VA Care) is authorized, Veterans may seek treatment from a provider in their community. This guide details what non-VA providers should expect in terms of authorizations and referrals, claims payment, and the return of medical documentation back to the authorizing VA Medical Center (VAMC). Learn more.
Legislation passed in 2015 that recalculates the 40 mile limit for Veterans to be able to utilize non-VA provider for health services, including physical therapists. The 40 mile limit has been changed from straight distance calculation to the driving distance of 40 miles.
Non-VA Care Provider Programs:
- CHOICE Act
"The Veterans Choice Program (.pdf), or Choice Program, is a temporary program that provides Veterans the ability to receive medical care in the community if VA cannot schedule an appointment within 30 days of the Veteran's preferred date, or the date determined medically necessary by their provider, or if the Veteran resides more than 40 miles from their closest VA medical facility. It was authorized under the Veterans Access, Choice and Accountability Act of 2014 and provides $10 billion for non-VA medical care to eligible Veterans. The temporary program will end when the allocated funds are used or no later than August 7, 2017. The Choice Program does not impact existing VA health care or any other Veteran benefits."
- Patient-Centered Community Care Contracts (PC3)
VA has expanded its Patient-Centered Community Care (PC3) contracts. PC2 is a VA nationwide program to provide eligible Veterans access to certain medical care when the local VA medical facility cannot readily provide the care due to lack of an available specialist, long wait times, geographic inaccessibility, or other factors. Review PC3 coverage map (.pdf)
"Project ARCH (.pdf) (Access Received Closer to Home) is a program that is intended to improve health care access for eligible rural and highly rural Veterans by connecting them to health care services closer to home."
If you have veterans living in the following locations who are interested in participating in the Project Arch pilot, they can contact AskProjectARCH@va.gov to obtain information on how to participate. This pilot program was schedule to end August 2016. Please watch for more information to see if Congress extends the pilot or implements the program.
Pilot Project Locations:
- VISN 1 - Northern Maine
- VISN 6 – Farmville, Virginia
- VISN 15 – Pratt, Kansas
- VISN 18 – Flagstaff, Arizona
- VISN 19 – Billings, Montana
- Program Integrity in the VA Health Care System
Provides resources and training to combat fraud, waste, and abuse (FWA) through various system safeguards, detailed auditing, and continuous awareness training. Learn more.
Highlights of the Interim Final Rule for Expanded Access to Non-VA Care Through the Veterans Choice Program for CY2014 (.pdf) - 11/17/14
Tricare Official Website
Includes information on rates and reimbursement
Outpatient Prospective Payment System (OPPS)
Includes therapy codes
Tricare Allowable Charges Tool
This interactive tool allows zip code input to find the CHAMPUS Maximum Allowable Charges (CMAC) for the most frequently used procedures or services. These charges are the maximum amounts TRICARE is allowed to pay for each procedure or service and are tied by law to Medicare's allowable charges. These amounts do not reflect TRICARE Beneficiary out of pocket cost shares, copayments, deductibles, or payments made by any other Health Plan Coverages.