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 email@example.com.
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.
Summaries and Comments
APTA Comments on VA Proposed Rule: Authority of Health Care Providers to Practice Telehealth (.pdf)
Highlights of the Interim Final Rule for Expanded Access to Non-VA Care Through the Veterans Choice Program for CY2014 (.pdf) - 11/17/14
The TRICARE program is administered by 3 separate contractors in 3 different regions: the North Region is administered by Health Net Federal, the South Region by Humana Military, and the Western Region by United Healthcare.
2018: What You Need to Know
Beginning January 1, 2018, the North Region and South Region will combine into a new Eastern Region administered solely by Humana Military. The Eastern Region will include Alabama, Arkansas, Connecticut, Delaware, the District of Columbia, Florida, Georgia, Illinois, Indiana, Iowa (Rock Island area), Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Mississippi, Missouri (St Louis area), New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas (excluding El Paso area), Vermont, Virginia, West Virginia and Wisconsin.
Also beginning in 2018, the Western Region will be administered by Health Net Federal and will include Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (except Rock Island arsenal area), Kansas, Minnesota, Missouri (except St Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (southwestern corner including El Paso), Utah, Washington, and Wyoming.
In addition, the current TRICARE Standard program will be renamed TRICARE Select.
Providers should have been or will be contacted by their new contractors concerning the changes to their TRICARE contracts. Learn more at the New Stateside Regions and Contractors on the TRICARE website.
Resources to Help You
APTA Managed Care Contracting Toolkit: Can be a helpful resource when contracting with managed care contractors such as those that administer TRICARE.
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.