Definitive Care Program Frequently Asked Questions

The NDMS Definitive Care Program is designed to Provide Care for:

• Injuries or illnesses resulting directly from the specified public health emergency.
• Injuries, illnesses, and conditions requiring essential medical services necessary to maintain a reasonable level of health temporarily not available as a result of the public health emergency.
• Injuries or illnesses affecting authorized emergency response and disaster relief personnel responding to the public health emergency.
  

The Basics

1. What Patients Qualify?
2. How Long are Patients Covered?
3. What Services are Covered?
4. What Providers are Eligible?
5. How are Benefits Coordinated?
6. What is the Definitive Care Process?
   

Eligibility and Reimbursement

1. Who is eligible for reimbursement?
   
2. Who qualifies as a NDMS federal patient?
3. Does NDMS now cover definitive care services other than inpatient care?
4. Will NDMS Definitive Care Program reimburse providers other than hospitals?
5. What services are covered for reimbursement?
6. Does the need for treatment have to be derived from the public health event?
7. Can NDMS federal patients be billed for any remaining deductible or coinsurance amounts?
8. If a patient is placed in an observation bed only, but not admitted, will the cost of observing the patient be paid by the NDMS Definitive Care Reimbursement Program?
9. Are ambulance services reimbursed through the NDMS Definitive Care Reimbursement Program?
   

Agreements and Registration

1. Do providers other than hospitals have to sign an agreement with NDMS?
2. Do the Provider Registration forms need to be completed prior to a public health emergency?
3. A health system owns and operates multiple hospitals, home health agencies, skilled nursing facilities and ambulatory surgery centers. Does each facility have to complete a separate Provider Registration form?
4. Can facilities that received NDMS federal patients, but did not execute a MOA with NDMS prior to the event execute a MOA after the fact?
   

Medicare and Medicaid

1. Why must providers actively participate in either Medicare or Medicaid?
2. Why do facilities who choose to execute a Memorandum of Agreement (MOA) with NDMS receive 110% of their Medicare rate versus 100% of the Medicare rate for facilities that choose not to execute a MOA with NDMS?
3. Since NDMS will reimburse providers using Medicare or Medicaid rates, does this mean that the patient has to be enrolled in Medicaid/Medicare at the time of treatment for the provider to be reimbursed?
4. The provider treated an NDMS federal patient who had both Medicare and Medicaid coverage (dual eligibility). The Medicare program made primary payment, and the Medicaid program (acting as a secondary payer) paid the Medicare deductible and coinsurance. Does the provider need to make a refund to Medicaid in this situation?
5. If a health care facility is unable to verify Medicare eligibility for an NDMS federal patient, can it be reimbursed by NDMS if the patient is more than 65 years old?
   If NDMS federal patients have Medicare Part B (physicians) coverage, but do not have Medicare Part A (hospital) coverage or any other hospitalization insurance, can the facility bill the NDMS Definitive Care Reimbursement Program?
6. If a provider has already mistakenly filed a claim for primary payment with the state Medicaid program and been paid, should the provider wait until the NDMS payment determination is made before returning the Medicaid funds?
   

Submitting Claims

1. How will providers submit NDMS claims?
2. Should claims be submitted to the local FCC for submission to the NDMS Definitive Care reimbursement contractor?
3. Where can a provider obtain the paper claim forms needed to request reimbursement?
4. How should claims be submitted for babies delivered at the NDMS facilities to an NDMS federal patient? The claim-submission process asks for the patient’s full name and Social Security Number (SSN). How would the baby’s information be completed?
5. Will a claim be paid if the only information available is the patient’s date of birth and name?
6. Should claims be submitted individually or can they be mailed in one package?
7. How do attending or admitting (or other) physicians indicate that they provided treatment to an NDMS federal patient at a particular NDMS health care facility.
   

Coordination

1. What is a Federal Coordinating Center (FCC)?
2. How will NDMS payments coordinate with other insurers?
3. Are Department of Defense (DoD) or Department of Veterans Affairs (VA) hospitals considered NDMS participating hospitals?
4. How will NDMS coverage coordinate with private sector payers?
   

Verification and Preventing Fraud

1. Since this program will not be run under Medicare or Medicaid, how will NDMS ensure that fraudulent claims are not paid?
2. How can a provider verify that a specific patient is on the NDMS federal patient roster?
3. Who should providers contact if they believe a patient who belongs on the roster is, in fact, not included on the roster?
   

---

The Basics

1. What Patients Qualify?

NDMS coverage begins when a Federal Coordinating Center (FCC) authorizes placement of a patient who has been evacuated from a disaster area into a facility for definitive medical care, and is referred to as a NDMS federal patient

2. How Long are Patients Covered?
   

NMDS payment ends when one of the following occurs, whichever comes first:

• Completion of medically indicated treatment (maximum of 30 days)
• Voluntary refusal of care
  
• Return to originating facility or other location for follow on care
  

3. What Services are Covered?

Subject to medical necessity (as a guideline, generally any service covered under Medicare Part A or Part B are eligible for reimbursement).

4. What Providers are Eligible?

NDMS Definitive Care extends beyond inpatient hospital care as medical necessity and coordination of care requires. Physicians and other practitioners are eligible for reimbursement.

A provider needs to be currently participating in Medicare or Medicaid to qualify for reimbursement and not debarred from participating in Federal or State programs.

5. How are Benefits Coordinated?

• Medicare, TRICARE or the VA - Considered payment in full by insurance; NDMS does NOT cover.
• Private health insurance or non-Federal public coverage other than Medicaid - Other insurance billed as primary payer; NDMS billed as secondary payer for any unreimbursed amounts not to exceed 110% of Medicare rate for Healthcare Facilities with Memorandum of Agreement with NDMS or 100% of Medicare rate for practitioners.
• Medicaid coverage only - NDMS billed as primary payer.
• Dual Eligible (Medicare and Medicaid) - Medicare Primary; NDMS will reimburse 100% of the Medicaid share.
  

-Top-

---

Eligibility and Reimbursement

1. Who is eligible for reimbursement?

Any Medicare or Medicaid participating provider who provided care to a NDMS federal patient within the first 30 days of that patient’s evacuation or placement.

2. Who qualifies as a NDMS federal patient?

In order to qualify as a NDMS federal patient, the transportation of the patient must have been coordinated through a Federal Coordinating Center (FCC).

3. Does NDMS now cover definitive care services other than inpatient care?

Yes. Subject to medical necessity, services such as emergency department visits and follow up outpatient care services are now covered by NDMS for up to 30 days from the date of evacuation or placement for the NDMS federal patient.

4. Will NDMS Definitive Care Program reimburse providers other than hospitals?

Yes. Subject to medical necessity and coordination of benefit guidelines, providers and services which are reimbursable under Medicare Part A, Medicare Part B or your State’s Medicaid Program may be eligible for reimbursement.

5. What services are covered for reimbursement?

Any service that is covered by the Medicare Part A, Medicare Part B or the State’s Medicaid benefits package. For example, medically necessary hospital care beyond the typical length of stay, home care, rehabilitation, physical therapy, primary care and hospice would be covered. If a provider determines that a patient needed a service or support that is not included in these benefit packages and the care is/was necessary for the patient’s treatment plan, the provider can apply to the Claims Processing Contractor for reimbursement on an exception basis. These claims will then be considered by NDMS leadership for possible reimbursement.

6. Does the need for treatment have to be derived from the public health event?

No. All care must meet medical necessity guidelines, but is not limited to just the injury or condition that prompted an FCC to coordinate transport or placement for the NDMS federal patient. All medically necessary care will be covered until the patient can be discharged from the NDMS.

7. Can NDMS federal patients be billed for any remaining deductible or coinsurance amounts?

Yes, however, the provider should also review whether the NDMS federal patient has other coverage that may reimburse these amounts.

8. If a patient is placed in an observation bed only, but not admitted, will the cost of observing the patient be paid by the NDMS Definitive Care Reimbursement Program?

Yes. Generally, any medically indicated service covered under Medicare Part A or Part B would be reimbursable.

9. Are ambulance services reimbursed through the NDMS Definitive Care Reimbursement Program

Yes, although the applicable reimbursement rates would depend upon whether the transport was emergent or non-emergent. Generally, Medicare Part B provides coverage for only for emergent transport while most Medicaid programs provide reimbursement for non-emergent transport.

-Top-

---

Agreements and Registration

1. Do providers other than hospitals have to sign an agreement with NDMS?

Yes, the Memorandum of Agreement applies to all health care facilities.

2. Do the Provider Registration forms need to be completed prior to a public health emergency?

No. It is important to have the most updated information possible for providers when completing the Provider Registration forms so it is preferred if providers wait until they actually care for NDMS federal patients during a public health emergency before submitting these forms. The Definitive Care Program Contractor will contact NDMS health care facilities to make them aware of the registration process during an event.

3. If health system owns and operates multiple hospitals, home health agencies, skilled nursing facilities and ambulatory surgery centers, does each facility have to complete a separate Provider Registration form?

If a health system anticipates submitting claims from multiple facilities, a separate W-9 form and ACH Vendor Enrollment form should only be completed for each facility if the payments are to be sent to different bank accounts.

4. Can facilities that received NDMS federal patients, but did not execute a MOA with NDMS prior to the event execute a MOA after the fact

Facilities that received NDMS patients but do not have an MOA, will be contacted by the closest Federal Coordinating Center (FCC) to execute an MOA and become an NDMS participating health care partner facility. NDMS will apply the Medicare rate plus 10% for the hospital’s qualifying claims.

-Top-

---

Medicare and Medicaid

1. Why must providers actively participate in either Medicare or Medicaid?

NDMS does not have the resources to credential their own network of providers across the country or create and maintain our own reimbursement rate structures. Thus, NDMS is leveraging policies from Medicare and Medicaid. The vast majority of providers are participating in either Medicare or Medicaid.

2. Why do facilities who choose to execute a Memorandum of Agreement (MOA) with NDMS receive 110% of their Medicare rate versus 100% of the Medicare rate for facilities that choose not to execute a MOA with NDMS?

As part of the MOA, facilities agree to use their best effort to make beds available to NDMS when needed. This requires active reporting of status and availability to an FCC during an event. The 10% premium reimbursed to facilities who execute a MOA with NDMS is an administrative fee to help cover the facility’s cost of administrative coordination and communication with NDMS.

3. Since NDMS will reimburse providers using Medicare or Medicaid rates, does this mean that the patient has to be enrolled in Medicaid/Medicare at the time of treatment for the provider to be reimbursed?

No. NDMS is simply leveraging existing policies and rate structures that providers are familiar with from Medicare and Medicaid for cost efficiency and ease of understanding for providers. It is important to note that any claims paid by NDMS are not Medicare or Medicaid claims and thus would not count towards any annual deductibles or coverage limits that may apply under Medicare or Medicaid.

4. The provider treated an NDMS federal patient who had both Medicare and Medicaid coverage (dual eligibility). The Medicare program made primary payment, and the Medicaid program (acting as a secondary payer) paid the Medicare deductible and coinsurance. Does the provider need to make a refund to Medicaid in this situation?

No. The NDMS Definitive Care Reimbursement Program does not cover deductibles or coinsurance (for either Medicare or other payers); consequently, the NDMS Definitive Care Reimbursement Program is not primary to Medicaid regarding the Medicare deductible or coinsurance amounts. In this situation, Medicaid properly made a secondary payment to Medicare, and the provider does not need to reimburse Medicaid.

5. If a health care facility is unable to verify Medicare eligibility for an NDMS federal patient, can it be reimbursed by NDMS if the patient is more than 65 years old?

Some health care facilities find it difficult to verify Medicare eligibility for some of their aged NDMS inpatients because they lack patient history and, often, patients are unable to supply their Medicare numbers. When hospitals, despite making every reasonable effort to verify patients’ Medicare eligibility, fail to secure Medicare reimbursement, they may bill the NDMS Definitive Care Reimbursement Program. The hospital must furnish a signed attestation to this effect. During the review of such claims, the Federal Fiduciary will also attempt to verify Medicare eligibility. If Medicare eligibility is found, the NDMS claim will be denied. If the Federal Fiduciary cannot validate Medicare eligibility, the claim will be reimbursed as though the patient were uninsured.

6. If NDMS federal patients have Medicare Part B (physicians) coverage, but do not have Medicare Part A (hospital) coverage or any other hospitalization insurance, can the hospital bill the NDMS Reimbursement Program?

Yes, in the absence of hospitalization coverage, the facility can bill for its inpatient facility services. Physicians, meanwhile, should bill Medicare Part B.

7. If a provider has already mistakenly filed a claim for primary payment with the state Medicaid program and been paid, should the provider wait until the NDMS payment determination is made before returning the Medicaid funds?

Yes, the provider may wait until it has received the NDMS payment determination (unless the state Medicaid agency takes a different position). However, once the provider receives a primary payment from the NDMS Definitive Care Reimbursement Program, the provider should make a refund to the state Medicaid program. Please note that the Federal Fiduciary will be responsible for contacting the Medicaid program office in each affected State to try to prevent erroneous billing of the Medicaid program. Also, please note that once a Medicaid program has discovered the billing mistake, they may often recoup the erroneous payment made by deducting the amount from a future payment to be made to the provider.

-Top-

---

Submitting Claims

1. How will providers submit NDMS claims?

When possible, providers should submit claims electronically via a claims clearinghouse service to payer code NDMSA (HHS NATIONAL DISASTER MEDICAL SYSTEM-APPRIO). For all electronic claims received, an electronic remittance advice will be returned which will make payment reconciliation more efficient for the provider. If needed, NDMS will continue to accept hard-copy submission of claims on either the CMS-1450 (UB-04) or the CMS-1500 claim forms.

2. Should claims be submitted to the local FCC for submission to the NDMS reimbursement contractor?

No, claims should be submitted directly to the contractor (Apprio). Details can be found on Reimbursement Rates.

3. Where can a provider obtain the paper claim forms needed to request reimbursement?

The claim forms are universal and are available from Internet-based vendors, as well as from office-supply stores, billing vendors, and others. For complete information about the forms they should use and how to acquire them, see:

• Hospitals (CMS-1450)
  
• Practitioners (CMS-1500)
  

4. How should claims be submitted for babies delivered at the NDMS facilities to an NDMS federal patient? The claim-submission process asks for the patient’s full name and Social Security Number (SSN). How would the baby’s information be completed?

The mother’s data (name, SSN, etc., to the extent available) should be entered on the claim form; the provider may use the HIC field of the claim to enter the mother’s SSN. Both the UB-04 and the CMS-1500 have blocks into which data about the “insured” may be entered, and this would be a logical place to enter the data about the NDMS patient/parent. The NDMS Definitive Care Reimbursement Program must associate the baby with the covered NDMS federal patient.

5. Will a claim be paid if the only information available is the patient’s date of birth and name?

It will be difficult to validate the patient is eligible for NDMS benefits without the specific additional information. However, every attempt will be made to verify the patient, and payment will be made if it can be verified that an FCC sent a patient to the hospital.

6. Should claims be submitted individually or can they be mailed in one package?

Providers can mail their claims as a group to the NDMS Definitive Care Reimbursement Program.

7. How do attending or admitting (or other) physicians indicate that they provided treatment to an NDMS federal patient at a particular NDMS health care facility?

When submitting claims to NDMS for payment, physicians should include the hospital’s name and/or provider number on the claim form. The practitioner should ensure the hospital is identified in block 32 of the CMS-1500 claim form.

-Top-

---

Coordination

1. What is a Federal Coordinating Center (FCC)?

Under the NDMS partnership, the FCCs are operated by the Department of Veterans Affairs (VA) and/or the Department of Defense. The FCCs are responsible for coordinating NDMS definitive care within their designated patient-reception areas. When individuals are medically evacuated through the NDMS patient-evacuation system, typically by air medical transport, FCC personnel coordinate with their local health care partner facilities.

2. How will NDMS payments coordinate with other insurers?

The provider should try to identify other insurance coverage for the patient that would be billed as the primary payer. Please note that during previous public health emergencies, NDMS evacuated large numbers of patients who had Medicare (most dialysis patients have Medicare coverage).

Subject to the availability of funding, the NDMS Definitive Care Reimbursement Program reimburses NDMS health care facilities at the lesser of billed charges for covered services or at 110 percent of the Medicare payment amount for individuals with no health-insurance coverage and for individuals whose only coverage comes through the Medicaid program (or other payers of last resort). If a patient has coverage through another federal health-care program (e.g., Medicare or TRICARE), the facility will bill the applicable program(s) for full payment. NDMS does not reimburse deductibles or coinsurance. The NDMS Definitive Care Reimbursement Program has no authority to set aside a facility’s Medicare participation agreement.

For individuals with private coverage (e.g., employment-based coverage), the NDMS Definitive Care Reimbursement Program may make a secondary payment to cover the difference between the full NDMS payment amount and the other payer’s (or payers’) allowance(s). However, NDMS does not cover deductibles and coinsurance associated with patients’ private coverage.

3. Are Department of Defense (DoD) or Department of Veterans Affairs (VA) hospitals considered NDMS participating hospitals?

While the VA and DoD are partners in the NDMS Definitive Care Program, their federal facilities would only be used for eligible beneficiaries.

4. How will NDMS coverage coordinate with private sector payers?

Claims should be submitted to the private payer eligible for any secondary reimbursement. However, NDMS will not pay for any coinsurance or deductible amounts. The NDMS payment is limited to payment of the difference in the allowable amounts (between the allowance of the primary payer and the allowance of the NDMS Definitive Care Reimbursement Program). The NDMS Definitive Care Reimbursement Program does not supersede contracts that facilities have with private payers that require the private insurers’ payouts be accepted as payment in full (also known as “Assignment”).

-Top-

---

Verification and Preventing Fraud

1. Since this program will not be run under Medicare or Medicaid, how will NDMS ensure that fraudulent claims are not paid?

The Claims Processing Contractor will implement many fraud and abuse prevention best practices in a prospective review of all claims for possible fraudulent activity before payment is made. Providers will be confirmed as a participating provider in Medicare or Medicaid and that they have not been debarred from any federal or state healthcare programs. Each new claim received will be analyzed against any existing claims history for the patient or provider to detect any anomalies in dates of service, place of service, distances traveled for services, provider specialty and service anomalies, diagnosis code mismatches, improper coding and duplicate billing. For any provider who submits multiple claims or a relatively high dollar value of claims and who has no previous claim submission history with the NDMS Definitive Care Reimbursement program, the Claims Processing Contractor will request copies of medical records and other documentation from the provider before processing payment.

2. How can a provider verify that a specific patient is on the NDMS federal patient roster? Who should providers contact if they believe a patient who belongs on the roster is, in fact, not included on the roster?

The provider may contact the Claims Processing Contractor who can verify the patient’s eligibility. If the provider believes the patient’s eligibility status is not accurate, the Claims Processing Contractor can escalate the issue to NDMS leadership for further investigation and resolution.