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Any Medicare or Medicaid participating provider who provided care to a NDMS patient within the first 30 days of that patient’s evacuation or placement.
In order to qualify as a NDMS patient, the transportation of the patient must have been coordinated through a Federal Coordinating Center (FCC).
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 patient.
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.
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 a NDMS Appeals Board for possible reimbursement.
Yes. The care must be medically necessary and linked to the injury or condition that prompted a FCC to coordinate transport or placement for the patient.
Yes, the claim should be submitted, but the FCC point of contact for that particular area should also be contacted to ensure the patient is verified and added to the patient roster used by the NDMS Reimbursement Program. Inclusion on the list is necessary for NDMS payment consideration.
Yes, however, the provider should also review whether the NDMS patient has other coverage that may reimburse these amounts.
Yes. Generally, any medically indicated service covered under Medicare Part A or Part B would be reimbursable.
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.
No, the Memorandum of Agreement applies only to hospitals at this time.
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 patients during a public health emergency before submitting these forms. It is the responsibility of the Contractor to contact NDMS hospitals to make them aware of the registration process during an event.
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.
If they wish, hospitals that received NDMS patients, but do not have an MOA, can contact the Federal Coordinating Center (FCC) to execute an MOA and become an NDMS participating hospital. NDMS will apply the Medicare rate plus 10% for the hospital’s qualifying claims.
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 in lieu of creating our own. The vast majority of providers are participating in either Medicare or Medicaid.
As part of the MOA, facilities agree to make up to 25 beds available to NDMS when needed. This requires active reporting of status and availability to a 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.
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 really Medicare or Medicaid claims and thus would not count towards any annual deductibles or coverage limits that may apply under Medicare or Medicaid.
No. The NDMS Reimbursement Program does not cover deductibles or coinsurance (for either Medicare or other payers); consequently, the NDMS 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.
Some hospitals 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 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.
Yes, in the absence of hospitalization coverage, the NDMS hospital can bill for its inpatient facility services. Physicians, meanwhile, should bill Medicare Part B.
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 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.
Due to the nature of the program and the time allotted for reimbursement consideration, all NDMS claims must be submitted on either the CMS-1450 (UB-04) or the CMS-1500 claim forms. Only hard-copy claims will be accepted.
No, claims should be submitted directly to the contractor (Apprio). Details can be found on Reimbursement Rates.
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, providers should visit these links:
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 Reimbursement Program must associate the baby with the covered NDMS patient.
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.
Providers can mail their claims as a group to the NDMS Definitive Care Reimbursement Program.
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.
Under the NDMS partnership, the FCCs are operated by the Department of Veterans Affairs (VA) and/or the Department of Defense (DoD) and are staffed by trained medical and logistical personnel. 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 their medical evaluation and referral.
Subject to the availability of funding, the NDMS Reimbursement Program reimburses NDMS hospitals 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 hospital will bill the applicable program(s) for full payment. NDMS does not reimburse deductibles or coinsurance. The NDMS Reimbursement Program has no authority to set aside a hospital’s Medicare participation agreement.
For individuals with private coverage (e.g., employment-based coverage), the NDMS 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.
The NDMS Reimbursement Program does not pay for care given to NDMS patients who are eligible for free care from the DoD, VA or through the TRICARE program. However, a DoD or VA provider may bill NDMS for inpatient treatment of civilian evacuees. This answer is contingent on approval by the DoD or VA hospital’s commander/administrator and legal department to bill for these NDMS patients and that the hospital is able to submit a bill (i.e., UB-04) in accordance with NDMS Reimbursement Program requirements.
Claims should be submitted to the private payer first, and then NDMS will consider whether the claim is 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 Reimbursement Program). The NDMS Reimbursement Program does not supersede contracts that hospitals have with private payers that require the private insurers’ payouts be accepted as payment in full (also known as “Assignment”).
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 researched to ensure that they are 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 Reimbursement program, the Claims Processing Contractor will request copies of medical records and other documentation from the provider before processing payment.
The provider should get in touch with the NDMS Federal Coordinating Center (FCC) point of contact for the provider’s geographic area.
You may leave a voice message or fax on the NDMS Reimbursement Program toll-free line: (888) 587-2352. You may also submit general written inquiries via e-mail to: DefinitiveCare@hhs.gov. Note: Please do not communicate any Protected Health Information via this email address.
For more information about Definitive Care, contact the NDMS Definitive Care Coordinator at 202.692.4686
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