Definitive Care Program: Frequently Asked Questions

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

In order to qualify as a NDMS federal 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 (unless otherwise directed) or placement for the NDMS federal 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, hospice, and other healthcare facilities a federal patient may need medical care 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.

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.

Yes, however, the provider should also review whether the NDMS federal 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.

Yes, the Memorandum of Agreement applies to all healthcare facilities.

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.

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 partner healthcare facility. NDMS will apply the Medicare rate plus 25% 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. The majority of providers are participating in either Medicare or Medicaid.

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.

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.

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.

Some healthcare 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.

Yes, in the absence of hospitalization coverage, the facility 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 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.

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, see:

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

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.

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). 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.

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 healthcare 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.

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

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").

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.