10-10145
Veterans Health Administration (VHA) Veterans Choice Program Provider Agreement
VA Form 10-10145 is the Veterans Health Administration (VHA) Veterans Choice Program Provider Agreement. The agreement says that, to receive payment for hospital care or medical services furnished under the Veterans Choice Program, the non-VA hospital care or medical services provider signs it to provide eligible Veterans with care authorized by VA. The term provider includes dental services providers. It is an agreement between a provider and VA, not a Veterans benefit application.
The form is six pages of terms in Sections A to K: general requirements, scope, covered services, payment, payment responsibility, claims submission, cancellation, period of performance, compliance with Federal laws, administrative appeals and the signature page. It cites section 101 of the Veterans Access, Choice, and Accountability Act of 2014 and 38 C.F.R. 17.1500 to 17.1540.
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The legal basis, eligible provider types, licenses and credentials verified at least once per 12-month period, malpractice insurance, exclusion lists, payment only for authorized care, records within 30 days and missed appointment notices within 5 business days.
The agreement covers authorized hospital care and medical services. The provider furnishes only medically necessary care authorized by VA, contacts VA before going beyond the authorization and follows VA National Formulary policy.
Payment at Medicare rates for the same care, if applicable, or at rates set under 38 C.F.R. 17.1535, 17.55 and 17.56, and when VA pays alone or after a Veteran's health-care plan, excluding Medicare, Medicaid and TRICARE.
Invoices go to VA electronically where possible, VA pays by electronic funds transfer after the course of treatment, including follow-up appointments, and the provider collects no more than the section D rate.
A 45 day written notice to cancel, a term of no more than five (5) years from the effective date, the laws that govern the agreement, and payment appeals under 38 C.F.R. 17.132 and 17.133 and Parts 19 and 20.
The provider practice or facility name, titles, printed names, signatures and dates for the provider and for the VA Medical Facility Director or Designee. The agreement is effective upon the date of last signature.
Section K says the parties acknowledge they have read and understand the agreement in its entirety and will abide by all of its terms and conditions.
Section A says providers submit current verification of their licenses and credentials to VA at least once per 12-month period and certify that they maintain medical malpractice insurance.
Enter the name of the provider practice or facility, the title, the printed name of the provider, the signature and the date signed.
The VA Medical Facility Director or designee signs for the Department of Veterans Affairs. The agreement takes effect on the date of last signature.
Section C says the provider furnishes only care authorized by an authorized VA official on the supporting documents, and contacts VA to request authorization for more.
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The form and VA's page do not print a mailing address. Section K says the VA Medical Facility Director, or a designee with written delegation, signs on behalf of VA.
Section A says the provider submits a copy of all medical and dental records for care under the agreement to the VA facility responsible for issuing it within 30 days of the appointment.
Section F says the provider submits all invoices to VA electronically, where possible, and VA pays by electronic funds transfer (EFT).
Section J says a provider may request reconsideration of the initial decision in writing to the VA facility that processed the reimbursement request.
The PDF footer reads VA FORM 10-10145 FEB 2016, matching the February 2016 revision date on VA's page.
10-10171
13 fields, 16 pages
10-10172
56 fields, 2 pages
10-10143g
31 fields, 1 page
10-7078
136 fields, 2 pages
The agreement says who signs it and who it covers.
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The non-VA provider signs for the provider practice or facility, and the VA Medical Facility Director or designee signs for the Department of Veterans Affairs.
Section E says that when VA notifies the provider it is solely responsible for payment, the provider accepts VA payment as payment in full and does not bill the Veteran or any other entity. It also says the provider does not collect any VA copayment amount from the Veteran.
Section D says payment is at the rates paid under the Medicare program for the same care, if applicable, or at rates determined under 38 C.F.R. 17.1535 and 38 C.F.R. 17.55 and 17.56, as applicable.
Section G says either party may cancel at any time with a 45 day written notice of intent to the signatories or their official representatives. Cancellation by VA is immediately effective when licensure, safety and quality requirements are not met.
Section H says that, except for the cancellation provisions, it continues until the authority provided by the Act expires but does not exceed five (5) years from the effective date.
Section I says the agreement is not treated as a Federal contract for the acquisition of goods or services and, except as it expressly provides, is not subject to laws governing such contracts.