S06 Attachment X - Monthly Invoice Template.xlsx
XLSX spreadsheet 109 KB Posted
- Solicitation number
- 36C10X25R0001
About this file
This document is a monthly invoice template for a Medical Disability Examination (MDE) contract opportunity with the Department of Veterans Affairs (VA) Medical Disability Examination Office (MDEO). The template includes data fields for capturing information such as vendor identification, contract details, Veteran information, appointment details, examiner details, travel costs, billing status, and other relevant data points required for invoicing contracted services. The template also provides invoicing instructions, including guidance on pricing, allowable charges, invoice submission, and other administrative requirements. This document serves as a standardized format for contractors to submit monthly invoices for MDE services performed under the MDEO contract.
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Data Dictionary
| Data Element | Description | Format | Example |
| Line# | Invoice Line Number | Number | 1 |
| Vendor | Vendor Name | Free Text | VenEx |
| District ID | Region/District identifier (R/D) followed by associated number (1-4, 6, or 7) | Free Text | R1 |
| InvoiceID | Vendor add invoice identifying information in the following format: "VESR1Jan2020OY1" | Free Text; (Vendor)_(Region/District)_(MMMYYYY)_(Contract Year) | VES_R1_Jan2020_OY1 |
| Original_InvoiceID | Vendor add invoice identifying information (Invoice ID) for when the action was originally invoiced. This will be primarily to link Rework/Credit. | Free Text; (Vendor)_(Region/District)_(MMMYYYY)_(Contract Year) | VES_R1_Dec2019_OY1 |
| ContractID | Contract number | Free Text | VA119A-16-D-0000 |
| ClaimantName | Name of Veteran | Free Text; Last, First, Middle | Last, First, Middle - "Johnson, Michael, David" |
| ESRUUID | Unique identifier for ESR | Free Text | a2671dab-bce4-4194-a488-f97fb5ce6c03 |
| ContentionUUID | Unique identifier for Contention | Free Text | 2d20b6e7-b320-4a12-9a44-b2d00dbbb9f6 |
| AppointmentUUID | Unique identifier for the actual appointment date/time | Free Text | 123456789 |
| FileID | Unique identifier for the file | Free Text | 19x2435bw3 |
| SPC | Provide specialty nature of appointment | Free Text | Gen Med |
| CLIN | Provide the Contract Line Item Number for charge | Free Text | 0022D |
| CPTCode | Current Procedural Terminology code that identifies specific diagnostic and associated cost. | Free Text | 85025 |
| DBQName | All DBQ names should be documented uniformly across vendors; as they appear on the DBQ. Ex: "DBQ Hearing Loss and Tinnitus" should not be recorded at "hearing loss and tinnitus) | Free text | DBQ Hearing Loss and Tinnitus |
| ExamType | Input one of the following values: |
A. ACE Exam F. In-Person Exam (face-to-face) T. Tele-C&P Exam I. IMO/MO only
| D. Diagnostic E. Housebound | Enter A, F, T, I, E or D only | D | ||
| Description | Free Text | Gen Med Comp Exam to include Gulf War DBQ Requiring 1-5 DBQs | ||
| Travel Type | Input one of the following values: |
1. Veteran Mileage to/from Exam site
2. Veteran Mileage to/from Diagnostic site
3. Veteran Mileage to/from Tele-C&P site
4. Special modes of transportation
5. Other (parking, tolls, etc)
6. Examiner travel time
| 7. Chaperone/Assistant/Tele Presenter travel time | Enter 1, 2, 3, 4, 5, 6 or 7 only | 1 |
| BillingStatus | Insert one of the following values. |
1. Debit (New Bill)
2. Debit (CPT Code Validation)
3. Debit (Audit Recoupment)
4. Debit (Self-Adjustment)
5. Debit (Invoice Validation)
6. Debit (Other)
7. Credit (CPT Code Validation)
8. Credit (Audit Recoupment)
9. Credit (Self-Adjustment)
10. Credit (Invoice Validation)
11. Credit (Other)
| 12. Rework | Enter 1, 2, 3, 4,5 ,6 ,7 ,8, 9, 10, 11, or 12 only | 10 | ||
| Amount | Additional detail for CPT code and CLIN code quantities or modifiers | Free Text | $325.00 | |
| Credit_Line_Identifer | Identify the line item number or Audit period for the credit identified in Column U | Free Text | Free Text: Invoice Feb 2021, credit for line 12,234 |
or Audit period 2020, objective 5
| CPT/CLIN_Modifier | Input only the following values: NA (not applicable) L (left) R (right) BL (bilateral) AND #1-100 (indicating quantity of procedure/service performed) | ||
| Input only NA, L, R, BL, or 1-100 | L 4 | ||
| Notes | Do not add information otherwise identifed in newly added fields. | Free Text | |
| RequestDate | Provide the date request for service was received | Free Text | 5/17/21 |
| ApptDate | Provide the date service was scheduled | Free Text | 5/22/21 |
| ServiceDate | If there is a different date of service from the date of appointment, (ie; for diagnostics) that appointment date and service date would be different. The date of service for each line should be the date the service was actually completed. The date of appointment will remain the date of appointment, regardless if the date of service was before or after the appointment. If the date of service extends into the following month, then the exam should be billed in that month regardless of appointment date. | ||
| Free Text | 5/22/21 | ||
| ESRCompletionDate | The ESR Completion Date on the invoice should match the date the ESR was completed. If contentions are completed but the ESR is still open, the ESR delivery/completion date will remain blank. | Free Text | 5/23/21 |
| RegionalOffice | Provide the name of the Regional Office (RO) | Free Text | Los Angeles |
| ApptLocationCity | Provide the name of the city in which the appointment was held | Free Text | Whittier |
| ApptLocationState | Provide the name of the state in which the appointment was held | Free Text | CA |
| ApptLocationZIP | Provide the zip code for the location in which the appointment was held | Number | 90224 |
| ExaminerName | Use the following format only: LAST NAME, FIRST NAME (all caps) middle initial may be used if needed, all CAP only. | Free Text | HOUSE, GREGORY |
| ExaminerState&LicenseNumber | Please list the state/s in which the examiner listed in line 33 is licensed. If the examiner is licensed in more than one state, please list all states and corresponding state license mumber. | Free Text | CA-123456 |
AL-321654
OH-789123
| NPI | Provide the examiner's unique National Provider Identifer | Number | 963258741 |
| AccountNumber | Provide any number used as an account identifier | Free Text | 23564 |
| PurchaseOrder | Provide any number used as a purchase order identifier | Free Text | 123456 |
| HomeofRecordCity | Provide the name of the city in which the Veteran lives | Free Text | Phoenix |
| HomeofRecordState | Provide the name of the state in which the Veteran lives | Free Text | AZ |
| HomeofRecordZipCode | Provide the zip code in which the Veteran lives | Number | 07724 |
| TotalMilesTraveled | Provide total number of miles Veteran traveled for this appointment. This number should be calculated to the nearest 10th of a mile (.10) | Number | 78.3 |
| ContractOptionY | Designate Base Year or Option Year being invoiced | Free Text | OY 1 |
| Examiner Travel (in hours) | Insert the number of miles to the .25 mile. | Number | 4.25 |
| PACT Act | Indicate if the line item is associated with PACT Act | Enter "Yes" or leave blank | Yes |
| Mobile Unit Days | Indicate the number of days that a mobile unit was billed for. | Number | 5 |
| VCC Examiner or Medically Necessary Attendant/Chaperone Hours | Indicate the number of hours (to the nearest quarter hour) an examiner was present at a Veterans Claims Clinic event and invoice to CLIN 0025A . Medically Necessary Attenants/Chaperones should be invoiced to CLIN 0026 (Administrative Staff should not be invoiced) | Number | 4.25 |
| Document ID | Provide the Vendor document ID for the invoiced item | Free Text | a2038cdd-2256-3c6e-80d4-2449d96488ae |
| Contention Completion Date | Provide the Contention Completion Date which is the package available date of the Results Available Package (RAP) | Date | 1/1/24 |
| DBQ Associated with Medical Opinion ID | Provide Vendor document ID for DBQ associated with the Medical Opinion being invoiced. | Free Text | a2038cdd-2256-3c6e-80d4-2449d96488ae |
Invoicing Instructions Contractor Invoicing Instructions
| The following information provides the contractor instructions for invoicing MDEO for the contracted services that have been provided. |
| I. General Invoicing Guidance |
| • Invoices must utilize the standard naming convention: Contractor Name_Region/District_Option Year_Year_Month of services invoiced (Ex: ABC_R1_OY1_2024_01) |
| • The contractor must use the pricing schedule in effect at the time of the contention completion date (RAP package available date) or contract modification date unless the Government states otherwise at the time of execution. For example, if the contention was completed in Option Year (OY)1, then OY1 pricing should be used to invoice for the completed results. |
| • The pricing must be based on the contention completion date, which is defined as the date the RAP was submitted to DAS “package available date”. If the contention was completed in Option Year (OY)1, then OY1 pricing should be used to invoice for the completed results. |
| • Retroactive invoicing is not permitted. Services must be invoiced no later than 90 days upon delivery to the Government. |
| • CLIN 0017 and Veteran Mileage Payments are the exception to the 90 day delivery rule. |
| • Invoice template must be filled in accurately and timely or the invoice may be returned. |
| • Invoice Submission platform: Monthly invoices shall be submitted in Tungsten which interfaces with IFAMS/IPPS (talk to Jen B to get lang that refers them to look at the contract) VA’s Electronic Invoice Presentment and Payment System – The Financial Services Center (FSC) in Austin, TX uses a third-party contractor, Tungsten, to provide electronic invoicing services, free of charge, to VAs vendor community. Please go to this website: http://www.tungsten-network.com/US/en/veterans-affairs/ and follow the instructions to login and submit electronic invoices. |
| • Pricing is activated based on the Negotiated Effective date, or Award date (date the Contracting Officer signed the contract or modification). |
| • In the event that a new CLIN is established or a new price is negotiated, Contractors will not be permitted to change invoicing amounts retroactively. |
| II. Travel Invoicing | ||
| • Examiner travel is invoiced at GSA rate (Per diem rates | GSA). | ||
| • Veteran mileage is invoiced at the 38 CFR rate (38 U.S. Code § 111 - Payments or allowances for beneficiary travel | U.S. Code | US Law | LII / Legal Information Institute (cornell.edu)). | ||
| • Mileage is reported to the 10th of a of a mile, and invoiced at the appropriate mileage rate times the reported mileage. | ||
| • Examiner time is reported to a quarter of an hour, and invoiced at the appropriate CLIN price times the reported hours. | ||
| • Mobile units are invoiced to the day. | ||
| • Requesting reimbursement for SMOT or examiner travel time, must be approved via the Special Authorization Portal prior to submitting the invoice (https://apps.gov.powerapps.us/play/e/default-e95f1b23-abaf-45ee-821d-b7ab251ab3bf/a/c38d0cca-5197-45e7-a175-4b34f409d33b?tenantId=e95f1b23-abaf-45ee-821d-b7ab251ab3bf). | ||
| • Invoicing MDEO for claimant travel reimbursement is done after the mileage reimbursement check has been cashed by the Claimant. | ||
| • When multiple appointments (including diagnostics) are conducted on the same day, the mileage to/from each location should be invoiced on separate invoice lines. | ||
| III. Medical Opinion Invoicing | ||
| • For requested medical opinions, to include embedded MO as identified in Attachment AK, the maximum number of MOs that can be invoiced is one per Examiner per DBQ for all examination types. | ||
| • Medical opinions may be requested with or without an accompanying contention specific Disability Benefits Questionnaire (DBQ), | ||
| * For requested medical opinions, with an accompanying contention specific DBQ, when no diagnosis is found, the Contractor shall not invoice for a MO. | ||
| o With the exception of undiagnosed illness for Gulf War, or when specifically requested as part of a Board of Veteran Appeals (BVA) remand or Regional Office request. | ||
| * For requested medical opinion(s) without an accompanying non-medical opinion DBQ, whether or not a diagnosis is found, the Contractor shall complete and invoice for medical opinion(s) similar to when there is an accompanying DBQ. This does not mean that an accompanying DBQ should be requested. | ||
| • Medical Opinions shall be invoiced under CLIN 0019G | ||
| IV. Medical Record Invoicing | ||
| Per the pricing schedule, there are two Medical Record Review CLINS. | ||
| • | CLIN 0019E is for medical record review for non-TERA requests. | |
| • | CLIN 0019F is for medical record review for TERA requests. | |
| Contractors shall invoice one medical record review (MRR) per examiner per ESR regardless of the number of DBQs. | ||
| The below table provides examples of Medical Opinion and Medical Record Review Invoicing |
https://www.gsa.gov/travel/plan-book/per-diem-rateshttps://www.law.cornell.edu/uscode/text/38/111https://apps.gov.powerapps.us/play/e/default-e95f1b23-abaf-45ee-821d-b7ab251ab3bf/a/c38d0cca-5197-45e7-a175-4b34f409d33b?tenantId=e95f1b23-abaf-45ee-821d-b7ab251ab3bf Invoice Template Update
| Update 1/5/24 | ADDED | ADDED | ADDED | ||||||||||||||||||||||||||||||||||||||||||||
| Line# | Vendor | DistrictId | InvoiceID | Original_InvoiceID | ContractID | ClaimantName | ESRUUID | ContentionUUID | AppointmentUUID | FileID | SPC | CLIN | CPTCode | DBQName | ExamType | Description | Travel Type | BillingStatus | Amount | Credit_Line_Identifier | CPT/CLIN_Modifier | Notes | RequestDate | ApptDate | ServiceDate | CompletionDate | RegionalOffice | ApptLocationCity | ApptLocationState | ApptLocationZIP | ExaminerName | ExaminerState&LicenseNumber | NPI | AccountNumber | PurchaseOrder | HomeofRecordCity | HomeofRecordState | HomeofRecordZipCode | TotalMilesTraveled | ContractOptionY | ExaminerTravelTime(inhours) | PACTAct | MobileUnitDays | VCCExaminerOrMedicallyNecessaryAttendant_ChaperoneHours | Document_ID | Contention_Completion_Date | DBQ_associated_with_medical_opinion_ ID |
| ExamVendor1 | 4 | 36C10X19D0000 | FirstLastM | 3a14xxxf-1911-42aa-b9a9-a328a1e8dxxx | 88511xxx-3378-4c92-8929-7edcba07axxx | Enter the specific UUID for the appointment | 19xx4567xx | DIA | 0022D | 0022D | Change in naming convention ONLY. |
All DBQ names should be documented uniformly across vendors; as they appear on the DBQ. Ex: "DBQ Hearing Loss and Tinnitus" should not be recorded at "hearing loss and tinnitus).
Each DBQ should appear on a single line. Please ensure all DBQs associated with an appointment are listed consecutively. Input one of the following values:
A. ACE Exam F. In-Person Exam (face-to-face) T. Tele-C&P Exam I. IMO/MO only D. Diagnostic E. Housebound Add a description of the line item as necessary. Input one of the following values:
1. Veteran Mileage to/from Exam site
2. Veteran Mileage to/from Diagnostic site
3. Veteran Mileage to/from Tele-C&P site
4. Special modes of transportation
5. Other (parking, tolls, etc)
6. Examiner travel time
7. Chaperone/Assistant/Tele Presenter travel time Insert one of the following values.
1. Debit (New Bill)
2. Debit (CPT Code Validation)
3. Debit (Audit Recoupment)
4. Debit (Self-Adjustment)
5. Debit (Invoice Validation)
6. Debit (Other)
7. Credit (CPT Code Validation)
8. Credit (Audit Recoupment)
9. Credit (Self-Adjustment)
10. Credit (Invoice Validation)
11. Credit (Other)
| 12. Rework | 1.14 | Identify the line item number or Audit period for the credit identified in Column U | 08/26/2019 | If there is a different date of service from the date of appointment, (ie; for diagnostics) that appointment date and service date would be different. | ||||||||||||||||||
| The Completion Date on the invoice should match the date the ESR was completed. If not complete it should remain blank. | Los Angeles, CA | San Pedro | CA | 11111 | Use the following format only: LAST NAME, FIRST NAME (all caps) middle initial may be used if needed, all CAP only. | Please list the state in which the examiner is licensed. If the examiner is licensed in more than one state, please list all states, separated by comma and record the corresponding license number in column AL, also separated by comma. | 1111111111 | 11111-1 | 101-J92000 | San Pedro | CA | 11111 | 20.1 | OY1 | 4.25 | Yes | 5 | 4.25 | a2038cdd-2256-3c6e-80d4-2449d96488ae | 1/1/24 | a2038cdd-2256-3c6e-80d4-2449d96488ae |
| Line# | Vendor | Region/District | InvoiceID | Original_InvoiceID | ContractID | ClaimantName | ESRUUID | ContentionUUID | AppointmentUUID | FileID | SPC | CLIN | CPTCode | DBQName | Exam Type | Description | Travel Type | BillingStatus | Amount | Credit-Debit Line Identifier | CPT/CLIN_Modifier | Notes | RequestDate | ApptDate | ServiceDate | ESRCompletionDate | RegionalOffice | ApptLocationCity | ApptLocationState | ApptLocationZIP | ExaminerName | ExaminerState&LicenseNumber | NPI | AccountNumber | PurchaseOrder | HomeofRecordCity | HomeofRecordState | HomeofRecordZipCode | TotalMilesTraveled | ContractOptionY | ExaminerTravelTime(inhours) | PACTAct | MobileUnitDays | VCCExaminerOrMedicallyNecessaryAttendant_ChaperoneHours | Document_ID | Contention_Completion_Date | DBQ_associated_with_medical_opinion_ ID |
| 1 | ExamVendor1 | R4 | VetFed_R4_Jan2020_OY1 | VetFed_R4_Jan2020_OY2 | 36C10X19D0000 | Last, First, Middle | 3a14xxx-1911-42aa-b9a9-a328a1e1xxx | 88511xxx-3378-4c92-8929-7edcba07axxx | 19xx4567xx | SPC | 0022D | NA | F | 4 | $ 8.30 | Invoice Feb 2021, credit for line 12,234 |
or
| Audit period 2020, objective 5 | NA | 08/26/2019 | 12/06/2019 | Los Angeles, CA | San Pedro | CA | 11111 | 1111111111 | 11111-1 | 101-J92000 | San Pedro | CA | 11111 | 20.1 | BY | 4.25 | YES | 5 | 4.25 | a2038cdd-2256-3c6e-80d4-2449d96488ae | 1/1/24 | a2038cdd-2256-3c6e-80d4-2449d96488ae | |||||||||||||||||||||||||
| Add new field Line#" to capture the invoice line number within each submitted invoice for easy reference; This should represent the invoice line number from the "All Data" sheet of the invoice. | __ | Change field name to Region/District to differentiate between Regions and Districts; updated the format for Regions to use a two (2) character identifier (i.e. Region 1 would be "R1"; Districts 7 would be "D7") | Add new field InvoiceID to identify what invoice each billed action is included in to allow invoiced actions to be tracked and referenced. | Add new field Original_InvoiceID to identify when a specific vendor action was originally invoiced for; this will generally be the same as InvoiceID unless an action is a rework or a credit for a previously invoiced action. | __ | Updated and standardized the ClaimantName input format. | No change; ensure all vendors use the field name "ESRUUID" | No change; ensure all vendors use the field name "ContentionUUID" | __ | __ | No change; ensure all vendors use the field name "CLIN" | Updated format; If there is no CPT Code, then the cell will contain "NA" | When populating the Exam Type, the entry shall be entered as a letter character only (without punctuation). | When populating the Travel Type, the entry shall be entered as a number character only (without punctuation). | No change; ensure all vendors use the field name "Amount" | Add new "CPT/CLIN_Modifier" field to allow vendors to provide additional detail for CPT code and CLIN code quantities or modifiers. Vendors will use the following one (1) or two (2) digit codes: "NA" - Not Applicable; "L" - Left; "R" - Right; "50" - Bilateral (any procedure); # - Qantity/count of prcedure or service/units completed (Example: "3" - indicates 3 units were completed) | Add new "Notes" field to allow space for vendors to provide additional context to the invoice action if needed; This will be required for any rework invoice lines and any credits being applied to explain why the rework/credit is being provided | __ | __ | __ | __ | __ | __ | Please list the state/s in which the examiner listed in line 33 is licensed. If the examiner is licensed in more than one state, please list all states and corresponding state license mumber. | __ | __ | __ | __ | __ | __ | Provide total number of miles the Veteran traveled for this appointment. This number should be calculated to the nearest 10th of a mile (.1) | Updated format; Vendors will use the following two (2) or three (3) digit identifier for the contract year moving forward: "BY" (Base Year); "OY1" (Option Year 1); "OY2" (Option Year 2); etc. | Please insert the number of hours that an examiner traveled for a housebound or incarcerated veteran examination. Travel time includes the time the Examiner traveled directly from his or her primary place of work or residence to the prison facility or Claimant residence. Invoice to the nearest 1/4 hour in decimal format (.25). Leave blank if not applicable. | If the line item being billed is labeled as a PACT Act Exam, place a "YES" in this column. If the line item is not PACT Act related leave this column blank. | Use this column to indicate the number of days that a mobile unit is being billed for. | Please insert the number of hours an examiner or medically necessary attendant/chaperone was present while working a Veterans Claims Clinic Event. | Please insert the Document ID in this column | Please insert the Contention Completion Date or Results Available Package (RAP) date in this column | Please insert the Document ID of an associated Medical Opinion in this column | ||||||||
| 1. This field should only contain five-digit CPT codes; Vendors should not input CLIN codes; If no CPT code is applicable the vendor shall input "NA" | 1. Modifiers for Professional (26) and Technical Components (TC) are not necessary and should not be represented here, or anywhere else on the invoice; 2. This field should ONLY contain a one (1) or two (2) digit modifier code as identified above, and any additional information the vendor feels should be included in the invoice record should be included in the new "Notes" field. | 1. This field is required for any rework invoice lines and any credits being applied to explain why the rework/credit is being provided. | 1. All vendors will ensure that the actions being invoiced for were requested within the period of performance of the purchase order being billed against (as identified in the RequestDate field) | 1. Mileage should only be applied to invoice lines that are billing for milage travel reimbursement; 2. All travel billing should be delineated as separate invoice lines(i.e. mileage reimbursement, other veteran travel reimbursement [tolls, taxi, etc.], and special mode of transportation (i.e. ambulance, ambulette, etc.); 3. All mileage reimbursement amounts should equate to the contractually required $0.415/mile (Amount / TotalMilesTraveled). | 1. All vendors must ensure that each invoiced action is billed to the correct purchase order based on the date the action was requested by the VA (RequestDate). | Use of this column should be in complaince with paragraph 2.12.3 "Examiner Travel" | This column should be populated with a whole number. | This column should be populated by a number invoiced to the nearest 1/4 hour. | This column should be populated with a date |
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