Dear Tribal Leader:

The Department of Veterans Affairs (VA) is writing to request tribal consultation to improve health care access for Veterans by re-issuing the VA Tribal Sharing and Reimbursement Agreements (TSRAs). Regarding the topic of adopting a new Agreement Template, VA held two nation-wide listening virtual sessions on December 16th, 2021, and January 13, 2022, and received written comments through February 13, 2022. In addition, the VA held an in-person and virtual listening event in Alaska on May 26, 2022, with written comment through August 8, 2022. The primary purpose of these sessions was to gain tribal health insights on expanding the Indian Health Service/Tribal Health Program (IHS/THP) Reimbursement Agreement Program (RAP) to adopt Purchase/Referred Care (PRC) and contract travel. As a result of the feedback received from Alaska’s THP representatives, we have developed a new draft Agreement template for discussion.

We are seeking consultation from Tribal Leaders (or their representative designees) on the attached draft Agreement template in its entirety. As a starting point for the dialogue, we request your thoughts on the following topics:

1) VA endeavors to make THP billing for PRC as easy as possible and heard from several stakeholders the preference for monthly billing submissions. VA proposes monthly billing submission to include a cover letter and excel spreadsheet with the THP facility information and claims information with associated EOBs or similar supporting documentation for THP PRC payments. Under this proposal, VA recommends THP electronically submit these documents using VA’s g-invoice or e-Invoice system1, which conforms to the X12 electronic data interchange (EDI).

a. Would THPs have technical issues invoicing VA for PRC as proposed? If so, what alternative approach do you propose that would be consistent with submitting invoices and associated supporting documentation for PRC payments.

2) Both Medicare and Medicaid pay providers separately from the IHS All Inclusive Rate (AIR) for certain outpatient services when not billed with a clinic visit.

a. Do THPs facilities have recommendations on services that should be excluded from the IHS AIR reimbursement and paid at Alaska’s Medicare Fee for Service rates instead? Please discuss the rationale for your proposed exclusions from the IHS AIR?

b. VA is proposing to maintain access to healthcare services for Non-Alaska Native/American Indian Veterans through the TRSAs. Are there any efficiencies that you would like to propose to the current process?

Please find attached a draft agreement template for your reference and review. An inperson consultation is scheduled for October 26, 2022, between 1:00pm – 4:00pm at 1201 North Muldoon Road, Anchorage, Alaska, hosted by the Alaska VA Healthcare System, Conference Rooms 2D101-2D111. Virtual participation will also be available via TEAMS (Meeting ID: 239 346 311 890; Passcode: syCseH)

Written comments may also be submitted to by December 1, 2022 For additional information regarding this effort, please contact Kara Hawthorne at

We look forward to meeting with you and we appreciate your support as we move forward together to enhance and improve the healthcare experience for our American Indian/Alaska Native Veterans and non-Native Veterans in Alaska.

Best Regards,

/s/Julianne Flynn, MD
Acting Deputy Assistant Under Secretary for Health
Office of Integrated Veteran Care

/s/Thomas A. Steinbrunner, FACHE
Executive Director
Alaska VA Healthcare System


cc: Draft Agreement

Share this story

Published on Sep. 28, 2022

Estimated reading time is 2.6 min.