Patient Administration - Army Publishing Directorate - U.S. Army

(b) In item 11a, Total Days, enter the number of days from admission to disposition or date of report.
(c) In item 11b, Days Absent from Hospital, enter the number of the days that were included in 11a during which
the patient was absent from the hospital (such as pass days, etc.).
(d) In item 11c, Net Days, enter the number of days the patient was actually in the hospital (11a minus 11b).
(e) In 11d, Rate, enter the appropriate inpatient rate as stated in the applicable Federal Register.
(f) In 11e, Total, if a per diem rate is applicable, enter the total charge for active hospitalization (11c multiplied by
11d). If a DRG rate is applicable, enter the full DRG charge. The DRG code and corresponding full written description
of the DRG code will be entered in Item 8, Diagnosis, section of the form.
(g) In 11f, Paid, enter any amount paid locally by the patient or on behalf of the patient by anyone other than an
agency of the Federal Government. Record the payer’s name. Enter only amounts received by the MSA as of the day
the notification is submitted. Promises to pay, arrangements for partial payments, or other transactions, such as transfer
of the account to the FAO, will not be reflected. If any amounts are received after the notification is submitted, a
corrected claim form (DA Form 2631) will be submitted.
(h) In 11g, Balance, enter the unpaid charges (11e minus 11f).
(i) In 12a, Visits, enter the number of outpatient visits by clinical service and/or other applicable outpatient charges,
such as high cost ancillary services or pharmaceuticals ordered by a civilian provider but provided by the MTF (for
example, MRI).
(j) In 12b, Rate, enter the applicable clinical service outpatient visit rate or other appropriate charge stated in the
applicable Federal Register or regulation.
(k) In 12c, Total, enter the total charge for all outpatient care (12a multiplied by 12b). If there are multiple
outpatient services and/or multiple sources of care, an itemized list of the charges may be provided on an attached
sheet of white bond paper. The list must contain the patient’s name and SSN, each provider/practitioner’s full name
and address, the treatment date(s), the applicable ICD-9-CM and CPT4 codes, and the applicable provider/practitioner
charge for each date(s) of treatment. The notation “See attached list” will be entered in Block 12, and the cumulative
total of all charges noted on the list will be entered in block 12c of the DA Form 2631.
(l) In 12d, Paid, enter any amount paid locally by the patient, or on behalf of the patient, by anyone other than an
agency of the Federal Government. Record the payer’s name. Enter only amounts received by the MSA as of the day
the notification is submitted. Promises to pay, arrangements for partial payments, or other transactions, such as transfer
of the account to the FAO, will not be reflected. If any amounts are received after the notification is submitted, a
corrected claim form (DA Form 2631) will be submitted.
(m) In 12e, Balance, enter the unpaid charges (12c minus 12d).
(2) Civilian source care.
(a) Item 13 includes any health care service obtained from a nonmilitary source. These include, but are not limited
to, emergent/urgent outpatient care provided to AD Soldiers and care obtained from civilian sources but paid for by an
MTF (such as care paid through the Supplemental Care Program).
(b) In 13a, enter type of care (outpatient, inpatient, ambulance, etc.).
(c) In 13b, enter name and address of provider/practitioner or source of care.
(d) In 13c, enter date(s) of care.
(e) In 13d, enter associated charge(s). If there are multiple civilian sources of care, an itemized list of charges may
be provided on an attached sheet of plain white bond paper. The itemized list must contain the patient’s name, rank,
and SSN, each provider/practitioner’s full name and address, the treatment date(s), and the applicable provider/
practitioner charge for each date(s) of treatment. The notation “See attached list” will be entered in block 13b and the
cumulative total of all charges noted on the list will be entered in block 13d of the DA Form 2631.
d. Consolidated statement of charges.
(1) When so requested by the RJA, the Army MTF will prepare a consolidated statement of charges. DA Form 3154
(or automated equivalent) will be used for this purpose. The information regarding all charges (military and civilian)
pertaining to the injury giving rise to the claim or expected litigation will be summarized. Totals will be entered in the
appropriate section of the DA Form 3154. When information is available that payment has been made by the Army to
civilian source(s), the amount paid by the Army will be entered in “Remarks” as follows: “Payment for care received
from civilian sources-see attached voucher(s).” The original and one copy of the DA Form 3154, used as required by
this paragraph, and with copies of supporting documentation, will be forwarded to the requesting RJA. The remaining
copies (3 and 4) will be conspicuously marked “USED FOR MEDICAL AFFIRMATIVE CLAIM BILLING ONLY”
and filed in the “Invoice Issued” file without being processed through the MSA.
(2) When it is apparent from the patient’s record that care was obtained at Army expense and information on the
value or cost of such care is not contained in the record, the MTF will obtain the necessary data regarding such care for
inclusion in the consolidated statement. MTFs will provide copies of the supporting documentation to the RJA upon
receipt.
84 AR 40–400 27 January 2010