va fee basis program claims address
As of April 2019, this guidebook is no longer being updated. Passed in 2014 with bipartisan support in Congress, its purpose is to increase Veterans access to health care.1 The Choice Act allows Veterans to receive health care through non-VA providers in the community if they are unable to schedule an appointment at their local VA within 30 days or by a date determined by their provider (wait-time goals), if they reside over 40 miles from a VA facility, or if they face an unusual or excessive burden in travelling to a VA facility.2 Under the Choice Act, ten ($10) billion dollars has been allocated towards Non-VA Medical Care for eligible Veterans through 2017.1 The Fee Basis files contain data for care received through the Choice Act, but in this guide, we do not distinguish for care provided under the Non-VA Medical Care program and that provided under the Choice Act. VA Informatics and Computing Resource Center (VINCI). There are two important variables to consider if evaluating the cost (VA reimbursement) of Fee Basis Care: the payment amount (AMOUNT in SAS, PaidAmount in SQL) or the Financial Management System (FMS) disbursed amount (DISAMT in SAS, DisbursedAmount in SQL). FSGLI: Family Servicemembers Group Life Insurance, Schedule of Payments for Traumatic Losses, S-DVI: Service-Disabled Veterans Life Insurance, Beneficiary Financial Counseling and Online Will, Lesbian Gay, Bisexual & Transgender Veterans, Pension Management Center (PMC) that serves your state, Claims Adjudication Procedures Manual/Live Manual, Link to subscribe to receive email notice of changes to the Live Manual. Documentation, including data contents, field frequencies, and record counts, is also available on VIReCs CDW Data Documentation page (VA intranet only: http://vaww.virec.research.va.gov/CDW/Documentation.htm). The zip code accompanying the VEN13 variable denotes the zip code to which VA sent reimbursement, not the zip code where the service was rendered. VA regulations 38 CFR 17.1000-17.1008. We gratefully acknowledge comments and contributions from Sharon Dally, Susan Schmitt and Paul Barnett. The data files in each fiscal year represent all claims processed in the FMS during the year. VINCI Data Description: Dimension [online; VA intranet only]. Payer ID: 1. A claim without errors or omissions is said to be clean. If VA has authority to pay the claim and the submitted documentation is sufficient then the claim is approved for payment. VA contracts out its hospice; therefore, the Fee Basis files contain a great deal of data related to hospice care. FPOV values of 32 and 33 also indicate ED visits, but are only observed in the Ancillary file. However, 99% of inpatient hospital invoices were associated with a length of stay of 33 days or less. The OI&T Enterprise Program Management Office does not endorse nor support Class 2 and Class 3 products and does not support data usage or application programmer interfaces (APIs) between Class 1 National Software products and Class 2 or Class 3 products. A claims scrubber software program is run to ensure completeness and to locate possible errors. All SAS prescription-related data is found in two files: the PHR file and the PHARMVEN file. Thus, one could not simply use the patient identifier and the admission and discharge dates to collapse these observations into one inpatient stay. Box 14830Albany, NY 12212. Some Fee Basis data will also appear in the non-VA medical SAS inpatient file (formerly called the Patient Treatment File). 9.2. The travel payments data contains reimbursements for particular travel events (TVLAMT). Facility charges vs. ancillary charges: There are instances when there may be claims for facility charges with no corresponding ancillary provider charge. Note: records with status= R can have missing values for the variables vistapatkey and vistaauthkey, depending on whether or not these were linked before rejecting as a re-route to HAC. Review the Supporting Documentation section below to learn how to properly submit supporting documentation with your claim. Detailed information about accessing each of these data sources is available at the VHA Data Portal (VA intranet only: http://vaww.vhadataportal.med.va.gov).See Table 10 for a summary of the data sources. When possible, VA will seek reimbursement for Non-VA Medical Care payments from sources such as workers compensation payments; payments resulting from motor vehicle accidents, crimes of personal violence, or torts; other agencies when the patient is a beneficiary; and third-party insurance plans. Most of these fields would be empty. Fee Basis data will be most useful for studying conditions where contract care is common, such as home-based care and nursing care, and for determining typical non-VA charges for health care services (both charges and payments are reported) and comparing those to VA costs. If the VA Fee Schedule does not include a rate for the covered service provided, reimbursement will be made at 100% of customary charges, as defined in the provider's VA CCN Payment Appendix. The Caregivers and Veterans Omnibus Health Services Act of 2010 (Public Law 111-163) authorizes VA to provide post-delivery and routine care to a newborn child of qualifying women Veterans receiving VA maternity care for up to seven days following the birth. FBCS is an auditing system which provides instructional prompts designed to interface with the Veterans Information Systems and Technology Architecture (VistA) package to track, report, and analyze fee claim data. ____________________________________________________________________________. In SAS, the outpatient data are housed in the MED files. Below we describe the general types of information in both the SAS and SQL data. Fact Sheet: Medical Document Submission Requirements for Care Coordination, ADA Dental Claim Form > American Dental Association website. In the SAS data, the patient identifier is the scrambled social security number (SCRSSN). Therefore, it is not possible to do an exact comparison across the datasets. This application completes the update of critical claims data into the FBCS shared MS SQL database for further processing and reporting. However, investigation has confirmed these are partial payments made for a single encounter or procedure. U.S. Department of Veterans Affairs. This application queues critical claims data into the FBCS shared MS SQL database for further processing and reporting. visit VeteransCrisisLine.net for more resources. Hit enter to expand a main menu option (Health, Benefits, etc). This is helpful in determining the location of care in inpatient claims in which MDCAREID is missing, and in outpatient claims for hospital-provided services. [FeeInpatInvoiceICDDiagnosis], [Dim]. We continue on this process until we find a gap greater than 1 day or we have evaluated all observations with that patient ID, STA3N and VEN13N. If electronic capability isnot available, providers can submit claims by mail or secure fax. visit VeteransCrisisLine.net for more resources. The FMS disbursed amount is the payment amount plus any interest payment. In the SAS data, the provider component of the inpatient stay is captured in the ancillary file. Second, there are some cases where the disbursed amount is $0, while the payment amount is greater than $0; these are cases in which the payment was cancelled and the true cost of care is thus $0. You can find more information about eligibility on the VHA Office of Community Care website. VA must be capable of linking submitted supporting documentation to a corresponding claim. The Non-VA Payment Methodology Matrix, prepared by the National Non-VA Medical Care Program Office (now the VHA Office of Community Care), presents guidelines for preauthorized care and emergency care for service and non-service connected conditions for both inpatient and outpatient care.17 VA will reimburse the same non-VA provider a different rate depending on whether the Veteran received: a) pre-authorized care; b) emergency care for a service-connected condition; or c) emergency care for non-service connected conditions and non-service connected Veterans. From there, it is sent weekly to AITC in SAS format and nightly to CDW in SQL format. This seeming complicated arrangement is an efficient way to store data. There is another category of Fee Basis care that is considered unauthorized care. There is no official data dictionary for the SAS Fee Basis data. For example, if the Veteran had an Emergency Department (ED) visit and then was admitted to the hospital, this would be considered inpatient care. With the exception of supplying remittance advice supporting documentation for timely filing purposes, these processes do not apply to authorized care. If FIPS 140-2 encryption at the application level is not technically possible, FIPS 140-2 compliant full disk encryption (FOE) must be implemented on the hard drive where the DBMS resides. There may be many providers that use the same vendor for billing. Mark Smith and Adam Chow were the authors of the original HERC guidebook, upon which this document builds. For more information call 1-800-396-7929. Veterans applying for and using VA medical care must provide their health insurance information, including coverage provided under policies of their spouses. Journal of Rehabilitation Research and Development. The amount claimed (PAMTCL) appears in the inpatient (INPT) file alone; there is no claimed amount on the outpatient side. When a claim has reached terminal status (A, P, D, R), the field ImportedDTStamp on the UB-92/HCFA tables represents the date it was processed. This application reads/creates/edits fee payment data in VistA and copies critical information into the central SQL database for off-line VistA applications to consume, and now includes Unauthorized payments. For example, there could be many NPIs associated with a VEN13N (e.g., a hospital employing multiple providers), or many VEN13Ns for a single provider (e.g., a surgeon with privileges at multiple hospitals). For a list of VA acronyms, please visit the VA AcronymLookup on the VA intranet at http://vaww.va.gov/Acronyms/fulllist.cfm. Chapter 8 provides references for further information about the Fee Basis program and data. To link an authorization to a claim, use the trifecta of what VistA would consider sta3n, PatientIEN, and AuthorizationIEN. These clams contain charges and are known as claimed amounts (PAMTCL in SAS, ClaimedAmount in SQL). VA Technical Reference Model v 23.2 DSS Fee Basis Claims Systems (FBCS) General Decision Reference Component Category Analysis General Information Technologies must be operated and maintained in accordance with Federal and Department security and privacy policies and guidelines. For example, if one wishes to evaluate the cost of certain diagnoses in inpatient care through SQL data, this would require the linking of multiple tables before being able to conduct any analyses such as [Fee]. Private health insurance coverage through a Veteran or Veteran's spouse is insurance provided by an employer, Veteran or other non-federal source, including Medicare . We are grateful for their cogent work. VA HEALTH CARE Management and Oversight of Fee Basis Care Need. Accesed October 16, 2015. (2) Additionally, a Veteran must also meet at least one of the following criteria. Prescription-related data in the PHARVEN file contain only summary payments by month. Table 3 lists their file names and gives a general description of their contents.10. This means the data were placed in the PIT and the claim was not paid through FBCS. To file a claim for services authorized by VA, follow instructions included in the Submitting Claims section of the referral. If the patient was transported to a VA hospital after stabilization (as indicated by the DISTYP, or disposition type, variable), the record of the VA stay should appear in VA utilization databases. Most commonly, authorized care refers to medical or dental care that was approved and arranged by VA to be completed in the community. Identifying Veterans in the CDW [online; VA intranet only]. Care provided to persons associated with a particular VA station can be found by selecting records by STA3N. However, in all data files, the vast majority of observations are missing values for this variable. The same concept (such as fiscal year, state, or county) may be represented by several variables, sometimes in differing formats. Appendix E includes a list of SQL fields related to the type of care a patient receives. Researchers will notice a high degree of concordance between SAS and SQL data in most years of analysis. Mail to: DEPARTMENT OF VETERANS AFFAIRS. Of note, the FBCS was not in place nationwide prior to FY 2008. This application is directly attached to TWAIN compliant scanners and works offline to VistA and the FBCS MS SQL databases. and constitutes unconditional consent to review and action including (but not limited For inpatient and outpatient care, in general, VA will pay the lesser of the Medicare rate (or MPFS rate) or the billed charges. This amounts to approximately 1.7 million claims processed per month and approximately $5-8 billion per year. SAS and SQL data are organized differently and contain different variables. Researchers evaluating care over time may want to use the DRG variable. Community providers should remain in contact with the referring VA Medical Center to ensure proper care coordination. The VHA Office of Community Care is the contact for all VA community care programs. The payment amount variables (AMOUNT and DISAMT) are missing (blank) in a small number of cases. There are multiple potential identifiers for provider/vendor in the SAS data: the VENDID, VEN13N, MDCAREID, SPECCODE and NPI. When evaluating the cost of care, use the disbursed amount. SAS data are also available in CDW, but are currently limited to those VA employees with operational access. For education claims, refer to the appropriate Regional Processing Office. For the inpatient data, we compared observations with the same patient identifier, based on PaidDate in SQL and TRANSDAT in SAS. Pre-2007, DISAMT and INTAMT each have two implied decimal places a value of 1000 would indicate $10.00. Patient type can take one of seven values: surgical; medical; home nursing; psych contract; psychiatric, neuro contract; or neurological. Of note, SQL and SAS data contain similar, but not exactly the same, information. Prosthetic items. The Fee Basis files primary purpose is to record VA payments to non-VA providers. Any variable that has an S prefix indicates secure data and requires special permission to access; researchers should be aware of this when submitting their IRB applications and their CDW DART data access requests. Once the process is exhausted for a particular patient, STA3N and VEN13N combination, we calculate length of stay as the difference between the admission date of the first record and the temporary end date.. Users of the data should keep in mind that these data represent the physical location of the entity billing for care, which may or may not be the same as the providers location. In the outpatient data, one observation represents a single CPT code. In this table, some ancillary data are associated with an inpatient FPOV code but have an outpatient FeeProgramProvided field. There may be multiple STA3Ns for a single inpatient stay. U.S. Department of Veterans Affairs. We view the patients insurance data in the VistA file if the claim is flagged as reimbursable in VistA and encompasses the dates on the claim. Researchers wishing to work with SAS Fee Basis data can access them at the Austin Information Technology Center (AITC). The Fee Purpose of Visit (FPOV) and Health Care Financing Agency Payment Type (HCFATYPE) variables feature values pertaining to setting (inpatient, outpatient, home-based), specific items (e.g., supplies and diagnostics), and miscellaneous purposes.[1]. HERC did not investigate use of NPI for this guidebook. We found SPECIALPROVCAT was missing in 93% of records. Eligibility and claims submission information for emergent care will be provided after notification is made to the VA. Claims for emergent care not eligible for authorization upon notification, may be eligible for consideration as Unauthorized Care. This component distributes fee workload to particular users using the FBCS MS SQL database and the VistA Gateway. In SAS data, there is also a primary service area variable (HOMEPSA) that indicates the station to which the Veterans residence is assigned based on geography. Another approach is to search other fee claims submitted by the same vendor to see if a Medicare hospital ID was assigned to those claims. Outpatient prescriptions beyond a 10-day supply. Use Azure Rights Management Services (Azure RMS) for encrypted email. If you are in crisis or having thoughts of suicide, Users interested in learning the rules in force at a particular point in time should contact the VHA Office of Community Care. have hearing loss. 1-800-273-8255 (Press 1), U.S. Department of Veterans Affairs | 810 Vermont Avenue, NW Washington DC 20420. To access the menus on this page please perform the following steps. National Non-VA Medical Care Program Office (NNPO). The process for filing a claim for services rendered to a Veteran in the community varies depending upon whether or not the services were referred by VA and by the entity through which the services were authorizedVA or one of the VA Third Party Administrators (TriWest Healthcare Alliance or Optum United Health Care). The VA Fee Basis medical program provides payment authorization for eligible Veterans to obtain routine medical treatment services through non-VA health care providers. See the FBCS page (CDW Raw) on the CDW SharePoint site (VA intranet only: https://vaww.cdw.va.gov/bisl/Database/SitePages/Raw%20Extractor.aspx) for more information. Money collected by VA from private health insurance carriers is returned back to the VA medical center providing the care. Many veterans now have access to Non-VA medical care through the new Veterans Access, Choice, and Accountability Act (VACAA, or Choice Act). When a claim is linked to VistA, the variable Other_Hlth_ins_present is populated. Fee Purpose of Visit is the recommended way to evaluate the category of the visit. Non-VA Payment Methodology Matrix [online; VA intranet only]. Medications dispensed in a health care facility such as a doctor's office, dialysis clinic, or hospital outpatient clinic, such as injectable medications or infusions, will be found in the outpatient data, where they will be identified by CPT code.
