va fee basis program claims address va fee basis program claims address

If a patient saw two different providers on the same date who use the same vendor for billing, it will not be possible to distinguish the two encounters. Paper claims and supporting documentation submitted to us are converted to Electronic Data Interchange (EDI) transactions. If you are in crisis or having thoughts of suicide, Fee Basis data files contain information regarding both the care the Veteran received and the reimbursement of the care. Fee Basis data can be broadly categorized into 4 classes: inpatient care, outpatient care, pharmacy, and travel data. However, 99% of inpatient hospital invoices were associated with a length of stay of 33 days or less. Veterans Health Administration. VA will arrange for transportation for them or will reimburse expenses on the basis of vouchers submitted. Persons looking to classify patients Veterans by race and ethnicity are encouraged to read VHA guidance available on the Data Reports page of the VHA Data Portal (available on the intranet at http://vaww.vhadataportal.med.va.gov/Resources/DataReports.aspx). There are no references identified for this entry. In SQL, there are additional variables that will denote the type and location of the care provided along with the vendor. [FeeInpatInvoice], [Fee]. Fee Basis data are housed in VA in both SAS dataset format and Microsoft SQL server tables (hereafter referred to as SQL data). VA Information Resource Center. If your claim was submitted to VA, call (877) 881-7618, If your claim was submitted to TriWest, call (877) 226-8749. These tables involve payments paid only through FBCS. Two domains in which researchers can find reports on Non-VA Care are Resource Management and Workload. This component provides a front end for scanning claim forms into a temporary image queue for a given patient. In both SAS and SQL, it can be difficult to determine the provider the Veteran saw for Fee Basis care. Please visit Emergency Care Claims to learn more. To enter and activate the submenu links, hit the down arrow. Our review of the data suggests that pharmacy and ancillary claims take longer to process than inpatient or outpatient claims. This rare event most likely indicates a transfer. U.S. Department of Veterans Affairs. However, one also needs to exercise caution with DRG; there are 2 different sets of DRGs used over time. On March 17, 2022, The U.S. Court of Appeals for the Federal Circuit issued a ruling that changes VAs ability to reimburse as secondary payer under 38 U.S.C.1725. This component is a service that communicates with an outside `Adjudication Engine` which scrubs claims data and sends back scrub results to the service via a secure Pretty Good Privacy (PGP) Secure Sockets Layer (SSL) web service connection. All instances of deployment using this technology should be reviewed to ensure compliance with. Community Care Network Region 5 (authorized), Office of Accountability & Whistleblower Protection, Training - Exposure - Experience (TEE) Tournament, Indian Health Service/Tribal Health Program, CHAMPVA In-house Treatment Initiative (CITI), Indian Health Services/Tribal Health/Urban Indian, Spina Bifida Health Care Benefits Program, Veterans Health Information Exchange Program, Durable Medical Equipment/ Pharmacy Requirements, War Related Illness & Injury Study Center, Clinical Trainees (Academic Affiliations), Medical Document Submission Requirements for Care Coordination, Azure Rights Management Services (Azure RMS), Call TTY if you [OEFOIFService]and [Dim].[POWLocation]. 1-800-273-8255 (Press 1), U.S. Department of Veterans Affairs | 810 Vermont Avenue, NW Washington DC 20420. Updated August 26, 2015. They do not represent all claims received during the year. The FeeSpecialtyCodeName contains information on the specialty of the provider seen, such as oncology, chiropractic, pathology, neurosurgery, etc., but is missing much data. SQL data must be linked from multiple tables in order to create an analysis dataset. The Fee Basis program or Non-VA Care is health care provided outside VA. NVCC Office coordinates services and payments for Veterans receiving non-VA care for emergent and non-emergent medical care. The Fee Basis files are stored in two formats: SAS and SQL. The following information should help you understand who to submit claims to and the requirements you must follow when submitting claims. 2. Chapter 6 provides information about how to access the Fee Basis data, while Chapter 7 provides information about the rules governing Fee Basis care. VA Informatics and Computing Resource Center (VINCI). It can be difficult to determine the provider and the location of the Non-VA care provider. National Non-VA Medical Care Program Office (NNPO). The veteran must wait over 30 days past their preferred appointment date or the date deemed medically necessary by their provider, b. The vendor and the provider may or may not be the same entities. 1. 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. 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. VHA Office of FinanceP.O. Federal law puts prosthetics into a special payment category that mandates full financial support from VA. As implemented in VA policy, it requires that VA facilities provide all necessary prosthetics, orthotics, and assistive devices (prosthetics) needed by patients. VA can waive the deductible in hardship cases. Please switch auto forms mode to off. 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). Some vendors use centralized billing services located in other cities, in a few cases in other states. VA's fee basis care program. HERC: Identifying Providers in VA Administrative Data - Veterans Affairs Smith MW, Chow A. Non-VA Medical Care (Fee Basis) Data: A Guide for Researchers. In most cases, if you don't sign up for Part B when you are first eligible, you'll have to pay a late enrollment penalty. YESElectronic Remittance (ERA)YESICD- 1. VAntage Point. To learn more, please visit the Provider Training section on the MES website . Summary Fee Basis expenditure data are also available through the VHA Support Services Center (VSSC) intranet site, further information about accessing these summary data can be found in Chapter 6. Accesed October 16, 2015. The data that is not available is the data element that indicates if it was generated by FBCS or manually entered by the user in FBCS. These variables relate to the VA station at which the Fee Basis care requests and claims are input. However, not all dates on the claim are approved. Before this time, data were entered by hand, and there was no easy way to tell whether the claim being entered was a duplicate one. Chief Business Office. Most, if not all, of this care should be emergency care. In this chapter, we discuss general aspects of Fee Basis data. 4. Therefore, it is not possible to do an exact comparison across the datasets. Submit a claim void when you need to cancel a claim already submitted and processed. When a claim is linked to VistA, the variable Other_Hlth_ins_present is populated. Thus, researchers using later years of data should be aware that files are not static and will continue to be updated. Accessed October 07, 2015. For additional information or assistance regarding Section 508, please contact the Section 508 Office at Section508@va.gov. Some Fee Basis data will also appear in the non-VA medical SAS inpatient file (formerly called the Patient Treatment File). There are also differences in the variables contained in the SAS versus SQL data. Hospice also appears to be billed monthly, with longest length of stay for a single hospice invoice of 31 days. All persons working with these data should review this information before conducting any analyses. There are nine situations in which Non-VA Medical Care is authorized. Claims for Non-VA Emergency Care Optum is a proud partner with the VA through its Community Care Network (CCN). If that analyst examines VEN13N and STA6A (in inpatient Fee Basis data, this field represents the VA hospital arranging care), there is often only one MDCAREID. VA Informatics and Computing Resource Center (VINCI). The Medicare Ambulance Fee Schedule consists of a base rate plus mileage. Compare the discharge date of the first observation to the admission date of the next (second) observation. Many variables in the Fee Basis files record details of invoice and check processing. The travel payments data contains reimbursements for particular travel events (TVLAMT). Table 1 in the Data Quality Analysis teams guide Linking Patient Data in the CDW Updateprovides a brief summary for each identifier (Available atthe VHA Data Portal. You can submit a corrected claim or void (cancel) a claim you have already submitted to VA for processing, either electronically or in paper. At the time of writing (October 2015), only operations staff will have permission to access the SAS data at VINCI. This improves claim accuracy and reduces the amount of time it takes for us to process claim determinations. There are 3 categories of geographic data: veteran-related information, vendor-related information and VA-station related information. All SAS variables are denoted in capital letters, while SQL fields are denoted without spaces, in accordance with how these fields are labeled in the SQL tables. This application is directly attached to TWAIN compliant scanners and works offline to VistA and the FBCS MS SQL databases. To access the menus on this page please perform the following steps. At the time of writing, no National Institute of Standards and Technology (NIST) vulnerabilities had been reported and no VA Cyber Security Operations Center (CSOC) bulletins had been issued for the latest versions of this technology. At the time of writing, SAS data at CDW are available only to those persons with VA operations access. If disbursed amount is missing (but not $0), use payment amount instead. Previously, VA could reimburse Veterans or pay non-VA hospitals directly only if a Veteran has no other health insurance. Claims for Non-VA Emergency Care Hit enter to expand a main menu option (Health, Benefits, etc). [FeePharmacyInvoice] and the [Fee]. 9.2. In both SAS and SQL data, outpatient data are organized in long format, with one record per CPT code. Data Quality Program. In this way, records that are missing MDCAREID can be given a MDCAREID based on the value of VEN13N and STA6A in the record. In the SAS data, the patient identifier is the scrambled social security number (SCRSSN). visit VeteransCrisisLine.net for more resources. If it cannot be located in the PTF Main file or DSS NDE for inpatient care, search other inpatient files. However, there are some outliers; some claims can take up to 8 years to process. Through patient identifier and travel date (TravelPaymentDate), one can link these payments to inpatient and outpatient encounters. SQL tables can be joined through linking keys. Accessed October 27, 2015. Primary keys are denoted by (PK) and foreign keys are denoted by (FK). This act expands the non-VA care veterans were able to receive before the act was passed. Veterans Crisis Line: One can use the FeeInitialTreatmentSID variable in the FeeServiceProvided table to link to the Fee.FeeInitialTreatment table. Complete and accurate standard Center for Medicare & Medicaid Services (CMS) or electronic transaction containing false claims notice (such as CMS 1450, CMS 1500 or 837 EDI transaction). Veterans should mail or fax correspondence pertaining to compensation claims to the below location. The vendor identity can be found through the VENDID or VEN13N variables in SAS. However, there is one situation in which the payment amount will be more accurate than the disbursed amount: when the disbursed amount is missing, and the payment was not cancelled, one should use the payment amount to capture the cost of care. Smith MW, Su P, Phibbs CS. VA intranet only: http://vaww.vhadataportal.med.va.gov/Resources/DataReports.aspx). VSSC web reports are organized into nine domains: Business Operations, Capital & Planning, Clinical Care, Customer Service, Quality & Performance, Resource Management, Special Focus, Systems Redesign, and Workload. VA is the primary and sole payer when VA issues an authorization. Available at: http://www.va.gov/opa/choiceact/documents/FactSheets/Veterans_Choice_Program_Eligibility_Details_August_1_Removal.pdf.. 3. There is another category of Fee Basis care that is considered unauthorized care. Note: A Veterans insurance coverage or lack of insurance coverage does not determine their eligibility for treatment at a VA health care facility. The Fee Purpose of Visit Code (FPOV) has strong guidance from VA Fee Basis Office and thus may be a more accurate way of categorizing care. Domains generally indicate the application in the VistA electronic health record system from which most of the data elements come (e.g., Vital Signs or Mental Health Assessment).6. For these reasons, VA strongly encourages Veterans to consider important factors, risks and benefits before making any changes to their private health insurance. Accessed October 16, 2015. The codes for the procedures provided for a given hospital stay are kept in a separate table, a table of procedures. Multiple claims may be submitted for each inpatient stay and the various claims do not have a common identifier indicating they are all part of the same inpatient stay. Florida Department of Veterans' Affairs | Connecting veterans to With additional permissions, researchers can also access City, Postal Code, Street Address, and Zip. The SQL prescription data are housed in the [Fee]. Veterans Health Administration. Through patient ID (SCRSSN) and travel date (TVLDTE) one can link these payments to inpatient and outpatient encounters. 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). U.S. Department of Veterans Affairs. Data from FY1998 and FY1999 have a greater degree of discordance. Veterans Affairs (VA) users must ensure VA sensitive data is properly protected in compliance with all VA regulations. Some missingness may indicate not applicable.. Please visit Provider Education and Training for upcoming events. To enter and activate the submenu links, hit the down arrow. 5. To enter and activate the submenu links, hit the down arrow. NOTE: The processes outlined below are exclusive to supplying documentation for unauthorized emergent care. privacy policies and guidelines. A claim void must be identical to the original claim that it is intended to cancel. Additional information on accessing the AITC mainframe is available on the VHA Data Portal (VA intranet only: http://vaww.vhadataportal.med.va.gov/Home.aspx). This guidebook is intended to help researchers understand and use the National Fee Basis files, which come in both SQL and SAS formats. The data files in each fiscal year represent all claims processed in the FMS during the year. Menlo Park, CA. File a Claim-Information for Veterans - Community Care - Veterans Affairs In order to qualify for round trip mileage, an appointment must be scheduled. Non-VA CareP.O. Before working with any SQL tables in CDW, we recommended familiarizing yourself with the schema diagram in order to understand how to link tables to one another. The electronic 275 transaction process may be utilized to supply Remittance Advice documentation for timely filing purposes. Each patient should have only one ICN in the entire VA, regardless of the number of facilities at which he is seen. [Spatient], and [Spatient]. For current information on Community Care data, please visit the page. In the SAS data prior to FY 2007, the disbursed amount (DISAMT) had an implied decimal point whereas the payment amount (AMOUNT) did not. Community providers should remain in contact with the referring VA Medical Center to ensure proper care coordination. HIPAA Transaction Standard Companion Guide (275 TR3)The purpose of this companion guide is to assist in development and deployment of applications transmitting health care claim attachments intending to support health care claim payment and processing by VA community care health care programs. Available at: http://www.mssny.org/Documents/Enews/Aug%208%202014/VA%20ProvidersGuide.pdf, 6. The SAS data are stored at AITC. Again, date of service is not available in the FeeServiceProvided table. SAS and SQL data are very similar, but not exact copies of each other. 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. 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. Access; upload; download; change; or delete information on this system; Otherwise misuse this system are strictly prohibited. Accessed October 16, 2015. SAS Fee Basis data can be linked to other SAS files with additional demographic data (e.g., Vital Status files, enrollment files). Additionally, we found 0.94% of records were approved Choice claims (e.g., records where SPECIALPROVCAT= CHOICE and STATUS= A (approved)). If you submit a noncompliant claim and/or record, you will receive a letter from us that includes the rejection code and reason for rejection. For care received under the Choice Act, Veterans will work with the third party administrators of the Choice program to find an eligible provider in their area.4. PDF Frequently Asked Questions for Providers - Logistics Health The travel payment data contains reimbursements for particular travel events (TravelAmount). Class 2 or Class 3 products must restrict their interfaces to Class 1 National Software to use of publicly-supported APIs ONLY. [FeeServiceProvided], [Fee]. All access or use constitutes understanding and acceptance that there is no reasonable The majority of claims, 99%, were processed within 2 years, with the exception of pharmacy data in FY 2004 and FY2008. Information from this system resides on and transmits through computer systems and networks funded by the VA. Available at: http://www.blogs.va.gov/VAntage/23201/va-implements-the-first-of-several-veterans-choice-program-eligibility-expansions/. 10. 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. 6. For more detailed information, researchers should visit the VHA Office of Community Care website. One way to do this is to concatenate the vendor identifier, the patient identifier, and the visit date. More information on the proper use of the TRM can be found on the Contact the VA North Texas Health Care System. Persons who wish to access data in the secure tables on CDW (denoted by a S prefix) must complete a Real SSN Access Request Form. This form must be signed by the IRB and Associate Chief of Staff for Research and submitted with the DART data request. However, there are data available regarding the category of visit. [FeeServiceProvided] table. [FeeVendor] table. Note that some physicians use the same ID number as the hospital. [Patient], [SPatient]. In both SQL and SAS data, there is also a variable regarding the fee specialty code. It is the patient identifier that uniquely defines a patient across all facilities. Non-emergency care must be approved before the Veteran seeks care in the community.3 For traditional Non-VA care, a Veterans VA provider will submit a request at the local VA facility for Veteran care provided by Fee Basis. You will have to pay this penalty for as long as you have Part B. *From the date the Veteran was discharged from the facility that furnished the emergency treatment; the date of death, but only if the death occurred during transportation to a facility for emergency treatment or if the death occurred during the stay in the facility that included the provision of the emergency treatment; or the date the Veteran exhausted, without success, action to obtain payment or reimbursement for treatment from a third party. Researchers will need to decide whether they will use the SAS or the SQL data and apply for appropriate IRB approval for use. Prior to the passage of this law on May 1, 2010, VA did not cover the cost of health care provided to dependent children, including newborns in situations where VA pays for the mothers obstetric care during the same stay. There is no separate payment for items such as oxygen or other supplies, the number of attendants, providing an EKG during the trip, etc. A primary key is a key that is unique for each record. 866-505-7263, Veterans Crisis Line: SQL data are housed at CDW, which is a collection of many servers. VA contracts out its hospice; therefore, the Fee Basis files contain a great deal of data related to hospice care. Consult the latest CDW schematic diagrams to understand the tables in which your variables of interest are housed and the primary key and foreign keys needed to link each pair of tables. PatientIEN is assigned by the facility. DART is a workflow application that guides users through the request by collecting the appropriate documents, distributing documentation to reviewers, and assisting in communication between requestors and reviewers. PDF Office of Inspector General - Oversight.gov VA Health Care: Management and Oversight of Fee Basis Care Need First, it includes both the payment amount and any interest that may apply. SQL Fee data are available through the VA Corporate Data Warehouse (CDW)/VA Informatics and Computing Infrastructure (VINCI). Training - Exposure - Experience (TEE) Tournament, Observational Medical Outcomes Partnership (OMOP), Personnel & Accounting Integrated System (PAID), Decision Analysis: Decision Trees, Simulation Models, Sensitivity Analyses, Measuring the Cost of a Program or Practice: Microcosting, List of VA Economists and Researchers with Health Economic Interests. access; blocking; tracking; disclosing to authorized personnel; or any other authorized The vendor no longer supports VA installations of this technology. Dental claims must be filed via 837 EDI transaction or using the most current. This Technology is currently being evaluated, reviewed, and tested in controlled environments. Such care is called Non-VA Medical Care, or Fee Basis care. If notification was not made to VA and you wish to have claims considered for payment, please submit claims and supporting documentation to VA as listed in the "Where to Send Claims" dropdown below. We believe that payments are then made from the claim data available from the Claims Reconciliation and Auditing: Program Integrity Tool (PIT) with lump sum/expedited payments being made on a weekly basis and retrospective review, as well as recoupment efforts for overpayments/duplicates. The amount claimed (PAMTCL) appears in the inpatient (INPT) file alone; there is no claimed amount on the outpatient side. (refer to the Category tab under Runtime Dependencies), Veterans Affairs (VA) users must ensure VA sensitive data is properly protected in compliance with all VA regulations. Health plans include private health insurance, Medicare, Medicaid, and other forms of insurance that will pay for medical treatment arising from the patients injury or illness (e.g., automobile insurance following a car accident). Veteran's ICN can be found on the VA issued HSRM referral. There is also a host of non-emergency surgery provided through Fee Basis mechanisms that may be of interest to researchers. Thus, in SQL the total cost of an inpatient stay would be determined by evaluating the DisbursedAmount in the [Fee]. [FeePrescription] tables. Records that relate PatientSID to PatientICN are found two tables: Patient.Patient and SPatient.Spatient. 3. [LocalDrug] table through LocalDrugSID to see whether there was the generic equivalent found in the VA drug file that was dispensed to the patient. Benefits Delivery at Discharge - Pre-Discharge - Veterans Affairs The Veteran files contain the richest patient demographic information in the SAS data; these include the Veterans date of birth, sex, prisoner of war status and war code. Please see Section 2.1.4. for HERC advice about how to collapse multiple observations to evaluate the length and cost of a single inpatient stay. While many Veterans qualify for free health care services based on a VA compensable service-connected condition or other qualifying factor, most Veterans are asked to complete an annual financial assessment, to determine if they qualify for free services. 3. ____________________________________________________________________________. Austin Information Technology Center (AITC) is one of the VAs five national data centers. Fee Purpose of Visit (FPOV) Document [online; VA intranet only]. We therefore use the PROC CONTENTS to describe SAS variables, found in Appendix A. SAS data use patient scrambled social security number (SCRSSN) as the patient identifier. For EDI 837, Referral Number is Loop = 2300, Segment = REF*9F, Position = REF02 or Prior Authorization. Identify Choice records by using tax ID and specialprovcat= CHOICE. We present here one way to collapse records into a single inpatient stay, but users may wish to develop their own method specific to the research question at hand. 16. Each year represents the year in which the claim was processed, not the year in which the service was rendered. As with the SAS data, the important variables in the SQL data are the AmountPaid and the DisbursedAmount. There is a CPT field in the inpatient files, but this is always missing; hospitals do not use CPT codes to bill. Attention A T users. and constitutes unconditional consent to review and action including (but not limited The procedure code table has just as many records as there were procedures on the invoice. The key that allows for this linkage is the FeeInpatInvoiceSID which is a primary key in the [Fee]. This guidebook describes characteristics of Fee Basis care data such as contents and missingness, and makes recommendations about its use for research purposes. The quantity dispensed. All observations for this particular patient ID, STA3N and VEN13N where the admission date comes on or after the admission date of the first record AND the discharge date comes on or before the temporary end date are considered to be part of the same inpatient stay. visit VeteransCrisisLine.net for more resources. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links. TriWest VA CCN ClaimsP.O. 3. Veterans Choice Program - Fee Basis Claims System in CDW - Veterans Affairs We encourage readers to seek out the latest guidance before conducting analyses, as CDW Data Quality Analysis team may have updates to this information. VINCI. As with inpatient data, researchers will need to collapse multiple observations in order to get a complete picture of the outpatient care provided on a single day. It is available in the PHARVEN and VEN files, albeit with a high degree of missingness. Hit enter to expand a main menu option (Health, Benefits, etc). Medication dosage/strength. Driving distance between a veterans residence and their closest VA facility is over 40 miles, c. The veteran must travel by boat or plane to access the VA facility closest to their home (excluding Guam, American Samoa, or the Republic of the Philippines), d. The veteran faces an excessive burden in traveling to a VA, including a body of water or geologic formation that cannot be crossed by road. Every one of the 700,000 health care professionals in the TriWest network has to meet VA-required quality standards to ensure that Veterans always receive the highest quality care. Medical specialty type (SPECCODE) is a provider-specific variable and indicates the specialty type of the provider rendering the service. DSS Fee Basis Claims Systems (FBCS) - DigitalVA