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Please switch auto forms mode to off. It can be difficult to identify the specific type of provider associated with Fee Basis care in the currently available national extracts of Fee Basis data. Relational Database Management Systems (RDBMS) such as Microsoft SQL server have multiple hierarchies for storing data: a domain contains many schemas, which in turn contain many tables. This technology integrates with Veterans Information Systems and Technology Architecture (VistA) through Massachusetts General Hospital Utility Multi-Programming System (MUMPS) or a Structured Query Language (SQL) database system on the backend. Emergent care patient liabilities not tied to copayments or deductibles will continue to be considered for secondary payment by VA. For additional questions, contact VA by phone, tollfree, at (877) 881-7618. 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. The following information should help you understand who to submit claims to and the requirements you must follow when submitting claims. If the Veteran has insurance, VA cannot pay even when the entire claim is less than the deductible. Non-VA providers submit claims for reimbursement to VA. The quantity dispensed. Missing values of PAYCAT could be imputed by finding the corresponding inpatient stay in the INPT file. This component communicates with the FBCS MS SQL and VistA database in real time. The key that allows for this linkage is the FeeInpatInvoiceSID which is a primary key in the [Fee]. The deadline for claims submission is dependent upon which program the care has been authorized through or which program the emergency care will be considered under. - The information contained on this page is accurate as of the Decision Date (11/02/2022). As noted above, there are differences in the patient identifier and the date variables in the SAS versus SQL data; both data sources do not contain the same variables regarding patient identifier or date the claim was paid. Attention A T users. The same cannot be said for DX2-DX25, however, as additional diagnosis codes are optional. It is only relevant for claims linked to VistA patients. 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. SAS and SQL also have several geographic fields related to the vendor providing the non-VA care, such as the vendors city, county, state and zip code. For example, accessing FY2014 data on Dec 1, 2014 will likely result in fewer observations than when accessing FY 2014 data on Dec 1, 2015. SQL tables can be joined through linking keys. For authorized care, the referral number listed on the Billing and Other Referral Information form. Box 537007Sacramento CA 95853-7007, CCN Region 5(Kodiak, Alaska, only)Submit to TriWest. Patient type can take one of seven values: surgical; medical; home nursing; psych contract; psychiatric, neuro contract; or neurological. The prescription must be for a service-connected condition or must otherwise have specific approval. If you are in crisis or having thoughts of suicide, 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 is specific to certain claims for Non-Service Connected emergency medical care under Title 38 USC 1725. Unlike the other patient identifiers in SQL such as PatientIEN or PatientSID, PatientICN is supposed to be unique to each patient across VA. A description of the Patient and SPatient schema is available on the VIReC CDW Documentation webpage: http://vaww.virec.research.va.gov/CDW/Documentation.htm (intranet only). For the inpatient data, we compared observations with the same patient identifier, based on PaidDate in SQL and TRANSDAT in SAS. Claims for Non-VA Emergency Care Please switch auto forms mode to off. 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. However, the VA may pay a rate higher than the Medicare Fee Schedule rate for care provided in highly rural areas, as long as this rate is determined to be fair and reasonable by VA. One can find more information on payment rates under the Veterans Choice Act in federal regulation 17.1500. the rates paid by the United States to Medicare providers). The Department of Veterans Affairs has implemented centralized mail processing (CM) for compensation claims to reduce incoming paper handling and shipping requirements. For current information on Community Care data, please visit the page. Each VA facility has a local Fee Office to which the non-VA provider submits a claim for reimbursement. FBCS is moving to a centralized system in the near future, where there will be centralized rules and national policies with 3 distinct groups: CCN (network), CCRA (authorization), and CCRS (reimbursement system; an IBM product). VA payment constitutes payment in full. 6. Community provider mails the paper claims and documentation to the new mailing address of VA's central claims intake location. There are also variables pertaining to Veteran geographic information, particularly ZIP, HOMECNTY and HOMESTATE in the SAS data and County, Country, Province, and State in the SQL data. U.S. Department of Veterans Affairs. U.S. Department of Veterans Affairs. FPOV values of 32 and 33 also indicate ED visits, but are only observed in the Ancillary file. Beware of VISNS 4, 15, and 23, as they have their own integrated system. The slight decrease in fiscal year 2012 spending from the fiscal year 2011 level was due to VA's adoption of Medicare rates as its primary payment method for fee basis providers. There are very limited data in both the SAS and the SQL Fee Basis data regarding the provider associated with care; the closest one can get to this information is to denote the vendor associated with the encounter (detailed more in sections 4.11 and 5.10). 10. SQL Fee Basis data are stored in CDW in multiple individual tables. You may use VA Form 10-583 to fulfill this requirement. To access the menus on this page please perform the following steps. [FeeServiceProvided] tables. Please review the Where To Send Claims and the Where To Send Documentation sections below for mailing addresses and Electronic Data Interchange (EDI) details. See 38 USC 1725 and 1728.). This act expands the non-VA care veterans were able to receive before the act was passed. Researchers and analysts will have to take care to collapse observations properly if warranted, for example to determine the costs, procedures or diagnosis associated with a single stay or visit. In SAS, these data can be found in the Vendor file. Veterans applying for and using VA medical care must provide their health insurance information, including coverage provided under policies of their spouses. If your claim was submitted to VA, call (877) 881-7618, If your claim was submitted to TriWest, call (877) 226-8749. Per the May 5th, 2015 memorandum from the VA Chief Information Security Officer (CISO) FIPS 140-2 Validate Full Disk Encryption (FOE) for Data at Rest in Database Management Systems (DBMS) and in accordance with Federal requirements and VA policy, database management must use Federal Information Processing Standards (FIPS) 140-2 compliant encryption to protect the confidentiality and integrity of VA information at rest at the application level. U.S. Department of Veterans Affairs. For Through patient ID (SCRSSN) and travel date (TVLDTE) one can link these payments to inpatient and outpatient encounters. Given these delays in processing claims, we recommend that analyses use Fee Basis data from 2 years prior to the current date to ensure almost complete capture of inpatient, ancillary and outpatient data. 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. The Implementer of this technology has the responsibility to ensure the version deployed is 508-compliant. UB-92 box 56 (ProviderNPI) represents the providers National Provider Identifier. Accessed October 16, 2015. PatientIEN is assigned by the facility. The SAS PHARVEN dataset contains information only about pharmacy vendors. 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 supplemental plans. INTIND and INTAMT are not always concordant. One exception to this is when identifying emergency department (ED) visits. [FeeInpatInvoice], [Fee]. FBCS is where weve spent the bulk of our time investigating. The Fee Basis files are stored in two formats: SAS and SQL. VA Directive 6402, Modifications to Standardized National Software, Document Storage Systems (DSS) DocManager, Microsoft Structured Query Language (SQL) Server, Optical Character Recognition (OCR) Module, Fidelity National Information Service (FIS) Compass. The SQL prescription data are housed in the [Fee]. Sign up to receive the VA Provider Advisor newsletter. These data records cannot be linked to particular patient identifiers or encounters. PMS-DRG was effective in FY 2008; prior to this time CMS-DRGs were used. Request and Coordinate Care: Find more information about submitting documentation for authorized care. After a claim is submitted electronically it must be entered manually into a Non-VA Medical Care approval system. [Spatient], and [Spatient]. [FeeServiceProvided], [Fee]. File a Claim for Veteran Care - Community Care - Veterans Affairs All Fee Basis care will be found in the Fee files. Outpatient data are housed in the FeeServiceProvided table. Move on to the next patient ID, STA3N, VEN13N combination and repeat the entire process above. VIReC. U.S. Department of Veterans Affairs. The SAS Fee Basis data are organized by fiscal year. 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. The variable DTStamp represent the date the claim was received. VA calculates PAMT from CMS pricer software on the basis of DRG and length of stay. The invoice table would have to have a sufficient number of fields to accommodate the maximum number of procedures report on any invoice. 5. The disbursed amount should be used to calculate the cost of care, except in the case where disbursed amount is missing. Box 30780 Tampa, FL 33630-3780, P2E Documentation Cover Sheet, VA Form 10-10143f. For home loan matters, contact a Regional Loan Center and for Veteran Readiness and Employment matters, contact your local regional office at their physical address. Researchers who have never before used CDW are encouraged to read the VA CDW First Time Users guide, available from the VIReC website (VAintranet only:http://vaww.virec.research.va.gov/CDW/Overview.htm). There are exceptions. 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. No, only one type of care can be covered by a single authorization. We recommend researchers use the FeePurposeOfVisit codes (FPOV) codes to eliminate observations related to non-outpatient care before beginning analyses. There are also differences in the variables contained in the SAS versus SQL data. HERC researchers found that claims for the professional component of hospital stays also appeared in the file of claims for outpatient services. The SAS data are stored at AITC. Accessed October 07, 2015. Emergency care can also be authorized by VA in certain circumstances when the VA is notified within 72 hours. Outpatient prescriptions beyond a 10-day supply. The Fee Basis data contain a unique variable not found in the traditional VA inpatient and outpatient datasets: the Fee Purpose of Visit (FPOV) variable. 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. Some encounters have multiple procedures that are paid as a single encounter; other encounters have multiple procedures and there are separate payments for each procedure. For billing questions contact: Health Resource Center Types of VA Disability Claims | PTSD Lawyers - Berry Law 3. . The Medicare ID is missing if the payment is determined via a different mechanism (e.g., a contract). This product is Class 2 or Class 3 VA-designed and built Local Software OR is a commercially-licensed software product purchased or leased that will run in a VA VISTA environment or integrate with Class 1 National VISTA Software. This is a critical difference from VA utilization files, which are organized by date of service. [FeePharmacyInvoice] table contains information on vendor, amount claimed, and amount paid. Each prescription record has a fill date and a patient identifier (either PatientICN or scrambled social security number). Fee Basis providers vary in how frequently they submit an invoice for Fee Basis care. This can become complicated by the fact that not all encounters relating to the same inpatient stay will have the same admission and discharge dates. If using payment amount, one would overestimate the cost of care. one episode of care, which can have multiple dates within the prescribed treatment, one provider, as identified by the Tax Identification Number (TIN), and. We assume here that new inpatient stays are defined by a change in vendor or a gap in treatment day more than 1 day. Given the variable definitions, it is not clear whether DX1 or DXLSF is the better choice to determine primary reason for inpatient stay. Review the Corrections and Voids page for more information. VA-station related information includes STA3N, STA6A and STANUM in SAS and Sta3n and PrimaryServiceInstitution in SQL. Appendix E includes a list of SQL fields related to the type of care a patient receives. (2) Additionally, a Veteran must also meet at least one of the following criteria. Paper claims and supporting documentation submitted to us are converted to Electronic Data Interchange (EDI) transactions. Domains represent logically or conceptually related sets of data tables. The table can be linked to the [Dim]. Billing & Insurance - South Central VA Health Care Network SAS Fee Basis data can be linked to other SAS files with additional demographic data (e.g., Vital Status files, enrollment files). Updated August 26, 2015. Contractor Announces Plan To Fix Non-VA Fee Basis Claims At the time of writing, version 4.2 is the most current version. For example, to understand the ICD-9 codes associated with a particular inpatient encounter, one would have to link the [Fee]. Veterans Health Administration. CLAIMS INTAKE CENTER. We gratefully acknowledge comments and contributions from Sharon Dally, Susan Schmitt and Paul Barnett. 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. Any supporting documentation that VA is unable to link to a claim will be returned to sender to for additional information. Data in any of the any S tables require Staff Real SSN access. Contact the VA North Texas Health Care System. A missing value of the primary diagnosis code should therefore be treated as truly missing. Inpatient care beyond the time when a patient is stabilized and can be transferred to a VA facility, except where a VA facility is not feasibly available. For emergency care of service connected conditions, there is a two-year limit to submit any bills. 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. The discussion below pertains to both SAS and SQL data. 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. VA systems are intended to be used by authorized VA network users for viewing and retrieving information only; except as otherwise explicitly authorized for official business and limited personal use under VA policy. The amount claimed (PAMTCL) appears in the inpatient (INPT) file alone; there is no claimed amount on the outpatient side. Please switch auto forms mode to off. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links. Electronic Data Interchange (EDI): Payer ID for medical claims is 12115. The inpatient data will also need to be linked to the ancillary data, or the data representing the professional services provided to a patient while in the hospital, in order to determine the total cost of the inpatient stay. The process of linking can be complex; analysts should take care to reduce errors during this process. First, it includes both the payment amount and any interest that may apply. However, there are best practices that all SQL-based analyses should follow. However, in Table 4, we present some comparisons to demonstrate the different between SAS and SQL data. Each year represents the year in which the claim was processed, not the year in which the service was rendered. Claims for Non-VA Emergency Care 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.. It is the patient identifier that uniquely defines a patient across all facilities. A Fee table will contain a record for an ICD-9 code, whereas a DIM table will contain the possible values of that ICD-9 code. 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. More information about can be found on their website: https://www.va.gov/communitycare/. 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. National Non-VA Medical Care Program Office (NNPO). Other work by HERC researchers indicates that in the FY 2014 data, DXLSF and DX1 were identical 47% of the time. Optum is a proud partner with the VA through its Community Care Network (CCN). One may therefore assume that all patients receiving treatment through the Non-VA Medical Care program are Veterans. Claims related to this care are considered authorized care. Box 202117Florence SC 29502, Logistics Health, Inc.ATTN: VA CCN Claims328 Front St. S.La Crosse WI 54601, Secure Fax: 608-793-2143(Specify VA CCN on fax). Some vendors use centralized billing services located in other cities, in a few cases in other states. 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. 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. 2010;47(8):725-37. National Provider Identifier: Submit all that are applicable, including, but not limited to billing, rendering/servicing, and referring. Non-VA Medical Care consumes a significant portion of VA spending; indeed, contract costs (i.e., the cost of all things purchased from non-VA health care providers) accounted for approximately 11% of VA expenditures in fiscal year 2014. Accesed October 16, 2015. There are also a number of other financial variables denoted in SAS (see Table 7). The unique patient identifier by which to conduct SQL-based Fee Basis analyses is PatientICN. 11. In both the SAS and the SQL data, there are usually multiple observations per patient encounter. However, not all dates on the claim are approved. U.S. Department of Veterans Affairs. In SAS, this variable is called DISTYP, or disposition type, and is located in the Inpatient and Ancillary tables. Electronic Data Interchange (EDI): Payer ID for medical and dental claims is VA CCN. This report covers the audit of payments made through VA's Fee Basis Claims System (FBCS), encompassing claims paid via that payment process from November 1, 2014 through September 30, 2016. We tried to link the UB-92 form to identify Choice authorizations; however, we found few records and decided to use obligation number. 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. Non-VA providers submit claims for reimbursement to VA. The impact on inpatient and emergent care is unclear, however, as the definition of prosthetic in VA is so broad as to include items placed inside the body, such as internal fixation devices, coronary stents, and cardioverter defibrillators. Non-VA Medical Care data are available in SAS form at the Austin Information Technology Center (AITC) and in SAS form and SQL form through the VA Corporate Data Warehouse (CDW)/VA Informatics and Computing Infrastructure (VINCI). The specific locations of the SAS payment variables and the SQL payment variables can be found in Chapters 4 and 5, respectively. The PatientSID is a CDW assigned identifier that uniquely identifies a patient within a facility. For EDI 837, Referral Number is Loop = 2300, Segment = REF*9F, Position = REF02 or Prior Authorization. Compare the discharge date of the first observation to the admission date of the next (second) observation. While all non-VA providers must submit a claim to VA in order to be reimbursed for care, the claim filing deadline depends on the type of claim. Electronic Data Interchange (EDI) Interface. Thus, our recommendation is as follows: Use disbursed amount to calculate the cost of care, except in the case where disbursed amount is missing and the payment was not cancelled. SAS data also contain an additional diagnosis variable that is not present in the SQL data -- DXLSF. DSS Fee Basis Claims Systems (FBCS) - DigitalVA Some VA medical centers purchase care from only one of the hospitals in the chain. Values for Fee Purpose of Visit (FPOV), HCFA Payment Type (HCFATYPE), Treatment Code (TRETYPE), Place of Service (PLSER), and Vendor Type (TYPE) appear in Appendix B. Reimbursement for Pharmacists Services in a Hospital-based, Pharmacist-managed Anticoagulation Clinic. For example, a hospital stay may last from Jan 1, 2010 to Jan 10, 2010, and have another claim for treatment provided on Jan 5, 2010. is ok, 12.6.5 is ok, 12.6.9 is ok, however 12.7.0 or 13.0 is not. 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). There is no separate payment for items such as oxygen or other supplies, the number of attendants, providing an EKG during the trip, etc. If the payment was made outside of FBCS, they wont show here. SQL data contain both SCRSSN and SSN, but these data reside in the SPatient table at CDW, and cannot be accessed by researchers without the CDW data manager and IRB approval. This component communicates with the FBCS MS SQL database and Veterans Health Information Systems and Technology Architecture (VistA) database in real time. These variables relate to the VA station at which the Fee Basis care requests and claims are input. The 2 sets of DRGs are not interchangeable. Accessed October 16, 2015. U.S. Department of Veterans Affairs | 810 Vermont Avenue, NW Washington DC 20420. However, Veterans may be responsible for a VA copayment depending on their assigned Priority Group. U.S. Department of Veterans Affairs. This amounts to approximately 1.7 million claims processed per month and approximately $5-8 billion per year. Office of Information and Analytics. Attention A T users. These inpatient tables have to be linked to FeeInpatInvoiceICDDiagnosis, FeeInpatInvoiceICDProcedure, FeeInitialTreatment and the appropriate DIM tables in order to understand the specific diagnoses and procedures associated with the inpatient observations in these tables. The definition of the DXLSF variable changes depending on the year of analysis. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links. Prescription-related data in the PHARVEN file contain only summary payments by month. Users must ensure that Microsoft .NET Framework, Microsoft Structured Query Language (SQL) Server, and Microsoft Excel are implemented with VA-approved baselines. 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 some vendors, there may be more than on possible hospital, for example, if the vendor is a hospital chain or an organization with a VA contract. Va Fee Basis Program Claims Address - rutrackersplus Please visit Provider Education and Training for upcoming events. expectation of privacy in the use of Government networks or systems. Attention A T users. SQL data must be linked from multiple tables in order to create an analysis dataset. Two domains in which researchers can find reports on Non-VA Care are Resource Management and Workload. (Anything) - 7.(Anything). If the patient is transferred from a non-VA to a VA hospital, the non-VA component of this care will be captured through Fee Basis, while the VA component of this care will be in the VA inpatient datasets. Money collected by VA from private health insurance carriers is returned back to the VA medical center providing the care. Through the CCN, Veterans have access to regional networks of high-performing, licensed health care . Pre-2007, DISAMT and INTAMT each have two implied decimal places a value of 1000 would indicate $10.00. Go to CDW Home, click on CDW MetaData, then click on the link for Purchased Care. Mark Smith and Adam Chow were the authors of the original HERC guidebook, upon which this document builds. The Fee Basis VA program allows Veterans to be seen by a community provider. Chapter 6 contains more information about how to access these data. All access Previous work conducted for the HERC 2008 Fee Basis guidebook found that the cost of inpatient pharmacy was included in the inpatient records of the SAS INPT file. 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. 4. 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. This section describes two elements of the program: the range of services covered and the payment rules used to determine the amount that VA will pay (DISAMT). If the Veteran received care in the community that was not pre-authorized, it is considered unauthorized by VA. Researchers with the appropriate DART permissions can ask the studys VINCI data manager to create a crosswalk file. 15. [XXX] tables.9,12 Tables under the DIM schema contain attributes that describe the records in the Fee tables. 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. 2. 7. In SQL, there are additional variables that will denote the type and location of the care provided along with the vendor. Of note, the FBCS was not in place nationwide prior to FY 2008. For example, a technology approved with a decision for 7.x would cover any version of 7. The outpatient pharmacy data includes medications dispensed in a pharmacy. The data regarding the clinical encounter as well as the charge and payment for that encounter are populated into the VA Health Information Systems and Technology Architecture (VistA). It will often times not be possible to determine the reason for an outpatient visit, as there will be multiple observations/CPT codes that denote a single visit.

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