We tried to link the UB-92 form to identify Choice authorizations; however, we found few records and decided to use obligation number. This technology can integrate with and alter database technologies. Veterans Health Administration. April 08, 2014. Some Fee Basis data will also appear in the non-VA medical SAS inpatient file (formerly called the Patient Treatment File). This component is a service that communicates with the Program Integrity Tool (PIT) which scores claims and sends results to FBCS. Home Health Agencies billing with an OASIS Treatment number use the Prior Authorization segment for the TAC and the Referral Number segment on the 837I submission. To evaluate the time it takes VA to process Fee Basis claims, we evaluated SAS data for FY2014. Non-VA Payment Methodology Matrix [online; VA intranet only]. The status value A stands for accepted, meaning the claim was paid. E-fax: Documentation sent via email to Veterans Affairs Medical Center (VAMC) fax machine. National Provider Identifier: Submit all that are applicable, including, but not limited to billing, rendering/servicing, and referring. The VHA Office of Community Care is the contact for all VA community care programs. Each patient should have only one ICN in the entire VA, regardless of the number of facilities at which he is seen. VA Fee Schedule. There are additional payments for direct medical education, capital-related costs, and other factors as appropriate. There is another category of Fee Basis care that is considered unauthorized care. Medical specialty type (SPECCODE) is a provider-specific variable and indicates the specialty type of the provider rendering the service. PracticeBridge. In VA datasets, the MDCAREID does not have an accompanying address, but one can use other non-VA datasets (e.g., Hospital Compare) and determine the address of the hospitals physical location through the common MDCAREID variable. This improves claim accuracy and reduces the amount of time it takes for us to process claim determinations. Use of this technology is strictly controlled and not available for use within the general population. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links. Chapter 6 contains more information about how to access these data. The Department of Veterans Affairs has implemented centralized mail processing (CM) for compensation claims to reduce incoming paper handling and shipping requirements. 1. These include Fee purpose of visit (FPOV), place of service (PLSER), type of treatment (TRETYPE), HCFA payment type (HCFATYPE), and record type (TYPE). DSS Fee Basis Claims Systems (FBCS) - DigitalVA In some cases it may appear that single encounters have duplicate payments. U.S. Department of Veterans Affairs. Race and ethnicity are found in the [PatientEthnicity], [PatSub]. This component provides a front end for validation and/or correcting the data that was read from the claim via the OCR module. 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. A summary of the payment guidelines can be found in Appendix I. If the gap is 0 or 1, it is part of the same hospital stay and we then want to assess its discharge date. Hit enter to expand a main menu option (Health, Benefits, etc). Edward J. Hines, Jr. VA Hospital, Hines, Ill. 2007. In the Fee Basis inpatient data, each record represents a separate claim; these separate claims must be aggregated to capture the totality of the inpatient stay. VA Technical Reference Model v 23.1 DSS Fee Basis Claims Systems (FBCS) General Decision Reference Component Category Analysis Vendor Release Information The Vendor Release table provides the known releases for the TRM Technology, obtained from the vendor (or from the release source). At the time of writing (October 2015), only operations staff will have permission to access the SAS data at VINCI. Unlike the other patient identifiers in SQL such as PatientIEN or PatientSID, PatientICN is supposed to be unique to each patient across VA. June 5, 2009. VA Palo Alto, Health Economics Resource Center; October 2013. Payment for these types of care falls under the Non-VA Medical Care program. Billing & Insurance - New York/New Jersey VA Health Care Network Additional information appears in a federal regulation, 38 CFR 17.52. 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]. For education claims, refer to the appropriate Regional Processing Office. 1728. PatientIEN is assigned by the facility. Chapter 6 provides information about how to access the Fee Basis data, while Chapter 7 provides information about the rules governing Fee Basis care. By June 2017, no Choice stays are found in FBCS. The values of Adjustment Codes 1 and 2 (ADJCD1 and ADJCD2) explain the reason for non-payment. 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.. Electronic Data Interchange (EDI): Payer ID for medical claims is 12115. For current information on Community Care data, please visit the page. The status value R stands for re-routed, meaning the claim was re-routed to the Health Administration Center (HAC). A claim void must be identical to the original claim that it is intended to cancel. For some years, there may be high rates of missingness of ICD-9 data in the Ancillary files. 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. 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). 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). Thus, researchers using later years of data should be aware that files are not static and will continue to be updated. If the Veteran went to the ED and was not admitted to the hospital, this would be considered outpatient care. Patient identifiers are also different across SAS and SQL data. 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. Lump sum payments are not paid via FBCS. We are the third-party administrator for the VA CCN for Regions 1, 2 and 3, encompassing 36 states, Puerto Rico, the U.S. Virgin Islands and the District of Columbia. To access the menus on this page please perform the following steps. For authorized care, the referral number listed on the Billing and Other Referral Information form. This schema contains sensitive information such as SSNs, bank accounts, and the actual name of personnel. Menlo Park, CA. For pension claims, use the Pension Management Center (PMC) that serves your state. Outpatient data are housed in the FeeServiceProvided table. VINCI Data Description: Dimension [online; VA intranet only]. The temporary end date is the maximum of these two values. MDCAREID is the Medicare OSCAR number, which is a hospital identifier. How to create a secondary claims in eclinicalworks electronically; . 8. In the outpatient data, one observation represents a single CPT code. Please review the Where To Send Claims and the Where To Send Documentation sections below for mailing addresses and Electronic Data Interchange (EDI) details. Five additional variables Financial Management System (FMS) transaction number, line number, date, batch number, and release date reflect processing of payments through the FMS. If the claims and records do not conform to the minimum requirements for conversion to the 837 or 275 electronic formats, they are rejected and sent back for correction. 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. CLAIM.MD | Payer Information | VA Fee Basis Programs Payer Information VA Fee Basis Programs Payer ID: 12115 This insurance is also known as: Veterans Administration Need to submit transactions to this insurance carrier? The vendor and the provider may or may not be the same entities. Available at:http://vaww.vhadataportal.med.va.gov/Resources/DataReports.aspx. [ICDProcedure] table through the ICDProcedureSID. Researchers wishing to work with SAS Fee Basis data can access them at the Austin Information Technology Center (AITC). These data records cannot be linked to particular patient identifiers or encounters. Available at: http://www.mssny.org/Documents/Enews/Aug%208%202014/VA%20ProvidersGuide.pdf, 6. [ SFeeVendor] table. Using the Non-VA Medical Care data for research requires a basic understanding of laws and regulations that govern it. TriWest VA CCN ClaimsP.O. 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. Health - Veterans Affairs Hit enter to expand a main menu option (Health, Benefits, etc). SAS and SQL contain different variables to identify the provider and/or vendor associated with the care. One can evaluate which encounters were unauthorized by joining the FeeUnauthorizedClaim table through the FeeUnauthorizedClaimSID key. One may therefore assume that all patients receiving treatment through the Non-VA Medical Care program are Veterans. The Choice Act represents one of the largest shifts in the organization and financing of healthcare in the Department of Veterans Affairs (VA) in recent years. 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. If it still cannot be found, then the stay may have ended on the day the person stabilized. For example: services provided at a hospital anticoagulation clinic are billable for facility charges only if the anticoagulation is considered incident to physician services and certain other conditions are met.8. Current Decision Matrix (10/21/2022) 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. DSS Fee Basis Claims Systems (FBCS) - oit.va.gov SQL inpatient data contain up to 5 diagnoses and 5 procedure codes, while SAS inpatient data contain up to 25 diagnosis codes and up to 25 procedure codes. VA systems are intended to be used by authorized VA network users for viewing and 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. retrieving information only; except as otherwise explicitly authorized for official There are substantial differences in quantity of inpatient diagnosis and procedure data available in SAS versus SQL. 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. Journal of Rehabilitation Research and Development. After a claim is submitted electronically it must be entered manually into a Non-VA Medical Care approval system. 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. The prescription must be for a service-connected condition or must otherwise have specific approval. INTIND and INTAMT are not always concordant. In particular, CDW also recommends Patient SIDs with a value of less than 1 be deleted. Payer Name: VA Fee Basis Programs - thePracticeBridge It may duplicate the PatientIEN of another patient at another facility, and should not be used as an identifier. Yes. 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. SQL data must be linked from multiple tables in order to create an analysis dataset. Non-VA providers submit claims for reimbursement to VA. 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. You can use NPI to link providers in VA and Medicare. HERC: Fee Basis Data: A Guide for Researchers - Veterans Affairs What documents are required by VA to process claims for. The same concept (such as fiscal year, state, or county) may be represented by several variables, sometimes in differing formats. VA Informatics and Computing Resource Center (VINCI). This is true for both the inpatient and outpatient data. 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. Reimbursements appear in the Travel Expenses (TVL) file. In summary, in order to create a research cohort, one must first identify the cohort based on PatientSID, then request the CDW data manager to link the PatientSIDs in her cohort to unique PatientICNs, and finally remove test/dummy/unnecessary PatientSIDs and PatientICNs. 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. Veterans Affairs (VA) users must ensure VA sensitive data is properly protected in compliance with all VA regulations. To access the menus on this page please perform the following steps. Fee Basis data files contain information regarding both the care the Veteran received and the reimbursement of the care. Our review of the data suggests that pharmacy and ancillary claims take longer to process than inpatient or outpatient claims. If billing electronically, please include "Other Payers Information" in Loop 2320, 2330A, 2330B, and 2430. All analyses using this cohort should use PatientICN as indicative of a unique patient. 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, sta3n 589A5 will be found as 589. Accessed October 27, 2015. Matching outpatient prosthetics order records in the VA National Prosthetics Patient Database (NPPD) to health care utilization databases. This amounts to approximately 1.7 million claims processed per month and approximately $5-8 billion per year. 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. 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. If electronic capability is not available, providers can submit claims by mail or secure fax. 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. Most of these fields would be empty. 1725 may only be made if payment to the facility for the emergency care is authorized, or death occurred during transport. To enter and activate the submenu links, hit the down arrow. Veterans are not responsible for the remaining balance shown as patient responsibility on the explanation of benefits from their insurance carrier. 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. A valid receipt showing the amount paid for the prescription. 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. More information about provider reimbursement can be found in the document Working with the Veterans Health Administration: A Guide for Providers (available on the VHA Office of Community Care website, on the Provider Resources page).5. We gratefully acknowledge comments and contributions from Sharon Dally, Susan Schmitt and Paul Barnett. [1] The Health Care Financing Administration (HCFA) was renamed the Centers for Medicare and Medicaid Services. The Customer Engagement Portal is a reporting tool for VA Medical providers to verify the status of claims as well as run payment reconciliation reports. Sign up to receive the VA Provider Advisor newsletter. Each year represents the year in which the claim was processed, not the year in which the service was rendered. Government contractor DSS Inc a new plan to fix VA's failing non-VA fee basis claims processing and management system with certain software updates - self-funded - to improve the system. Once the VA system user has a TSO account, s/he may connect to the AITC mainframe through the Attachmate Reflection File Transfer Protocol (FTP). Each observation in the SAS and SQL data has an accompanying vendor ID. (2) Additionally, a Veteran must also meet at least one of the following criteria. 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. Sort data by the patient ID, STA3N, VEN13N, and the admission dates. In both the SAS and the SQL data, there are usually multiple observations per patient encounter. VA employees working on operations studies can build their own crosswalk file as they have permission to use these file. For example, DISAMT=1000 in FY06 really indicates DISAMT=10.00. Analyses of FY 2014 data indicate approximately 50% of inpatient observations and 43% of outpatient observations are missing NPI. This guide serves as an addendum to any technical documentation supplied by the healthcare clearinghouse when establishing a trading partner agreement. For example, a technology approved with a decision for 7.x would cover any version of 7. Generally, VA does not bill Medicare or Medicaid for reimbursement; however, VA does bill other types of health insurance including Medicare Supplemental plans for covered services. Access; upload; download; change; or delete information on this system; Otherwise misuse this system are strictly prohibited. In SAS, ICD-9 diagnosis codes are in the Inpatient, Outpatient and Ancillary files. 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. While a researcher could theoretically conduct a Fee Basis analysis using SAS data and then upload these SAS data to CDW and pull in the relevant variables from the SQL Patient domain, this poses some logistical challenges. 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. If a Veteran has only Medicare Part B or has both Medicare Parts A and B, no VA payment may be made.
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