va fee basis program claims address

988 (Press 1). Users must ensure that Microsoft .NET Framework, Microsoft Structured Query Language (SQL) Server, and Microsoft Excel are implemented with VA-approved baselines. and constitutes unconditional consent to review and action including (but not limited Outpatient data are housed in the FeeServiceProvided table. Payment for care provided under the Veterans Choice Act may not exceed the Medicare Fee Schedule (i.e. Researchers should use PatientICN to link patient data within CDW. Researchers with VA intranet access can access these sites by copying and pasting the URLs into their browser. Guidance can be found under "VHA Data Quality Program Reports. Fee Purpose of Visit is the recommended way to evaluate the category of the visit. Community providers have three options that allow for that linkage: Submit the claim electronically via 837 transaction and the supporting documentation via 275 transaction. The base rate varies by level of ambulance service provided, locality of the Medicare carrier area, and Point of Pickup (POP) zip code classification: urban, rural, or "super rural." Researchers can read more information about accessing CDW on the VHA Data Portal (http://vaww.vhadataportal.med.va.gov/DataSources/CDW.aspx; VA intranet only). Questions about care and authorization should be directed to the referring VA Medical Center. This latter table contains a variable called InitialTreatmentDateTime. We are grateful for their cogent work. All access or use constitutes understanding and acceptance that there is no reasonable VA will arrange for transportation for them or will reimburse expenses on the basis of vouchers submitted. Claims processed after March 17, 2022, will be reviewed and aligned with the federal ruling which prohibits secondary payment on emergency care copayments and deductibles. All SAS prescription-related data is found in two files: the PHR file and the PHARMVEN file. A foreign key is a key that uniquely identifies a record of another table. 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). Technologies must be operated and maintained in accordance with Federal and Department security and Primary keys are denoted by (PK) and foreign keys are denoted by (FK). For dual pension and compensation claims, use the mailing address below for compensation claims. For To access the menus on this page please perform the following steps. Office of Media and Public Relations. - The information contained on this page is accurate as of the Decision Date (11/02/2022). VA evaluates these claims and decides how much to reimburse these providers for care. (In SAS the admission date is denoted by the TREATDTF variable and the discharge date by the TREATDTO variable, in SQL the admission date is denoted by the AdmissionDate field and the discharge date is denoted by the DischargeDate field). 21. Review the Supporting Documentation section below to learn how to properly submit supporting documentation with your claim. This component provides a front end for validation and/or correcting the data that was read from the claim via the OCR module. U.S. Department of Veterans Affairs. Veterans Health Administration. Appendix G lists all available FPOV codes and classifies them as inpatient or outpatient. Persons looking to find the date of service should be advised that it will not be contained in the FeeServiceProvided table. 3. A valid receipt showing the amount paid for the prescription. Address. If using payment amount, one would overestimate the cost of care. Ready. VA's fee basis care program. Sort data by the patient ID, STA3N, VEN13N, and the admission dates. Persons looking to classify Veterans military service are encouraged to read the Data Quality Analysis Teams guidance on Identifying Veterans in the CDW(VA intranet only:http://vaww.vhadataportal.med.va.gov/Portals/0/DataQualityProgram/Reports/Identifying_Veterans_in_CDW.pdf).14. Therefore, on the outpatient side as well one must aggregate multiple records to get a full picture of the outpatient encounter. MDCAREID is available in most inpatient SAS Fee Basis records. At the time of writing, SAS data at CDW are available only to those persons with VA operations access. 2. The funds are used to provide the best care possible to our Veterans. In order to qualify for round trip mileage, an appointment must be scheduled. The alternative, putting the procedure code fields in the invoice table, would not be as efficient. (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. 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, 7. 3. VA contracts out its hospice; therefore, the Fee Basis files contain a great deal of data related to hospice care. Business Product Management. VA is required by law to bill private health insurance carriers for medical care, supplies and prescriptions provided for treatment of Veterans' nonservice-connected conditions. The two tables can be joined through FeePharmacyInvoiceSID. There is very limited outpatient pharmacy data in the Fee files. 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. [Spatient], and [Spatient]. Care provided under contract is eligible for interest payments. 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? VA evaluates these claims and decides how much to reimburse these providers for care. This application reads, creates, edits authorization data in VistA, and copies critical information into the central SQL database for off-line VistA applications to consume. This is true for both the inpatient and outpatient data. There may be multiple CPT codes associated with a single encounter. Therefore, to make a complete assessment of the payments for inpatient cases, researchers should evaluate the outpatient files along with the inpatient and ancillary files. Researchers can look at the disposition variable as an indicator of transfer between VA and non-VA care. 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. Move on to the next patient ID, STA3N, VEN13N combination and repeat the entire process above. (Available at the VHA Data Portal. The vendor and the provider may or may not be the same entities. Lump sum payments are not paid via FBCS. When a key field is missing, SQL indicates this with a value of -1. *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. Get the latest updates on VA community care, including program changes, resources and more! Go to CDW Home, click on CDW MetaData, then click on the link for Purchased Care. For example, if the Veteran had an Emergency Department (ED) visit and then was admitted to the hospital, this would be considered inpatient care. Some web reports contain PHI and access to these is restricted. The FMS disbursed amount is the payment amount plus any interest payment. [SpatientAddress] tables. If electronic capability is not available, providers can submit claims by mail or secure fax. Our review of the data suggests that pharmacy and ancillary claims take longer to process than inpatient or outpatient claims. Multiple claims can be paid against a single authorization. Money collected by VA from private health insurance carriers is returned back to the VA medical center providing the care. The unique patient identifier by which to conduct SQL-based Fee Basis analyses is PatientICN. Call: 988 (Press 1), U.S. Department of Veterans Affairs | 810 Vermont Avenue, NW Washington DC 20420. You are strongly encouraged to electronically submit claims and required supporting documentation. Available at: http://www.mssny.org/Documents/Enews/Aug%208%202014/VA%20ProvidersGuide.pdf, 6. For billing questions contact: Health Resource Center 13. This act expands the non-VA care veterans were able to receive before the act was passed. 14. Researchers will need to decide whether they will use the SAS or the SQL data and apply for appropriate IRB approval for use. Providers who continue to elect to submit paper claims and paper documentation to support claims for unauthorized emergency care should be aware of the following: VHA Office of Integrated Veteran Care P.O. Accessed October 16, 2015. Questions about non-VA care claims may be directed to the Fee Basis Unit between the hours of 8:00 a.m. Email Address Required. 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. 2010;47(8):725-37. 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. Each prescription record has a fill date and a patient identifier (either PatientICN or scrambled social security number). This variable is defined as 1st Diagnosis Code. A comparison from FY 2009 to 2014 data reveals that DX1 in SAS corresponds to DX1 in SQL data, and up to 2008, DXLSF in SAS corresponds to DX1 in SQL (see Table 5). Payer ID: 1. 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. Compare the discharge date of the first observation to the admission date of the next (second) observation. The same cannot be said for DX2-DX25, however, as additional diagnosis codes are optional. By June 2017, no Choice stays are found in FBCS. Please switch auto forms mode to off. These data indicate the specialty code associated with the vendor, such as orthopedic surgery, cardiology, family practice, etc. Six additional variables indicate the setting of care and vendor or care type. One exception to this is when identifying emergency department (ED) visits. NNPO. 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. As of April 2019, this guidebook is no longer being updated. When a claim is linked to VistA, the variable Other_Hlth_ins_present is populated. Providers cannot bill both VA and the patient or another insurer for the same encounter. To understand what procedures were performed during an inpatient stay in the [Fee]. In this table, some ancillary data are associated with an inpatient FPOV code but have an outpatient FeeProgramProvided field. U.S. Department of Veterans Affairs. [FeePharmacyInvoice] table contains information on vendor, amount claimed, and amount paid. [FeeInpatInvoiceICDProcedure] table. Several variables are available for locating care in particular settings. Researchers wishing to work with SAS Fee Basis data can access them at the Austin Information Technology Center (AITC). VIReC Research User Guide: VHA Medical SAS Outpatient Datasets FY2006. For pension claims, use the Pension Management Center (PMC) that serves your state. VAntage Point. This guidebook is intended to help researchers understand and use the National Fee Basis files, which come in both SQL and SAS formats. They appear in Table 6, where an X indicates that the variable appears in the file.10 Vendor type (TYPE), payment category (PAYCAT), treatment code (TRETYPE), and place of service (PLSER) all provide information on the type or setting of 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. U.S. Department of Veterans Affairs. Customer Call Center: 877-881-76188:05 a.m. to 6:45 p.m. Eastern TimeMondayFriday, Sign up for the Provider Advisor newsletter, Veterans Crisis Line: Most commonly, authorized care refers to medical or dental care that was approved and arranged by VA to be completed in the community. If electronic capability is not available, providers can submit claims by mail. The Medicare ID is missing if the payment is determined via a different mechanism (e.g., a contract). Accessed October 16, 2015. In FY05, DRG001 means CRANIOTOMY- >17 W CC, compared to HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC for DRG001 in FY15 DRG001. Non-VA providers submit claims for reimbursement to VA. April 08, 2014. If the provider declines VA payment then it may be able to charge the patient a greater total amount. Researchers evaluating care over time may want to use the DRG variable. Users must ensure their use of this technology/standard is consistent with VA policies and standards, including, but not limited to, VA Handbooks 6102 and 6500; VA Directives 6004, 6513, and 6517; and National Institute of Standards and Technology (NIST) standards, including Federal Information Processing Standards (FIPS). The VA payment (DISAMT) is typically less than or equal to the PAMT value, although in some cases VA will pay more than Medicare would pay. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links. 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. ____________________________________________________________________________. We encourage readers to seek out the latest guidance before conducting analyses, as CDW Data Quality Analysis team may have updates to this information. YESInstitutional/UB Claims. 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. As a single encounter may have more than one CPT code, users may have to aggregate multiple observations in order to evaluate the care received on a particular day. 2. If the Veteran received care in the community that was not pre-authorized, it is considered unauthorized by VA. The procedure code table has just as many records as there were procedures on the invoice. Some missingness may indicate not applicable.. Last updated August 21, 2017 National Non-VA Medical Care Program Office (NNPO). Both ancillary and outpatient files have one record per CPT code. The VA pays for both emergency and non-emergency care through Fee Basis mechanisms. Contact: 1-877-353-9791; Email Customer Engagement; Customer Engagement Portal Login. If a Veteran has only Medicare Part B or has both Medicare Parts A and B, no VA payment may be made. [ICDProcedure] table through the ICDProcedureSID. http://www.va.gov/opa/choiceact/documents/FactSheets/Veterans_Choice_Program_Eligibility_Details_August_1_Removal.pdf. FBCS is where weve spent the bulk of our time investigating. 1. Treatment date correlates to covered from/to. Thus, researchers using later years of data should be aware that files are not static and will continue to be updated. The new temporary end date is the maximum of the discharge date of the third observation and temporary end date from Step 2. 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. 10. From there, it is sent weekly to AITC in SAS format and nightly to CDW in SQL format. field. 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. Most importantly, they do not represent all care provided during the fiscal year. Up to FY2008 data, DXLSF is labeled as 1st Diagnosis Code. In FY2009 and on, DXLSF is labeled as the Admitting or Primary Diagnosis Code. In FY 2009 and later SAS data, there is also another variable, DX1, which is not present in SAS data prior to FY2009. [ICDProcedure] table and a foreign key in the [Fee]. This is true for both the inpatient and the outpatient data, albeit for different reasons. or use of this system constitutes user understanding and acceptance of these terms 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. Veterans Access, Choice, And Accountability Act of 2014: Title I: Choice Program and Health Care Collaboration [online]. JANESVILLE, WI 53547-4444. or Fax to: TOLL FREE: 844-531-7818 & 248-524-4260 (Utilized for Foreign Claimants) return to top. Veterans Crisis Line: 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. These clams contain charges and are known as claimed amounts (PAMTCL in SAS, ClaimedAmount in SQL). 5. The 2015 update to the Fee Basis Medical Care guidebook describes for the first time the SQL Fee Basis files, and contains a host of information about how SAS versus SQL Fee Basis files differ. Also, you may have to wait until the General Enrollment Period (from January 1 to March 31) to enroll in Part B. Unauthorized inpatient or outpatient claims must be submitted within 90 days from the date of care. U.S. Department of Veterans Affairs | 810 Vermont Avenue, NW Washington DC 20420. 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. MDCAREID is not available in the outpatient SAS Fee Basis data, even though some outpatient services are provided in a hospital. Chapter 6 provides information about how to access the Fee Basis data, while Chapter 7 provides information about the rules governing Fee Basis care. U.S. Department of Veterans Affairs. This schema contains sensitive information such as SSNs, bank accounts, and the actual name of personnel. SAS has more data on inpatient diagnosis and procedure variables than do SQL data. 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. Q. In this way, records that are missing MDCAREID can be given a MDCAREID based on the value of VEN13N and STA6A in the record. This amounts to approximately 1.7 million claims processed per month and approximately $5-8 billion per year. Prosthetic items. VA intranet only: http://vaww.vhadataportal.med.va.gov/Resources/DataReports.aspx). Appendix D contains information on the primary and foreign keys needed to link the various SQL tables. For example, the meaning of DRG001 is not the same in FY05 vs FY15. Providers are not required to accept VA payment in all cases. The key field indicates which invoice they appeared on. PatientIEN is assigned by the facility. While not required to process a claim for authorized services, medical documentation must be submitted to the authorizing VA medical facility as soon as possible after care has been provided. Researchers will have to select observations from the SQL FeeServiceProvided table in order to ensure they are only evaluating outpatient data. The Medicare Ambulance Fee Schedule consists of a base rate plus mileage. To determine the location of care, MDCAREID will be more useful than VEN13N. For these reasons, VA strongly encourages Veterans to consider important factors, risks and benefits before making any changes to their private health insurance. The vendor has verified that the VA no longer has an active contract for this technology and any instances of this software on the VA network should be removed. Starting in 2009, there are also a number of DXPOA variables in the SAS data, which indicate diagnoses that are present on admission. 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). It is also possible that researchers will find a slight difference in the observations that the SAS versus SQL data contain. Community provider mails the paper claims and documentation to the new mailing address of VA's central claims intake location. A claim for which the Veteran had coverage by a health plan as defined in statute. 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. a. 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. Additionally, our health care providers make certain that Veterans' VA medical records remain updated by returning information about Veteran care and treatment to VA. If you are in crisis or having thoughts of suicide, The SAS Fee Basis data are organized by fiscal year. The Vendor Release table provides the known releases for the. Veterans Choice Program (VCP) Overview [online]. The prescription must be for a service-connected condition or must otherwise have specific approval. 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. In SQL, the outpatient data are housed in the FeeServiceProvided table. FBCS supports payment of claims via VistA. Mark Smith and Adam Chow were the authors of the original HERC guidebook, upon which this document builds. If a researcher wishes to find the Medicare hospital provider ID, one approach is to use the vendor identification variables (VEN13N, VENDID) to locate the vendors name and location in the VEN file, and then to use this information to find the Medicare provider ID using publicly available files from CMS, the agency that oversees the Medicare program. 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. For example, to understand the ICD-9 codes associated with a particular inpatient encounter, one would have to link the [Fee]. Unscheduled trips may be reimbursed for the return mileage only. For inpatient and outpatient care, in general, VA will pay the lesser of the Medicare rate (or MPFS rate) or the billed charges. The National Provider Identifier (NPI) is a unique 10-digit identification number issued by the Centers for Medicare and Medicaid Services to all health care providers in the United States. 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. For these reasons, the program does not pay for 100% of care that was otherwise eligible. Any supporting documentation that VA is unable to link to a claim will be returned to sender to for additional information. There are 34 Fee Basis Claims Systems (FBCS) servers, which were originally designed for episodes of care. Claims Assistance | Veterans' Affairs Home Claims Assistance Claims Assistance Contacting the Columbia VA Regional Office Call us at (803) 647-2488, or email VetAsst.VBACMS@va.gov, and provide your: Name Contact information and, Best time of day for contact between 8:00am and 4:00pm The Veteran's full 9-digit social security number (SSN) may be used if the ICN is not available. 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. 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. Table 8 denotes on which CDW servers Fee Basis data are housed. These variables relate to the VA station at which the Fee Basis care requests and claims are input. Claims. VA Information Resource Center VHA Corporate Data Warehouse [webpage]. One can use the same approach as for the inpatient SQL data described above to locate the date of service. Hit enter to expand a main menu option (Health, Benefits, etc). This application is directly attached to TWAIN compliant scanners and works offline to VistA and the FBCS MS SQL databases. The vendor identity can be found through the VENDID or VEN13N variables in SAS. However, there are best practices that all SQL-based analyses should follow. TriWest VA CCN ClaimsP.O. Working with the Veterans Health Adminstration: A Guide for Providers [online]. Each VA facility has a local Fee Office to which the non-VA provider submits a claim for reimbursement. The length of stay for a single hospital invoice varied greatly, with a maximum length of stay of 980 days. 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). Additional information appears in a federal regulation, 38 CFR 17.52. There are multiple potential identifiers for provider/vendor in the SAS data: the VENDID, VEN13N, MDCAREID, SPECCODE and NPI.