Claims for Non-VA Emergency Care 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 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. We are grateful for their cogent work. The clinic of jurisdiction, or medical facility, authorizes such care under the fee-basis program . [FeeVendor] table. 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. There may be many providers that use the same vendor for billing. 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). Therefore, it is not possible to do an exact comparison across the datasets. Claims. Money collected by VA from private health insurance carriers is returned back to the VA medical center providing the care. Sort data by the patient ID, STA3N, VEN13N, and the admission dates. If the Veteran has insurance, VA cannot pay even when the entire claim is less than the deductible. business and limited personal use under VA policy. VA-station related information includes STA3N, STA6A and STANUM in SAS and Sta3n and PrimaryServiceInstitution in SQL. VA Fee Basis Programs. In SAS, the cost of an inpatient stay can be determined by summing the cost from DISAMT in the inpatient files with the DISAMT from the ancillary observations that correspond to the inpatient stay; however, the inpatient and ancillary files alone may not be sufficient to account for the entire cost of care. Compare the admission date of the third observation to the temporary end date from above. 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. All access Accessed October 07, 2015. Hospice also appears to be billed monthly, with longest length of stay for a single hospice invoice of 31 days. 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. HERC investigation of Fee Files reveals certain data anomalies of which researchers should be aware. Fee Basis data will be most useful for studying conditions where contract care is common, such as home-based care and nursing care, and for determining typical non-VA charges for health care services (both charges and payments are reported) and comparing those to VA costs. According to the Health Administration Center Internet website, the proportion of claims processed within 30 days rose from under 40% in 2007 to over 97% by the end of 2008. 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. Include the claim, or a copy of the claim, on top of the supporting documentation that is mailed to the following address: Include a completed cover sheet with the supporting documentation that is mailed to the above address. (Available at the VHA Data Portal. Last updated August 21, 2017 Hit enter to expand a main menu option (Health, Benefits, etc). While there is limited information about the vendor available in the SAS datasets; the most comprehensive information about the vendor can be found in the SAS VEN and SAS PHARVEN datasets. For more information call 1-800-396-7929.Claims for Non-VA Emergency CareVeterans need to make sure any bills for non-VA emergency care of non-service connected conditions are submitted to the VA Medical Centers NVCC Office within 90 days. Institutional Aspects of the Non-VA Medical Care System, https://www.va.gov/health-care/get-reimbursed-for-travel-pay/, http://www.va.gov/opa/choiceact/documents/Choice-Program-Fact-Sheet-Final.pdf. The VEN13N is the vendor ID with a suffix; VEN13N is more detailed than VENDID and is thus recommended for use. Include the 17 alpha-numeric (10 digits + "V" + 6 digits) VA-assigned internal control number (ICN) in the insured's I.D. Payment of ambulance transportation under 38 U.S.C. These vendors are presumably hospital chains. (refer to the Category tab under Runtime Dependencies), Users must ensure that Microsoft Structured Query Language (SQL) Server, Microsoft Internet Explorer (IE), and Microsoft Excel are implemented with VA-approved baselines. You can find more information about eligibility on the VHA Office of Community Care website. Treatment date correlates to covered from/to. More information about can be found on their website: https://www.va.gov/communitycare/. To access the menus on this page please perform the following steps. The SAS files also include a patient type variable (PATTYPE). When a claim is linked to VistA, the variable Other_Hlth_ins_present is populated. Use the column 'estimated cost' and it is available in the CDW FBCS data. Veterans are not responsible for the remaining balance shown as patient responsibility on the explanation of benefits from their insurance carrier. Those options are: Utilize HealthShare Referral Manager (HSRM) for referrals, authorizations and documentation exchange. The prescriptions filled by fee-basis pharmacies are often small quantities of medication to meet the patients emergency or short-term needs while a CMOP prescription is being filled. Office of Information and Analytics. The Department of Veterans Affairs' (VA) fee basis care spending increased from about $3.04 billion in fiscal year 2008 to about $4.48 billion in fiscal year 2012. See 38 USC 1725 and 1728.). one setting of care (inpatient or outpatient). For example, to understand the ICD-9 codes associated with a particular inpatient encounter, one would have to link the [Fee]. VIReC Research User Guide: VHA Medical SAS Outpatient Datasets FY2006. 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: 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. 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. You can submit a corrected claim or void (cancel) a claim you have already submitted to VA for processing, either electronically or in paper. VA Informatics and Computing Resource Center (VINCI). 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 Veterans applying for and using VA medical care must provide their health insurance information, including coverage provided under policies of their spouses. Accesed October 16, 2015. Clinical variables in SAS format include ICD-9 diagnosis codes, ICD-9 surgical codes, CPT codes and CPT modifier codes, DRG codes and Present on Admission codes. Please switch auto forms mode to off. VA has set a goal of processing all clean claims within 30 days. For the inpatient data, we compared observations with the same patient identifier, based on PaidDate in SQL and TRANSDAT in SAS. To access the menus on this page please perform the following steps. 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. Under the Veterans Choice Act, eligible veterans are able to obtain outpatient care outside the VA using their Choice Card. Veterans Health Administration. Note: A Veterans insurance coverage or lack of insurance coverage does not determine their eligibility for treatment at a VA health care facility. Conversely, all stays should have at least one discharge diagnosis. 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). FBCS is an auditing system which provides instructional prompts designed to interface with the Veterans Information Systems and Technology Architecture (VistA) package to track, report, and analyze fee claim data. Both the SAS and SQL Fee Basis are housed at VINCI; the SQL data is also found at the Corporate Data Warehouse (CDW). [FeeInpatInvoiceICDProcedure] table. 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. Appropriate access enforcement and physical security control must also be implemented. have hearing loss. Chapter 6 contains more information about how to access these data. Hit enter to expand a main menu option (Health, Benefits, etc). VA has adopted a policy of processing payments for certain EDI claims outside of FBCS (Choice/PCCC) by rerouting the EDI claims back to the HAC, causing them to reach terminal status in FBCS and triggering a transition to the PIT repository. Our review of the data suggests that pharmacy and ancillary claims take longer to process than inpatient or outpatient claims. You can use NPI to link providers in VA and Medicare. Patient identifiers are also different across SAS and SQL data. Researchers with VA intranet access can access these images by copying and pasting the URLs into their browser. Community providers have three options that allow for that linkage: Submit the claim electronically via 837 transaction and the supporting documentation via 275 transaction. Chapter 4 offers detailed information SAS Fee Basis data; Chapter 5 provides detailed information about SQL Fee Basis data. The variable DTStamp represent the date the claim was received. The process of linking can be complex; analysts should take care to reduce errors during this process. PO BOX 4444. 1-800-273-8255 (Press 1), U.S. Department of Veterans Affairs | 810 Vermont Avenue, NW Washington DC 20420. 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. Bowel and Bladder Care. A record is created only if there is a code on the invoice to be recorded. 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." At the time of writing, SAS data at CDW are available only to those persons with VA operations access. 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. Regardless of whether the care was pre-authorized or not, non-VA providers submit claims to VA if they wish to be reimbursed for care. and constitutes unconditional consent to review and action including (but not limited Fact Sheet: Medical Document Submission Requirements for Care Coordination, ADA Dental Claim Form > American Dental Association website. To locate the facility at which the Veteran usually receives VA care, the VA Information Resource Center (VIReC) recommends consulting the preferred facility indicator in the VHA Enrollment Database.7. SQL data must be linked from multiple tables in order to create an analysis dataset. Veterans who meet certain criteria may be eligible for mileage reimbursement for travel to and from VA or Non-VA care. If electronic capability is not available, providers can submit claims by mail or secure fax. Medical specialty type (SPECCODE) is a provider-specific variable and indicates the specialty type of the provider rendering the service. 1728. If a Veteran has only Medicare Part B or has both Medicare Parts A and B, no VA payment may be made. If you are in crisis or having thoughts of suicide, Under this regulation, ambulances will be reimbursed at the lesser of (a) the amount the Veteran is personally liable or (b) 70 percent of the applicable Medicare Ambulance Fee Schedule. It is available in the PHARVEN and VEN files, albeit with a high degree of missingness. FBCS Upload leverages LEADTOOLS Professional Optical Character Recognition (OCR) and is included in the FBCS workstation install package. 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. VA is the primary and sole payer when VA issues an authorization. One way to do this is to concatenate the vendor identifier, the patient identifier, and the visit date. Fee Basis data can be broadly categorized into 4 classes: inpatient care, outpatient care, pharmacy, and travel data. 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. When a key field is missing, SQL indicates this with a value of -1. Using SQL data will allow the researcher to link to other rich data found in CDW, such as the Health Factors data. 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). 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. VA evaluates these claims and decides how much to reimburse these providers for care. In this chapter, we discuss general aspects of Fee Basis data. This care will be approved (or denied) by the local VA Fee Office; the Veteran is then free to seek non-VA care. The unique patient identifier by which to conduct SQL-based Fee Basis analyses is PatientICN. If, however, VA is authorized to pay for only certain days in an inpatient stay, then the provider may bill the patient for the remaining days. Emergency care can also be authorized by VA in certain circumstances when the VA is notified within 72 hours. Please note that this method providers an indication of the care provided to a Veteran on a single day, rather than in a single encounter, because multiple providers may use the same billing vendor. [LocalDrug] table through LocalDrugSID to see whether there was the generic equivalent found in the VA drug file that was dispensed to the patient. SAS and SQL contain different variables to identify the provider and/or vendor associated with the care. Payment guidelines for non-VA are outlined in federal regulations 17.55 and 17.56. A valid receipt showing the amount paid for the prescription. [ SFeeVendor] table. This component allows the site access to Communications, Configuration and Reporting options for FBCS. MDCAREID is the Medicare OSCAR number, which is a hospital identifier. The majority of claims, 99%, were processed within 2 years, with the exception of pharmacy data in FY 2004 and FY2008. Domains represent logically or conceptually related sets of data tables. Identify Choice records by using tax ID and specialprovcat= CHOICE. The definition of the DXLSF variable changes depending on the year of analysis. The vendor no longer supports VA installations of this technology. The FPOV variable can be found in both the SAS and SQL data. 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. 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. To evaluate the time it takes VA to process Fee Basis claims, we evaluated SAS data for FY2014. VINCI. 1. All information in this guidebook pertains to use of ICD-9 codes. 2. Here, ICDProcedureSID is a primary key in the [Dim]. In SAS, this variable is called DISTYP, or disposition type, and is located in the Inpatient and Ancillary tables. Prescription information: Prescribing provider's name. Care provided under contract is eligible for interest payments. 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. VIReC.