A summary of the payment guidelines can be found in Appendix I. 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. SAS and SQL contain different variables to identify the provider and/or vendor associated with the care. 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. Last updated validated on Tuesday, January 3, 2023 Unauthorized inpatient or outpatient claims must be submitted within 90 days from the date of care. Table 1 in the Data Quality Analysis teams guide Linking Patient Data in the CDW Updateprovides a brief summary for each identifier (Available atthe VHA Data Portal. The FeeSpecialtyCodeName contains information on the specialty of the provider seen, such as oncology, chiropractic, pathology, neurosurgery, etc., but is missing much data. 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. Optum is a proud partner with the VA through its Community Care Network (CCN). Note that some physicians use the same ID number as the hospital. Veterans who meet certain criteria may be eligible for mileage reimbursement for travel to and from VA or Non-VA care. In the outpatient data, one observation represents a single CPT code. While VA always encourages providers to submit claims electronically, on and after May 1, 2020, it is important that all documentation submitted in support of a claim comply with one of the two paper submission processes described. At the time of writing, SAS data at CDW are available only to those persons with VA operations access. 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. Veterans Access, Choice, and Accountability Act of 2014 (VACAA): The Choice Program and the Choice Card [presentation]. Veterans who have private health insurance should consider a number of important factors before canceling their health insurance, such as: If you cancel your Medicare Part B Coverage, you need to know that you cannot be reinstated until January of the following year, and you may be penalized for reinstatement. Business Product Management. Accessed October 16, 2015. 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. VINCI. Available at: http://vaww.virec.research.va.gov/CDW/Overview.htm. 1. Please review the Where To Send Claims and the Where To Send Documentation sections below for mailing addresses and Electronic Data Interchange (EDI) details. Primary keys are denoted by (PK) and foreign keys are denoted by (FK). The Veterans Access, Choice, and Accountability Act (Veterans Choice Act), passed in 2014, expanded veterans access to non-VA care. Researchers using this tactic also run the risk of not being able to properly link their cohort, as other HERC investigations have revealed an imperfect relationship between SCRSSN and ICN; some SCRSSNs do not have an accompanying PatientICN; some SCRSSNs have multiple PatientICNs. 1. Then, to see which ICD procedure codes were coded for this inpatient stay, one must link to the [Dim]. 2. (Available at the VHA Data Portal. For example, there are observations in which INTIND = 1 and INTAMT = $0. Fee Basis: 214-857-1397 C & P. VA Claims Representation; RESOURCES. Facility Information Security Officers (ISOs) are often the CUPS POC. Appropriate access enforcement and physical security control must also be implemented. Inpatient procedures are captured by ICD-9 procedure codes (SURG9CD1-SURG9CD25) in the hospital claims file. Payer Name: VA Fee Basis Programs - thePracticeBridge All preauthorized claims are then processed through the Fee Basis Claims System (FBCS) at the local facility as well as sent to the payment team. Table 9 lists a number of financial variables the SQL data contain. Identifying Veterans in the CDW [online; VA intranet only]. Hit enter to expand a main menu option (Health, Benefits, etc). Available at:http://vaww.vhadataportal.med.va.gov/Resources/DataReports.aspx. 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? Dental claims must be filed via 837 EDI transaction or using the most current. [FeeInitialTreatment], [Fee]. Researchers will thus need permissions to allow the CDW data manager to obtain SCRSSN or SSN to PatientICN crosswalk to allow for the necessary data linkages. [FeeInpatInvoiceICDDiagnosis], [Dim]. U.S. Department of Veterans Affairs. Each table has only one primary key field. This guide serves as an addendum to any technical documentation supplied by the healthcare clearinghouse when establishing a trading partner agreement. However, investigation has confirmed these are partial payments made for a single encounter or procedure. 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). This FPOV variable broadly categorizes the reason for the encounter, such as hospice or respite care. retrieving information only; except as otherwise explicitly authorized for official These represent cases in which payment is disallowed. One can use the FeeInitialTreatmentSID variable in the FeeServiceProvided table to link to the Fee.FeeInitialTreatment table. There are a number of different variables that denote the category of care a Veteran received through Fee Basis (see Table 2) Appendices B and H present more details about the values these variables can take. June 5, 2009. While NPI is available in SQL data, it does require special permissions to access, as it is located in the [Sstaff]. Compare the discharge date of the first observation to the admission date of the next (second) observation. b. 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. Some vendors use centralized billing services located in other cities, in a few cases in other states. PDF VA Community Care - Veterans Affairs As noted above, in SAS, the patient identifier is the SCRSSN; this is unique to each patient across the entire VA. SAS data are housed in 8 ready-to-use datasets per fiscal year. April 08, 2014. Accessed October 16, 2015. These clams contain charges and are known as claimed amounts (PAMTCL in SAS, ClaimedAmount in SQL). 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. [OEFOIFService]and [Dim].[POWLocation]. If the Veteran received care in the community that was not pre-authorized, it is considered unauthorized by VA. This table contains information on inpatient care. October 1, 2015. SQL data are housed at CDW, which is a collection of many servers. One can use the same approach as for the inpatient SQL data described above to locate the date of service. Go to CDW Home, click on CDW MetaData, then click on the link for Purchased Care. For care received under the Choice Act, Veterans will work with the third party administrators of the Choice program to find an eligible provider in their area.4. FBCS is where weve spent the bulk of our time investigating. Users must ensure sensitive data is properly protected in compliance with all VA regulations. When a key field is missing, SQL indicates this with a value of -1. Fee Basis Services - VetsFirst We assume here that new inpatient stays are defined by a change in vendor or a gap in treatment day more than 1 day. NPI is available within the VA CDW SStaff table. We are grateful for their cogent work. Fee-for-Service Providers | DMAS - Department of Medical - Virginia We detail differences amongst the SAS and SQL Fee Basis data in the guidebook below. The Veteran's full 9-digit social security number (SSN) may be used if the ICN is not available. Patient identifiers are also different across SAS and SQL data. VA Fee Basis Programs. In SQL, the fields containing these data can be found in the FeeDispositionCode and FeeDispositionName Refer to Appendix C for a list of Fee Disposition Codes. The vendor identity can be found through the VENDID or VEN13N variables in SAS. 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. There are also differences in the variables contained in the SAS versus SQL data. The same concept (such as fiscal year, state, or county) may be represented by several variables, sometimes in differing formats. visit VeteransCrisisLine.net for more resources. Quality of Life and Veterans Affairs Appropriations Act of 2006 (Public Law 109-114),the FSC offers a wide range of financial and accounting products and services to both the VA and Other Government Agencies (OGA). UB-92 box 56 (ProviderNPI) represents the providers National Provider Identifier. Fee Basis data are housed in VA in both SAS dataset format and Microsoft SQL server tables (hereafter referred to as SQL data). Accessed October 07, 2015. URLs are not live because they are VA intranet only. VA HEALTH CARE Management and Oversight of Fee Basis Care Need. Attention A T users. The process of linking can be complex; analysts should take care to reduce errors during this process. To link an authorization to a claim, use the trifecta of what VistA would consider sta3n, PatientIEN, and AuthorizationIEN. SQL Fee data are available through the VA Corporate Data Warehouse (CDW)/VA Informatics and Computing Infrastructure (VINCI). The DSS Fee Basis Claims System (FBCS) is a web-based claim management system. U.S. Department of Veterans Affairs. If the gap is 0 or 1, evaluate the discharge date of the first and second observation. The charge for an ambulance trip to a non-VA hospital may be paid through the Non-VA Medical Care program if the medical center determines that the hospital services meet the criteria for an unauthorized claim or a 38 U.S.C 1725 (Mill Bill) claim, or if the patient died while in route to the facility. HERC researchers found that claims for the professional component of hospital stays also appeared in the file of claims for outpatient services. American Society of Health-System Pharmacy (ASHP). [FeeVendor] table. 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. 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. To find all care provided in a particular fiscal year requires searching by treatment date over several years of Non-VA Medical Care claims. There is a lack of publicly available technical documentation and support may be limited to specific forums. Office of Accountability & Whistleblower Protection, Training - Exposure - Experience (TEE) Tournament, New York/New Jersey VA Health Care Network, Call TTY if you These tables involve payments paid only through FBCS. 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. Box 14830Albany, NY 12212. 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. Fee Basis data files contain information regarding both the care the Veteran received and the reimbursement of the care. For dual pension and compensation claims, use the mailing address below for compensation claims. DSS Fee Basis Claims Systems (FBCS) - oit.va.gov Missingness can vary substantially by year and by file. 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). Name of the medication. The discussion below pertains to both SAS and SQL data. VA intranet users can visit https://vaww.va.gov/communitycare/ (intranet only). *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. 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: All SAS prescription-related data is found in two files: the PHR file and the PHARMVEN file. A claim without errors or omissions is said to be clean. If VA has authority to pay the claim and the submitted documentation is sufficient then the claim is approved for payment. It is also possible that researchers will find a slight difference in the observations that the SAS versus SQL data contain. [Patient], [Spatient]. 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). 9.2. Basic demographic variables can be found in the [Patient]. VA contracts out its hospice; therefore, the Fee Basis files contain a great deal of data related to hospice care. The two tables can be joined through FeePharmacyInvoiceSID. 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. The process for filing a claim for services rendered to a Veteran in the community varies depending upon whether or not the services were referred by VA and by the entity through which the services were authorizedVA or one of the VA Third Party Administrators (TriWest Healthcare Alliance or Optum United Health Care). Veterans Affairs (VA) users must ensure VA sensitive data is properly protected in compliance with all VA regulations. Researchers will have to select observations from the SQL FeeServiceProvided table in order to ensure they are only evaluating outpatient data. This component distributes fee workload to particular users using the FBCS MS SQL database and the VistA Gateway. This table also includes claims related to inpatient care and other services. Users interested in learning the rules in force at a particular point in time should contact the VHA Office of Community Care. or use of this system constitutes user understanding and acceptance of these terms MDCAREID is the Medicare OSCAR number, which is a hospital identifier. 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. These rules are subject to change by statute or regulation. See 38 USC 1725 and 1728.). There are multiple potential identifiers for provider/vendor in the SAS data: the VENDID, VEN13N, MDCAREID, SPECCODE and NPI. Data Quality Program. _____________________________________________________________________________. These clams contain charges and are known as claimed amounts (PAMTCL in SAS, ClaimedAmount in SQL). 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. In the SAS data prior to FY 2007, the disbursed amount (DISAMT) had an implied decimal point whereas the payment amount (AMOUNT) did not. To file a claim for services authorized by VA, follow instructions included in the Submitting Claims section of the referral. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but didn't sign up for it. Va Fee Basis Program Claims Address - rutrackersplus However, there are best practices that all SQL-based analyses should follow. The Veterans Emergency Care Fairness Act (Public Law 111-137), signed February 1, 2010, authorizes VA as a secondary payer to third party liability insurance not related to health insurance. No, only one type of care can be covered by a single authorization. Types of VA Disability Claims | PTSD Lawyers - Berry Law (formerly known as VA Fee Basis or NonVA)-Community provider submits the claim and supporting documentation through their EDI provider services in . For more information call 1-800-396-7929. 1725 (the Mill Bill) by enabling VA to pay for or reimburse Veterans enrolled in VA health care for the remaining cost of emergency care if the liability insurance only covered part of the cost. [LocalDrug] table through LocalDrugSID to see whether there was the generic equivalent found in the VA drug file that was dispensed to the patient. Some important DIM tables that will be useful in analyzing Fee Basis data are FeePurposeOfVisit, FeeSpecialtyCode, FeeVendor, ICD, ICDProcedure Code, DRG, CPT, and CPT Category. In this case the first record would have an admission date of Jan 1, 2010 and a discharge date of Jan 10, 2010. [ICDProcedure] table and a foreign key in the [Fee]. Patient type can take one of seven values: surgical; medical; home nursing; psych contract; psychiatric, neuro contract; or neurological. The mileage fee varies by type of ambulance service: ground, fixed wing, or rotary wing, POP zip code classification, and loaded mileage. 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. 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. Hit enter to expand a main menu option (Health, Benefits, etc). The key that allows for this linkage is the FeeInpatInvoiceSID which is a primary key in the [Fee]. [ SFeeVendor] table. This rule applies even when the patient is incapable of making a call. [FeeInpatInvoiceICDProcedure] table. Defining a cohort is an activity that is different for each project and depends on the research question at hand. For the inpatient data, we compared observations with the same patient identifier, based on PaidDate in SQL and TRANSDAT in SAS. 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. For more information call 1-800-396-7929. Search VA Fee Basis Programs PayerID 12115 and find the complete info about VA Fee Basis Programs Insurance Type, LOB, ENR, RTE, RTS, ERA, SEC, Customer Service Number and more . 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. Attention A T users. 1. VA Informatics and Computing Resource Center (VINCI). These clams contain charges and are known as claimed amounts (PAMTCL in SAS, ClaimedAmount in SQL). Accessed October 16, 2015. This guidebook describes characteristics of Fee Basis care data such as contents and missingness, and makes recommendations about its use for research purposes. Federal law puts prosthetics into a special payment category that mandates full financial support from VA. As implemented in VA policy, it requires that VA facilities provide all necessary prosthetics, orthotics, and assistive devices (prosthetics) needed by patients. All SAS variables are denoted in capital letters, while SQL fields are denoted without spaces, in accordance with how these fields are labeled in the SQL tables. There is a strong, but imperfect, concordance, between the observations housed in the SAS and SQL data. These data records cannot be linked to particular patient identifiers or encounters. These geographic variables indicate the VA station paying for the service. Working with the Veterans Health Adminstration: A Guide for Providers [online]. Researchers should use PatientICN to link patient data within CDW. 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. The Implementer of this technology has the responsibility to ensure the version deployed is 508-compliant. This application is directly attached to TWAIN compliant scanners and works offline to VistA and the FBCS MS SQL databases. 17. These data indicate the specialty code associated with the vendor, such as orthopedic surgery, cardiology, family practice, etc. They could form part of an overall strategy to locate care provided in specialized settings, such as state homes, or of specialized services like kidney dialysis. For these reasons, the program does not pay for 100% of care that was otherwise eligible. Emergency care can also be authorized by VA in certain circumstances when the VA is notified within 72 hours. Available at: http://www.mssny.org/Documents/Enews/Aug%208%202014/VA%20ProvidersGuide.pdf, 6. Each patient should have only one ICN in the entire VA, regardless of the number of facilities at which he is seen. Users of the data should keep in mind that these data represent the physical location of the entity billing for care, which may or may not be the same as the providers location. The veteran must wait over 30 days past their preferred appointment date or the date deemed medically necessary by their provider, b. VA Information Resource Center VHA Corporate Data Warehouse [webpage]. In SAS, these data can be found in the Vendor file. to) monitoring; recording; copying; auditing; inspecting; investigating; restricting Use of this technology is strictly controlled and not available for use within the general population. 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. The SQL prescription data are housed in the [Fee]. There are often multiple observations per inpatient stay and multiple observations per outpatient encounter. Authorized care claims must be submitted within 6 years of the date of service, service-connected emergency care claims must be submitted within 2 years of the date of service, and non-service-connected emergency care claims must be submitted within 90 days of the date of service/discharge. For example, DISAMT=1000 in FY06 really indicates DISAMT=10.00. The Non-VA Medical Care program covers the full range of medical and dental care, with these exceptions: Although VA utilization files contain many non-Veterans, Non-VA Medical Care files do not. This care will be approved (or denied) by the local VA Fee Office; the Veteran is then free to seek non-VA care. Many classes of Veterans are eligible for travel payments. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links. 5. 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. Veteran's ICN can be found on the VA issued HSRM referral. If a researcher decides to use FPOV, please note that an FPOV value of 52 indicates ED visit for persons whose care is covered under the Millennium Bill and should thus be included in evaluating ED care. INTIND and INTAMT are not always concordant. 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. Fee Basis Services. VA employees working on operations studies can build their own crosswalk file as they have permission to use these file. Multiple SQL tables contain these variables. Include the authorization number on the claim form for all non-emergent care. Second, there are some cases where the disbursed amount is $0, while the payment amount is greater than $0; these are cases in which the payment was cancelled and the true cost of care is thus $0. is ok, 12.6.5 is ok, 12.6.9 is ok, however 12.7.0 or 13.0 is not. . Other Health Insurance (OHI) and Explanation of Benefits (EOBs), Any other document type normally sent via paper in support of a Veteran unauthorized emergency claim. Hit enter to expand a main menu option (Health, Benefits, etc). SAS Fee Basis data can be linked to other SAS files with additional demographic data (e.g., Vital Status files, enrollment files). VA Palo Alto, Health Economics Resource Center; October 2013. For pension claims, use the Pension Management Center (PMC) that serves your state. Domains represent logically or conceptually related sets of data tables. A primary key is a key that is unique for each record. The key field indicates which invoice they appeared on. For current information on Community Care data, please visit the page. Make sure you have received an official authorization to provide care or that the care is of an emergent nature. It is available in the PHARVEN and VEN files, albeit with a high degree of missingness. VA Information Resource Center. [FeePrescription] tables. The National Provider Identifier (NPI) is a unique 10 digit identifier mandated to be used in health claims under the Health Insurance Portability and Accountability Act (HIPAA).