Veterans Affairs (VA) users must ensure VA sensitive data is properly protected in compliance with all VA regulations. Facility Information Security Officers (ISOs) are often the CUPS POC. (2) Additionally, a Veteran must also meet at least one of the following criteria. If using payment amount, one would overestimate the cost of care. All access Please visit Emergency Care Claims to learn more. Optum is a proud partner with the VA through its Community Care Network (CCN). The payment amount variables (AMOUNT and DISAMT) are missing (blank) in a small number of cases. 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. Fee-for-Service Providers | DMAS - Department of Medical - Virginia As of July 2015, the current mileage reimbursement rate is 41.5 cents per mile. Bowel and Bladder Care. It is not available for claims in which payment was based on a contract amount. PatientICN is assigned by CDW. Fee Basis providers vary in how frequently they submit an invoice for Fee Basis care. If there are multiple providers using the same entity to bill their claims, it will not be possible to disaggregate what type of provider the patient saw (e.g., an internal medicine physician or an infectious disease specialist). PO BOX 4444. This rare event most likely indicates a transfer. 15. The Department of Veterans Affairs has implemented centralized mail processing (CM) for compensation claims to reduce incoming paper handling and shipping requirements. VA Technical Reference Model v 23.2 DSS Fee Basis Claims Systems (FBCS) General Decision Reference Component Category Analysis General Information Technologies must be operated and maintained in accordance with Federal and Department security and privacy policies and guidelines. VA may be a secondary payer for unauthorized emergent claims under 38 U.S.C. The Vendor Release table provides the known releases for the. In general, persons on active duty in the U.S. military are excluded even if they are transitioning to VA care. The status value R stands for re-routed, meaning the claim was re-routed to the Health Administration Center (HAC). Plan Name or Program Name," as this is a required field. Mark Smith and Adam Chow were the authors of the original HERC guidebook, upon which this document builds. Domains generally indicate the application in the VistA electronic health record system from which most of the data elements come (e.g., Vital Signs or Mental Health Assessment).6. The 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. Private health insurance coverage through a Veteran or Veteran's spouse is insurance provided by an employer, Veteran or other non-federal source, including Medicare . This guide was published in October 2015; the same month the United States switched from ICD-9 to ICD-10. Health plans include private health insurance, Medicare, Medicaid, and other forms of insurance that will pay for medical treatment arising from the patients injury or illness (e.g., automobile insurance following a car accident). Data Quality Program. Claims for Non-VA Emergency Care A valid receipt showing the amount paid for the prescription. The clinic of jurisdiction, or medical facility, authorizes such care under the fee-basis program . It is also possible that researchers will find a slight difference in the observations that the SAS versus SQL data contain. Inpatient data are housed in the FeeInpatInvoice table as well as the FeeServiceProvided table, although the latter does not contain only inpatient data. How Does VGLI Compare to Other Insurance Programs? Each table has only one primary key field. [Patient], [PatSub]. April 14, 2014. Under the Veterans Choice Act, eligible veterans are able to obtain outpatient care outside the VA using their Choice Card. The Fee Card (VET) file contains only summary payment figures by month, although researchers can match the records to other data by SCRSSN and other identifiers. One can use the FeeInitialTreatmentSID variable in the FeeServiceProvided table to link to the Fee.FeeInitialTreatment table. The Veteran files contain the richest patient demographic information in the SAS data; these include the Veterans date of birth, sex, prisoner of war status and war code. Journal of Rehabilitation Research and Development. 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. On March 17, 2022, The U.S. Court of Appeals for the Federal Circuit issued a ruling that changes VA's ability to reimburse as secondary payer under 38 U.S.C.1725. The prescription must be for a service-connected condition or must otherwise have specific approval. 3. There are five forms of patient identifiers in SQL files at CDW (including but not limited to the Fee Basis files): PatientICN, PatientSID, PatientSSN, ScrSSN, and PatientIEN. It may duplicate the PatientIEN of another patient at another facility, and should not be used as an identifier. We encourage readers to seek out the latest guidance before conducting analyses, as CDW Data Quality Analysis team may have updates to this information. If the provider declines VA payment then it may be able to charge the patient a greater total amount. Of note, SQL and SAS data contain similar, but not exactly the same, information. Accessed October 16, 2015. access; blocking; tracking; disclosing to authorized personnel; or any other authorized Users interested in learning the rules in force at a particular point in time should contact the VHA Office of Community Care. VA Information Resource Center VHA Corporate Data Warehouse [webpage]. 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. 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. Accessed October 16, 2015. Some vendors use centralized billing services located in other cities, in a few cases in other states. 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. 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. There may be multiple vendor IDs (VENDIDs) for a single inpatient stay. [1] The Health Care Financing Administration (HCFA) was renamed the Centers for Medicare and Medicaid Services. [FeePharmacyInvoice] table contains information on vendor, amount claimed, and amount paid. This application reads/creates/edits fee payment data in VistA and copies critical information into the central SQL database for off-line VistA applications to consume, and now includes Unauthorized payments. Private health insurance coverage through a Veteran or Veteran's spouse is insurance provided by an employer, Veteran or other non-federal source, including Medicare supplemental plans. VA evaluates these claims and decides how much to reimburse these providers for care. The VA Fee Basis medical program provides payment authorization for eligible Veterans to obtain routine medical treatment services through non-VA health care providers. Appendix D contains information on the primary and foreign keys needed to link the various SQL tables. VA HEALTH CARE Management and Oversight of Fee Basis Care Need. [ICD] table, the latter of which contains a list of all possible ICD-9 codes. The vendor identity can be found through the VENDID or VEN13N variables in SAS. There are nine situations in which Non-VA Medical Care is authorized. Through the CCN, Veterans have access to regional networks of high-performing, licensed health care . VA intranet only: http://vaww.vhadataportal.med.va.gov/Resources/DataReports.aspx). At the time of writing (October 2015), only operations staff will have permission to access the SAS data at VINCI. For EDI 837, Referral Number is Loop = 2300, Segment = REF*9F, Position = REF02 or Prior Authorization. 1725 when remaining liability to the Veteran is not a copayment or similar payment. Chapter 6 contains more information about how to access these data. In SAS, ICD-9 diagnosis codes are in the Inpatient, Outpatient and Ancillary files. Additionally, we found 0.94% of records were approved Choice claims (e.g., records where SPECIALPROVCAT= CHOICE and STATUS= A (approved)). Note that the vendor may represent the hospital, a hospital chain or the entity billing on behalf of the provider. 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. VINCI. 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. Hit enter to expand a main menu option (Health, Benefits, etc). Also, you may have to wait until the General Enrollment Period (from January 1 to March 31) to enroll in Part B. 10. The majority of claims, 99%, were processed within 2 years, with the exception of pharmacy data in FY 2004 and FY2008. Using the Non-VA Medical Care data for research requires a basic understanding of laws and regulations that govern it. Get Help from Our VA Disability Claim Appeals Lawyers Today. All Fee Basis care will be found in the Fee files. The VA pays for both emergency and non-emergency care through Fee Basis mechanisms. There are no references identified for this entry. 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. The Implementer of this technology has the responsibility to ensure the version deployed is 508-compliant. Care provided to persons associated with a particular VA station can be found by selecting records by STA3N. Available at: http://vaww.virec.research.va.gov/CDW/Overview.htm. One can evaluate which encounters were unauthorized by joining the FeeUnauthorizedClaim table through the FeeUnauthorizedClaimSID key. To link an authorization to a claim, use the trifecta of what VistA would consider sta3n, PatientIEN, and AuthorizationIEN. In that case, use payment amount instead. 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. CDW Data Quality Analysis Team has particular recommendations for excluding observations before beginning analyses on your cohort.13 Corporate Data Warehouse (CDW) contains dummy data as well as test patients that will need to be removed from tables before conducting analyses. SAS Fee Basis data can be linked to other SAS files with additional demographic data (e.g., Vital Status files, enrollment files). These clams contain charges and are known as claimed amounts (PAMTCL in SAS, ClaimedAmount in SQL). Veterans who meet certain criteria may be eligible for mileage reimbursement for travel to and from VA or Non-VA care. FPOV values of 32 and 33 also indicate ED visits, but are only observed in the Ancillary file. 5. There are substantial differences in quantity of inpatient diagnosis and procedure data available in SAS versus SQL. When MDCAREID is not available, it is possible to assign MCCAREID based on the relationship between VEN13N and STA6A. Make sure the services provided are within the scope of the authorization. For these reasons, the program does not pay for 100% of care that was otherwise eligible. Payer Name: VA Fee Basis Programs - thePracticeBridge However, there are some outliers; some claims can take up to 8 years to process. There may be many providers that use the same vendor for billing. Multiple SAS datasets have VENID and VEN13N. However, in all data files, the vast majority of observations are missing values for this variable. privacy policies and guidelines. Veterans Health Administration. A missing value of the primary diagnosis code should therefore be treated as truly missing. Austin Information Technology Center (AITC) is one of the VAs five national data centers. Thus, unauthorized care is not unpaid care it is simply not PRE-authorized care. Include the authorization number on the claim form for all non-emergent care. A foreign key is a key that uniquely identifies a record of another table. FBCS is designed to be used in the Fee Basis Departments of the Veteran Affairs Medical Centers (VAMCs). The amount of interest paid on the claim, if any, appears as the variable INTAMT. You will have to pay this penalty for as long as you have Part B. If electronic capability is not available, providers can submit claims by mail. 2. 3. 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. When a claim is linked to VistA, the variable Other_Hlth_ins_present is populated. 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.