HERC: Veterans Choice Program - Fee Basis Claims System in CDW
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Veterans Choice Program - Fee Basis Claims System in CDW

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Fee Basis Claims System (FBCS) in the VA Corporate Data Warehouse

All Choice claims are processed by VISN 15. This amounts to approximately 1.7 million claims processed per month and approximately $5-8 billion per year. There are 34 Fee Basis Claims Systems (FBCS) servers, which were originally designed for episodes of care. FBCS is moving to a centralized system in the near future, where there will be centralized rules and national policies with 3 distinct groups: CCN (network), CCRA (authorization), and CCRS (reimbursement system; an IBM product). FBCS is where we’ve spent the bulk of our time investigating. Below are some answers to general questions about the FBCS tables.

  • What types of claims show up in the FBCS tables?
    • These tables involve payments paid only through FBCS. If the payment was made outside of FBCS, they won’t show here.
  • How can I identify Choice records in FBCS?
    • Identify Choice records by using tax ID and ‘specialprovcat’= “CHOICE”. You can further refine by selecting records on or after November 4, 2014, when Choice was first enacted.
  • Are there any facilities with known Choice data problems?
    • Beware of VISNS 4, 15, and 23, as they have their own integrated system. We suggest using only the first 3 characters from sta3n for the merge. For example, sta3n 589A5 will be found as 589.
  • What do the values for “status” mean and how can I use it?
    • The ‘status’ value “A” stands for accepted, meaning the claim was paid.
    • The ‘status’ value “R” stands for re-routed, meaning the claim was re-routed to the Health Administration Center (HAC). This means the data were placed in the PIT and the claim was not paid through FBCS. Note: records with ‘status’= “R” can have missing values for the variables ‘vistapatkey’ and ‘vistaauthkey’, depending on whether or not these were linked before rejecting as a re-route to HAC.
  • Are authorization numbers used more than once?(e.g., can multiple visits be authorized with one authorization number?
    • Yes. Multiple claims can be paid against a single authorization.
  • Can there be multiple types of care (e.g., categories of care) included in a single authorization?
    • No, only one type of care can be covered by a single authorization.
  • What is the variable name in FBCS for estimate of cost?
    • Use the column 'estimated cost' and it is available in the CDW FBCS data. 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.
  • How long does it take for traditional Fee and Choice paid claims to show up in CDW FBCS data?
    • Roughly within 7 days.
  • Do “Lump Sum/Expedited Payments” end up in FBCS?
    • Lump sum payments are not paid via FBCS. FBCS supports payment of claims via VistA. 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. 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.
  • What happened to the Choice data in FBCS in FY2016-2017?
    • It appears that starting in FY2016, Choice data is now bypassing FBCS and residing in the PIT. By June 2017, no Choice stays are found in FBCS.

We tried to link the UB-92 form to identify Choice authorizations; however, we found few records and decided to use obligation number. Below are some answers to general questions about linking the UB-92 form to the FBCS data.

  • How can I link the UB-92 to Choice authorizations?
    • To link an authorization to a claim, use the “trifecta” of what VistA would consider sta3n, PatientIEN, and AuthorizationIEN. The UB-92 equivalent variables would be: facility (after merging in facility name from the FBCS_Facilities table), vistapatkey, and vistaauthkey, respectively.
  • What variables do I use to link a treatment date in my dataset to the UB-92?
    • Treatment date correlates to covered from/to. However, not all dates on the claim are approved.
  • What do the different dates on the UB-92 mean?
    • 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 variable DTStamp represent the date the claim was received. The dates of service are represented by the covered from/to fields of the UB-92. Note: Admission date is only relevant for inpatient stays; it is not relevant for outpatient visits.
  • What variables describe the health insurance present?
    • When a claim is linked to VistA, the variable ‘Other_Hlth_ins_present’ is populated. We view the patient’s insurance data in the VistA file if the claim is flagged as reimbursable in VistA and encompasses the dates on the claim. It is only relevant for claims linked to VistA patients.
  • What variables describe the provider on the UB-92?
    • UB-92 box 56 (ProviderNPI) represents the provider’s National Provider Identifier.
  • What do you know about the UB-92 variable SPECIALPROVCAT?
    • We found SPECIALPROVCAT was missing in 93% of records. Additionally, we found 0.94% of records were approved Choice claims (e.g., records where SPECIALPROVCAT= ‘CHOICE’ and STATUS= ‘A’ (approved)).

Last updated: September 6, 2018