VA RFI: FBCS (741 Claims Pricing and Audit Support)

Notices

Notice ID: 36C10B21Q0034

Department of Veterans Affairs (VA) Technology Acquisition Center, is seeking information for VA, VHA, concerning the availability of capable contractors to provide support and IPERA (Improper Payments Elimination and Recovery Act) compliance audits for claims processed and paid through the Fee Basis Claims System (FBCS) and provide pricing support for Medical Claims.

VA currently uses the Fee Base Claim System (FBCS) to manage and process Fee claims in an electronic environment which improved the ability to keep track of claims in-process and enables identification of duplicate and non-compliant claims. However, VA is in the process of retiring the FBCS software and going forward VA will use other systems to authorize and pay claims. Certain types of claims will still need to be priced that cannot be priced in the newer system which, going forward, is the Electronic Claims Adjudication Management System (eCAMS). The eCAMS cannot process historical claims because it does not have the original claims (frequency code 7s) information.

Our requirement is for a separate system that that can price claims with a frequency code 7.

Additionally, there will be mandatory periodic audits on claims processing for historical claims, which will require a review of the prices paid to non-VA health care providers compared to Centers for Medicare and Medicaid Services(CMS) allowable rates on the Government’s fee schedule for the applicable year, in which the claim was adjudicated (the scope of these audits may review up to seven years in the past). According to the CMS.gov website, a fee schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers.  This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee-for-service basis.  CMS develops fee schedules for physicians, ambulance services, clinical laboratory services, and durable medical equipment, prosthetics, orthotics, and supplies.

Pricing of specific types of Medical Claims

The contractor shall provide website access to provide pricing support for small subset of Medical Claims to ensure proper pricing of claims. This pricing support entails upload of a claim to the website and a price returned with the claim. This subset of claims is expected to be between 1,000 and 1,500 claims per week and will decrease over time as the claims age. These claims use a Frequency code of either 7 (corrected or replacement claim) or 8 (voided or cancelled claim) which requires the original claim / price information to be processed. The Contractor shall provide a secure means of accepting 837 Health Care Claims (Professional, Institutional, & Dental) (aka EDI X12 Health Care Claim) files to be priced. The contractor will need access to the original claim price information to be able to price these claims. The Alpha II database (preferred) and the FBCS archive are the primary sources for original claim information. These claims will need to be priced in accordance with all associated CMS fee schedules used by the VA.

The contractor shall price claims sent to them in accordance with all applicable CMS fee schedules. At a minimum the below list of CMS fee schedules shall be used to price VA claims. The contractor shall ensure the latest CMS fee schedule are used to price claims.

Read more here.

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