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At VA, our community partners are key to making sure Veterans
have access to timely, high-quality health care.
When VA refers a Veteran to a community provider, a detailed
authorization is issued by VA or one of VA’s Third Party
Administrators (TPAs). The authorization allows the
community provider to provide care to the Veteran and for VA
or the TPA to pay for the care.
After a community provider furnishes care to a Veteran
based on the scope of services in the authorization, a claim
for reimbursement should be filed with the appropriate
authorizing party, either VA or a TPA. Instructions for filing
the claim are included in the authorization. Filing claims and
supporting documentation electronically is recommended
because it reduces the risk of errors and speeds up
reimbursement. While not required to process a claim for
authorized services, medical documentation should be
submitted to the authorizing VA medical facility as soon as
possible after care has been provided. This is important
because it allows VA to incorporate it into the
Veteran’s medical record. Please note that for care authorized
through a TPA, claims for reimbursement can only be filed
with the appropriate TPA that generated the authorization.
For community providers who provide emergency care to a
Veteran, VA must be notified within 72 hours of the emergency
room visit.
Upon notification, and after receiving supporting
documentation, VA may generally approve payment for emergency
care based on whether the care provided is related to a
Veteran’s service-connected condition, if the community
provider is in VA’s network, and whether or not VA was notified
within 72 hours.
If the emergency care is approved after appropriate
notification, an authorization will be generated by VA or a TPA
and provided to the community provider.
Claims for that care should be filed according to
instructions in the authorization.
In some cases, emergency care may not be authorized. This
generally occurs when the care provided is not related to a
Veteran’s service-connected condition, the community
provider is not in VA’s network, and/or VA was not notified
within 72 hours.
When the community provider is out-of-network and/or VA was not
notified within 72 hours, claims may be filed with the nearest VA
medical facility for reimbursement consideration.
In addition, please note the following about unauthorized
emergency care claims: VA may require and request medical
documentation, and community providers should use electronic
claim and documentation submission processes.
After a claim has been filed and processed, it will be classified
as accepted (approved for payment) or denied. Claims are
denied when the care was not authorized and when the Veteran
does not meet eligibility requirements. To avoid having a
claim denied, make sure you have received an official
authorization to provide care from either VA or the TPA,
include the authorization number with the claim, and make sure
the care being requested for reimbursement is within the
scope of that authorization.
Claims are also denied when they cannot be paid due to billing
errors or the need for more information. To avoid having a
claim denied, include the authorization number in the
referral/authorization field, check the accuracy of billing
codes, make sure claims are submitted in accordance with
nationally standardized billing requirements, include the
Veteran’s full nine-digit Social Security number in the insured’s
ID number field, send the claims to the correct authorizing party
(VA or TPA), and, for emergency care claims, medical
documentation may be required, such as the ER report, and for
inpatient care, history and physical, discharge summary,
and progress notes.
To find out the status of a claim filed with a TPA, contact
the appropriate TPA. For claims filed directly with the VA,
community providers can check VA’s Customer Engagement Portal,
or CEP, at this website. Registration is required.
To learn more about filing claims for Veteran community
care, visit our website at this address.