Pre-Authorized Outpatient Medical Care

The Fee Program provides payment authorization for eligible veterans to obtain routine outpatient medical services through community providers. This authorization may be granted when it has been determined that direct VA services are either geographically inaccessible or VA facilities are not available to meet a veteran’s needs. All community services must be pre-authorized before a veteran receives treatment.

However, it may not be possible to contact VA prior to treatment in emergency situations. Each individual veteran’s eligibility status and medical care needs are reviewed to decide whether community treatment can be approved. The VA also requires a 72 hour notification for emergency room care to be considered pre-authorized.

Individual eligibility determinations are difficult, and therefore outside the scope of this general information. Please contact your local VA health care facility for individual veteran eligibility questions or concerns.

A local VA health care facility may request medical documentation to support adjudication of a submitted claim from a community health care provider. In addition, standard billing forms such as the CMS-1500 or CMS-1450 are required. Examples of these forms are shown on the Forms page.

Basic authorities and payment methodologies to provide preauthorized medical care are contained in: 38 U.S.C. 1703 & 38 CFR 17.52 – 17.56.