Community Care

Most commonly, authorized care refers to medical or dental care that was approved and arranged by VA to be completed in the community. Emergency care can also be authorized by VA in certain circumstances when the VA is notified within 72 hours. To file a claim for services authorized by VA, follow instructions included in the “Submitting Claims” section of the referral.

There are three routes for filing claims for authorized care which depend on your status in VA’s network and how the care was authorized:

• Community Care Network (CCN)–If you are part of the CCN with TriWest HealthCare Alliance (TriWest) or Optum United Health Care (Optum), you must file the claim with the correct CCN Third Party Administrator (TPA) as per the authorization/referral.
  • For CCN Regions 1-3, file with Optum.
  • For CCN Region 4, file with TriWest.
• Patient Centered-Community Care (PC3) Network–If you are part of Patient Centered Community Care Network (PC3), file claims with TriWest.
  *NOTE: Once fully deployed, CCN will replace PC3. Any and all existing PC3 referrals will remain intact and valid for the entire scope and length of the approved referral.
• Veterans Care Agreement (VCA)/Local Contract–If you have a Veterans Care Agreement (VCA) established with VA or are not part of one of VA’s formal networks, file claims with VA.

All non-urgent and non-emergent care requires authorization from VA in advance. Eligibility and claims submission information for emergent care will be provided after notification is made to the VA. Claims for emergent care not eligible for authorization upon notification, may be eligible for consideration as Unauthorized Care. If notification was not made to VA and you wish to have claims considered for payment, please submit claims and supporting documentation to VA’s Centralized Claims Intake center listed in the "Where Do I Send my Claims and Documentation?" section below.

Please visit Emergency Care Claims to learn more.

• Complete and accurate standard Center for Medicare & Medicaid Services (CMS) or American Dental Association (ADA) billing form or electronic transaction containing false claims notice (such as CMS 1450, CMS 1500 or 837 EDI transaction).
• National Provider Identifier: Submit all that are applicable, including, but not limited to billing, rendering/servicing, and referring.
• For authorized care, the “referral number” listed on the “Billing and Other Referral Information” form.

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The deadline for claims submission is dependent upon which program the care has been authorized through or which program the emergency care will be considered under.

Electronic 837 claim and 275 supoorting documentation submissions can be completed through VA’s contracted clearinghouse, Change Healthcare, or through another clearinghouse of your choice.

Change Healthcare Contacts

EDI Referral/Authorization Annotation Information

• For EDI 837, Referral Number is Loop = 2300, Segment = REF*9F, Position = REF02 or Prior Authorization,
  Loop = 2300, Segment = REF*G1, Position = REF02.
• Home Health Agencies billing with an OASIS Treatment number use the Prior Authorization segment for the TAC and the Referral Number segment on the 837I submission.

VA strongly encourages community providers submit claims and required supporting documentation electronically through VA’s clearinghouse, Change Healthcare. Doing this can improve claim accuracy and reduce the amount of time for claims processing determinations. Paper claims and supporting documentation submitted to VA will be converted to EDI transactions through the P2E process prior to acceptance.

For information on the P2E process, please visit Paper to Electronic Claims.

Authorized Care

While not required to process a claim for authorized services, medical documentation must be submitted to the authorizing VA medical facility as soon as possible after care has been provided.

There are multiple methods by which community providers may electronically provide VA with the required medical documentation for care coordination purposes. Those options are:

Join the Veterans Health Information Exchange (VHIE) which enables bi-directional sharing of Veteran Health Information

Utilize HealthShare Referral Manager (HSRM) for referrals, authorizations and documentation exchange.

Use Azure Rights Management Services (Azure RMS) for encrypted email.

E-fax: Documentation sent via email to Veterans Affairs Medical Center (VAMC) fax machine. Please contact the referring VAMC for e-fax number.

More information about submitting documentation for authorized care can be found at Request and Coordinate Care

The electronic 275 transaction process may be utilized to supply Remittance Advice doumentation for timely filing purposes. The 275 transaction process should not be utilized for the submission of any other documentation for authorized care.

NOTE: The processes outlined below are exclusive to supplying documentation for unauthorized emergent care. With the exception of supplying remittance advice supporting documentation for timely filing purposes, these processes do not apply to authorized care.

Unauthorized Emergent Care

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. Any supporting documentation that VA is unable to link to a claim will be returned to sender to for additional information.

Providers who continue to elect to submit paper claims and paper documentation to support claims for unauthorized emergency care should be aware of the following:

• VA must be capable of linking submitted supporting documentation to a corresponding claim.
• Community providers have three options that allow for that linkage:
  • Submit the claim electronically via 837 transaction and the supporting documentation via 275 transaction.
  • Include the claim, or a copy of the claim, on top of the supporting documentation that is mailed to the following address:

    VHA Office of Community Care
    P.O. Box 30780
    Tampa, FL 33630-3780

  • Include a completed cover sheet with the supporting documentation that is mailed to the above address.
    

    Cover sheets can be found electronically on the Paper to Electronic Claims (P2E) webpage.

Documentation in support of a claim may include:

*NOTE: Documentation not required includes flowsheets and medication administration

• Make sure you have received an official authorization to provide care or that the care is of an emergent nature.
• Submit the claim to the correct payer.
• Include the authorization number on the claim form for all non-emergent care.
• Make sure the services provided are within the scope of the authorization.
• Check the accuracy of billing codes.
• Include the Veteran’s full nine-digit social security number in the insured’s I.D. number field.

VA is the primary and sole payer when VA issues an authorization.

VA may be a secondary payer for unauthorized emergent claims under 38 U.S.C. §1725 (nonservice-connected conditions) when balances left due are not tied to a copayment.

Community providers should remain in contact with the referring VA Medical Center to ensure proper care coordination. Questions about care and authorization should be directed to the referring VA Medical Center.

• If your claim was submitted to VA, (877) 881-7618
• If your claim was submitted to TriWest, call (855) 722-2838
• If your claim was submitted to Optum:
  • Region 1: (888) 901-7407
  • Region 2: (844) 839-6108
  • Region 3: (888) 901-6613

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