Community Care

Precertification Requirements

The VA is required by law to bill Third Party Payers (TTP) for care that is not related to a Veteran’s service-connected disability or Special Authority. This requires VA to call TPPs for precertification for patients who are VHA beneficiaries with other billable health insurance (OHI). Please note that claims for ancillary services will be processed in accordance with Medicare National Correct Coding Initiative(NCCI), Medically Unlikely Edits (MUE), and related edits.

The preferred method for submitting requests is via the HealthShare Referral Management (HSRM) provider portal using the Task: CCN PRECERTIFICATION NOTIFICATION. Although this is the preferred method of notifying Revenue Operations of precertification, the request can also be submitted via fax.

Once the community care provider has notified VHA Revenue Operations that the test/procedure/admission requiring TPP precertification is scheduled, there is no requirement to wait for the TPP approval or response prior to performing the test/procedure/admission included as part of the SEOC referral.

If you are interested in more information about HealthShare Referral Manager, please review our Care Coordination page. To sign up for the HSRM Provider Portal, please select the Community Care Referral and Authorization (CCRA) option from the AccessVA website.

Fax numbers by Consolidated Patient Account Center (CPAC) Region are listed below:

Standardized Episodes of Care (SEOC) Billing Code Information

The VA SEOC Billing Code List provides preapproved billing codes associated to the services within each available SEOC. The list also contains billing codes that require TPP precertification, called "Precertification (Precert) Codes.” While the codes have been clinically approved in the referral by the VA as part of the SEOC, an additional precertification request must be submitted by VHA Revenue Operations to the Veteran’s TPP for the precert codes.

Prior to viewing the VA SEOC Billing Code List, you must accept the terms and conditions defined in the License for Use Of Current Procedural Terminology

Additional Coding Information

Ancillary Codes: Please note that claims for ancillary services will be processed in accordance with CMS NCCI, MUE, and related edits.

If code(s) are not on SEOC: Services provided must be appropriate and necessary to accomplish the intent of the referring providers order/consult request. The Standardized Episode of Care (SEOC) describes the most likely scope of care necessary, but other services may be allowed in certain circumstances if necessary for completing the referral.

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