VA Community Care: What Happens After a Referral

A Step-by-Step Guide for Veterans and Family Caregivers

Provided by Veterans Desk, Inc. – Supporting Veterans Through Every Step

Navigating VA Community Care can feel confusing, especially if this is your first time receiving care outside the VA system. Many Veterans and family caregivers worry about scheduling delays, unexpected bills, or whether they are “doing it right.” These concerns are valid—but the process becomes much easier when you understand what happens after a referral and what your responsibilities actually are.

This guide explains each step of the VA Community Care process in plain language, so you know what to expect, how to protect yourself from billing problems, and where to turn if something goes wrong. Whether you are managing your own care or helping a loved one, this step-by-step breakdown is designed to keep you informed, confident, and in control.

Step 1: The VA Approves the Referral

Once your VA clinician determines that Community Care is appropriate, the VA will issue an authorization allowing you to receive care outside the VA system. This authorization is often documented using VA Form 10-10172 or entered electronically into VA systems.

A referral may be approved for several reasons, including:

• Long wait times for VA appointments 
• Excessive distance or travel burden to a VA facility 
• No available VA specialist for your condition 
• Clinical necessity or best medical interest

This authorization is critical. It confirms:

• What type of care is approved 
• How many visits are allowed 
• The timeframe during which care must occur

What you should do:
Keep a copy of your referral and authorization number in a safe place. Take a photo of it on your phone and store a paper copy if possible. This number connects every appointment, claim, and payment—and it is your strongest protection if a billing issue arises later.

Step 2: Scheduling the Appointment

After authorization, the VA or a Third Party Administrator (TPA), either Optum or TriWest, depending on your region, will help schedule your appointment with an approved community provider.

In some cases:

• The VA or TPA will contact you directly to schedule 
• The provider may reach out to you 
• You may be permitted to schedule the appointment yourself

If you schedule the appointment on your own, authorization must already be in place, and you should notify your VA care team so your records remain accurate.

Important reminder:
Never attend a community appointment unless you have confirmed that:

• The provider received VA authorization 
• The appointment falls within the authorized date range

Attending care without confirmed authorization is one of the most common reasons Veterans receive improper bills.

Step 3: Attend the Appointment

On the day of your appointment:

• Go to the provider as scheduled 
• Receive only the services listed in your VA authorization

You do not need to:

• Present private insurance 
• Pay a co-pay or any out-of-pocket cost 
• Sign financial responsibility forms for authorized care

If the provider believes you need additional visits, tests, or services, they must request VA approval before providing them. Extra services without approval may not be covered.

Step 4: The Provider Bills the VA, Not You

After your visit, the community provider is responsible for billing:

• The correct TPA (Optum or TriWest), or 
• The VA directly, depending on the referral type

The provider must submit:

• Your authorization number 
• Correct billing and diagnosis codes 
• Required medical documentation

The provider is not allowed to bill you for VA-authorized care even if:

• The claim is delayed 
• The claim is denied initially 
• The provider made a billing error

Once the claim is reviewed and approved, the VA pays the provider directly.

Step 5: Keep Records

Good recordkeeping protects you. Create a personal folder, digital or paper, that includes:

• Your VA authorization letter or form 
• Appointment confirmations 
• The provider’s After Visit Summary, which outlines: 
  • Care received 
  • Medications prescribed 
  • Follow-up instructions 
• Any bills you receive (do not pay them) 
• Notes from phone calls with the VA, TPA, or provider

These records are invaluable if you ever need to dispute a bill or clarify what services were authorized.

Step 6: What If You Receive a Bill?

Do not pay. Do not ignore it. Take these steps:

1. Contact the Provider’s Billing Office:
   • Inform them that the care was VA-authorized and that you are not responsible.
   • Give them the authorization number and date of service.
   • Request that they submit the bill to the VA or resubmit if previously denied.
2. Call the VA Community Care Office:
   • Use the phone number listed in your referral paperwork.
   • Ask for help resolving the billing error.
3. Call the TPA (TriWest or Optum):
   • Provide your authorization number and date of service.
   • Ask for claim status and clarification.
4. Veterans Desk:
   • Visit VeteransDesk.org for word template examples to avoid collections
   • These templates are for educational purposes only.

• This should not happen.
• You have rights under the VA MISSION Act to dispute medical debt caused by VA billing delays.

Take action:

• Contact the collections agency and explain that this is VA-authorized care.
• Request a pause on collections while you resolve the issue with the VA.
• If you’re having trouble resolving a billing issue, you can file a formal complaint with the VA Office of Community Care. This office is responsible for overseeing the Community Care program and can help you resolve disputes. File a formal complaint with the VA Office of Community Care.

Veterans Desk is here to help with step-by-step templates and outreach support, providing you with the reassurance and support you need during this process. You are not alone in this journey.

Step 7: Help the VA Pay the Provider (if needed)

In some cases, a claim is denied because:

• The provider used the wrong billing code
• The claim was submitted late.
• There was a missing progress note.e

While it’s not your job to fix this, you can:

• Provide your referral and date of service
• Your VA Community Care Coordinator can help the provider resubmit the claim if needed. They are there to assist you throughout the process, from the initial referral to the final payment. Ask your VA Community Care Coordinator to help the provider resubmit.
• Ask Veterans Desk for sample letters to help move the claim forward.d

How the Provider Gets Paid

1. Provider receives VA authorization.
2. The provider sees the veteran and documents the care.
3. Provider submits claim to TriWest or Optum with:
   • Correct VA authorization number
   • CPT/diagnosis codes
   • Progress notes
4. TPA/VA reviews and approves payment.
5. The VA pays the provider—not the veteran.

If the provider skips a step or files late, they may be denied, but still cannot bill you.

Summary

• Veterans never pay for VA-authorized Community Care.
• Always keep your authorization number and appointment records. This will help you stay organized and in control of your care.
• Never ignore a bill—respond, dispute, and reach out for help.
• Use VeteransDesk.org to download templates, track your case, and protect your credit.

IMPORTANT NOTICE

Educational use only. No medical or legal advice.

Veterans Desk is a 501(c)(3) nonprofit, not a government agency, and not affiliated with the U.S. Department of Veterans Affairs or any federal or state agency.

Veterans Desk does not provide medical treatment, prescribe medications or collect or store protected health information (PHI).

Veterans Desk provides only education and navigation support.
All healthcare decisions belong to you and your licensed clinicians.

Emergency: 911 | Veterans Crisis Line: 988 (Press 1)