VA Community Care: Veteran Patient Care From Exam Room to Paid Claim

Part 1 of 4 — Ask for Community Care & Get Authorized

Your mission in Part 1:
Leave your VA visit with a clear answer: Are you eligible for Community Care, and is your referral properly documented and authorized? Here’s how to make that happen—step by step.

Step A: Find out if you qualify

Community Care allows certain medical services outside the VA if you meet eligibility criteria. Common reasons:

• Wait time or drive time is too long: 
  • Primary care, mental health, extended care: No appointment within 20 days or more than 30 minutes away.
  • Specialty care: No appointment within 28 days or more than 60 minutes away. (VA News, Veterans Affairs) 
• Service isn’t available at your VA site. 
• Best medical interest: e.g., specialized treatment only available elsewhere.

What to say:
“Can you check and document whether I meet the criteria for Community Care—like wait time, drive time, or best medical interest—and place a referral if I do?”

Step B: Make sure your referral is entered and authorized

If approved, your clinician creates a referral (consult) and selects a Standardized Episode of Care (SEOC), which defines your covered services. This flows into the VA’s HealthShare Referral Manager (HSRM), which both VA and community providers use to track care. (Veterans Affairs)

Ask your clinician for:

• SEOC name 
• Start and end dates 
• Quick summary of covered services (imaging, procedures, consults)

Step C: Know your authorization letter

After scheduling, VA sends an authorization letter—your “golden ticket” for outside care. It lists:

• Referral number 
• Authorized services 
• Scheduling instructions

Pro tip: Save a photo and paper copy of this letter. You’ll need the referral number for billing, clinic visits, and any issues. If you don’t get your letter, call your VA care team.

Step D: Know what you pay

For VA-authorized care:

• Clinics should never bill you. 
• Non-service-connected care may require a VA copay, billed by VA—not the clinic. 
• If you see a bill saying “patient responsibility,” confirm with VA before paying.

Part 2 of 4 — Book Your Appointment & Stay Inside the Window

Goal: Schedule care quickly, stay within referral dates, and ensure smooth billing.

Step A: Schedule smart

Appointments may be scheduled by:

• VA via External Provider Scheduling (EPS) 
• You are directly with the community provider

If you schedule yourself, notify your VA team within 14 days. Before confirming, check:

• Clinic is in VA’s Community Care Network (CCN) or authorized 
• Appointment falls within SEOC dates 
• The clinic can see your referral in HSRM

Step B: Bring what you need

Think of this as your Community Care “boarding pass”:

• Authorization letter (paper or phone screenshot) 
• Photo ID 
• Any VA instructions or requested documents

The authorization number connects your visit to the referral and claim.

Step C: Rescheduling? Stay inside the window

If you need a new date or extra services, the clinic must request VA approval using VA Form 10-10172 through HSRM. (Veterans Affairs, ccracommunity.va.gov)

What to say:

“My care is authorized under a VA SEOC. If we need a new date or extra services, can you submit VA Form 10-10172 before the visit?”

Step D: Exception — Urgent Care

No referral needed if:

• You’re enrolled in VA care, and 
• Had a VA or in-network visit in the past 24 months

Use for non-emergency issues that can’t wait.

Step E: Keep paperwork tight

• Save the authorization letter and appointment confirmations 
• Write down the clinic name, appointment date, and contact 
• After the visit, check the VA Explanation of Benefits (EOB) 
• Call VA immediately if billed for authorized care

Quick “Do / Don’t” for Parts 1 & 2

Do:

• Ask the VA doctor to document eligibility and enter the referral 
• Confirm SEOC name, dates, and services in HSRM 
• Notify VA if you schedule yourself 
• Keep the authorization letter handy

Don’t:

• Accept appointments outside the authorization window without VA Form 10-10172 
• Pay the clinic directly for authorized care

Why it matters: Proper referral and scheduling ensure claims match authorization, get paid quickly, prevent errors, and let VA handle copays.

Part 3 of 4 — From Exam Room to Paid Claim

Goal: Ensure care is billed correctly and paid by VA without landing a bill in your lap.

Claim Lifecycle: After Your Appointment

1. Care is provided within referral: Services must match the SEOC, dates, and codes. Extra services need a new authorization. 
2. Provider sends visit notes to VA: Usually via HSRM or secure fax within 30 days. Missing records can delay claims. Ask: “Will you send my notes to VA within 30 days?” 
3. Provider submits claim: 
   • CCN referrals → Optum or TriWest 
   • VCA referrals → VA
     Claims must be filed within 180 days. 
4. Claim is reviewed: TPA or VA verifies authorization number, dates, codes, and documentation. 
5. Provider receives payment notice: Tracked via eCAMS Provider Portal (VA) or TPA portals. 
6. Payment issued: Paid electronically. Federal debts may reduce payment but don’t affect you. 
7. Case closed: Referral marked closed in VA.gov or VA Health & Benefits app.

What You Can Do

At the clinic: Confirm your visit matches the referral, and notes are sent to VA. Write down the visit or claim ID.
At home: Call 877-881-7618 to check remaining visits or referral status.

Warning Signs:
Bills marked “Self-pay,” “Balance after insurance,” or “Patient responsibility” may indicate provider error. Call VA immediately.

Timing matters: Claims must be submitted within 180 days. Delays risk denied claims and possible billing to you.

Part 4 of 4 — Catch the Bill Before It Hits Your Credit

Goal: Stop billing issues quickly before they affect finances or credit.

Step-by-Step

1. Don’t pay the bill until confirmed. 
2. Call the provider billing office: Verify claim sent to the correct payer, includes referral number and dates. Ask to resubmit if needed. 
3. Call VA Community Care: 877-881-7618 (TTY 711). VA confirms authorization, identifies the payer, and assists the provider. 
4. Provide documentation: Send the authorization letter and appointment confirmation as instructed. 
5. Track resolution: Ask when the claim will be resubmitted and updated. 
6. Escalate if unresolved: Use Ask VA (AVA), call your facility’s Community Care office, or VA Community Care for emergency care bills. 

Prevent Future Billing Issues

• Stay within referral dates 
• Request an updated referral for extra visits 
• Confirm visit notes sent to VA 
• Save VA Community Care Billing Help: 877-881-7618

Frequently Asked Questions

Q: Can a provider bill me if VA hasn’t paid them yet?
A: No. If the care was authorized and billed correctly, the provider must resolve payment with VA or the TPA—not with you.

Q: How can providers check the claim status?

A: For VA-direct claims, Providers use the eCAMS Provider Portal (ePP) 

For CCN claims, Providers use the Optum or TriWest portals 

Q: What’s the deadline for billing authorized care?
A: Claims must be submitted within 180 days of the date of service. This includes urgent care visits.

Bottom Line

• Make sure your visit matches the VA authorization 
• Confirm the clinic sends documentation back to VA 
• Ensure the provider bills the correct payer on time 
• Call 877-881-7618 at the first sign of a billing issue 

These few steps help prevent billing errors, avoid credit damage, and ensure your VA Community Care experience stays on track. (Veterans Affairs)

IMPORTANT NOTICE

Educational use only. No medical or legal advice.

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