VA Community Care Claims Guide

Step 1 – Receive & Accept the Referral (HSRM)

A VA clinician determines that a veteran qualifies for Community Care based on drive-time, wait-time, or best-interest criteria outlined in the MISSION Act. Once confirmed, VA staff create a referral using the HealthShare Referral Manager (HSRM). This system generates a 10-digit authorization number, lists approved CPT/HCPCS codes, and sets the episode date range.

When a ‘Pending Acceptance’ notification appears in your HSRM inbox, be sure to click Accept right away. Doing so confirms your responsibility for the case and initiates the reimbursement timeline—delays here can lead to denials.

Pro Tip: Print the referral summary—it includes the payer ID, veteran demographics, and fax instructions for your post-care documentation bundle.

Step 2 – Deliver the Care

• In-person Visits: Deliver services exactly as outlined in the referral.
• Telehealth Visits: Confirm the veteran’s identity on camera, document their consent for virtual care, record the location of both provider and patient, and ensure the session is synchronous video unless specified as ‘audio-only.’

Step 3 – Create Encounter Notes & VA Form 10-10172

Within 7 calendar days of the appointment, upload the following:

• Final encounter/progress notes
• Any ancillary reports (e.g., imaging, lab results)
• VA Form 10-10172, only if requesting additional services or date extensions

Upload via HSRM or as an attachment to the electronic 275 file paired with your 837 claim.

Step 4 – Build the Claim

Field	What to Include
Loop 2300, REF*G1 (or REF*9F)	10-digit authorization number. Missing this = automatic denial.
Payer ID	Found on the referral (TriWest or Optum).
Place of Service (POS)	11 for office; 02 for telehealth.
Modifiers	e.g., 95 for synchronous video.
Diagnosis / Procedure Codes	Must match the referral or be supported by a valid 10-10172.

Most providers use EDI 837 format (837I for institutional, 837P for professional, 837D for dental). Paper submissions (UB-04 or CMS-1500) are accepted but take significantly longer to process.

Step 5 – Submit the Claim & Attach Documents

• Option A: Use VA’s free Direct Data Entry portal via their clearinghouse.
• Option B: Submit through any commercial clearinghouse (e.g., Availity, Change Healthcare).

Attach documentation either as an electronic 275 or upload it to HSRM. Faxing is allowed, but it slows processing due to manual indexing.

Step 6 – Adjudication & Payment

Once received, clean claims are reviewed by the TPA’s adjudication engine.

• If Medicare rates exist, they’re applied. If not, VA’s Fee Schedule is used.
• Claims are auto-matched to the correct authorization number.
• EFT payments are typically issued within 25–30 days if no edits are required.
• Providers receive an Electronic Remittance Advice (ERA) detailing any adjustments (e.g., CO45 reductions).

Step 7 – Handling Denials: Quick Fixes

Denial Code	Common Cause	What to Do
CO-16	Missing information or authorization number	Correct the 837 loop and resubmit within 90 days.
PI-204	Code not covered	Verify the CPT code matches the referral. If additional services are needed, submit a 10-10172.
CO-29	Late submission	Claims must be submitted within 180 days from the date of service. If late, include a “good cause” letter with your appeal.

Appeals (called “reconsiderations” by VA) must be submitted within one year. Include the revised claim, supporting clinical notes, and valid authorization.

Special Considerations for Telehealth

The COVID-19 pandemic accelerated telehealth adoption. VA now fully integrates it into Community Care when appropriate. The core claim process remains the same, but with specific nuances:

1. Authorization is Still Required
   As TriWest clearly states: “Have an approved referral/authorization, excluding urgent care.” Urgent care visits (walk-in or virtual) fall under a separate VA contract and do not require prior authorization.
2. Modifiers & Codes

• POS 02 = Telehealth (not in the patient’s home)
• POS 10 = Telehealth (in patient’s home)
• Use modifier 95 for synchronous video, GQ for asynchronous.
• CPT codes like 99212–15, 99441–43, and HCPCS codes like G0438–39 are reimbursed at Medicare’s non-facility rate.

1.  Licensing Across State Lines
   VA’s “Anywhere-to-Anywhere” rule applies only to VA employees. Community Care providers must be licensed in the state where the veteran is located during the call. TPAs check this during credentialing.
2. Documentation Must Include:

• Modality (video or audio-only)
• Provider and patient locations
• Consent for telehealth
• Any technical disruptions
  Upload these notes just like in-person visits—VA audits look for these details.

1. No-Shows & Tech Failures
   Do not bill VA for missed appointments. If the call disconnects but resumes the same day, submit one claim only.
2. Telehealth vs. Urgent Care – Know the Difference
   Urgent Care (UCC) Benefit
   Veterans can access minor care through walk-in clinics or contracted virtual platforms without prior authorization—if enrolled and seen by VA in the past two years. Payment is handled at fixed VA rates.

Telehealth Community Care

These are planned virtual visits with a primary care or specialty provider. Authorization is required, and the billing process is identical to in-person care.

Mixing up urgent care and telehealth rules is the most common reason for claim denials. Always match the visit type to the correct benefit.

Six Compliance Tips to Speed Up Payment

1. Enroll in EFT/ERA under the correct TIN—paper checks delay payments by up to two weeks.
2. Accept the HSRM referral within 7 days; it expires automatically after 14 days.
3. Upload documents promptly—ideally the same day as the appointment.
4. Run claims through Medicare edits first; CCN follows CMS rules.
5. Bundle services (like labs) under the original authorization. Need more? File a 10-10172.
6. Use the CCN Provider Portal to track claims in real time—don’t wait for mail.

Following these habits can reduce first-time denial rates to under 2%, according to TPA dashboards.

Frequently Asked Questions (FAQ)

Q1: My claim was denied for “missing referral.” Can I fix and resubmit?
A: Yes—if you’re within the 180-day filing window. Add the referral number to the 837 REF segment or box 63 on the UB-04, attach the denial EOB, and resend.

Q2: Do ancillary services like imaging or PT need separate authorization?
A: Not usually. They’re covered under the main referral if CPT codes are listed. If not, submit a 10-10172.

Q3: How long does payment take after approval?
A: Typically 25–30 days via EFT. Delays may occur if no Medicare rate exists or documents are missing.

Q4: Does VA apply Medicare sequestration cuts?
A: Yes—expect a 2% reduction starting from 2022, reflected in your ERA.

Bottom Line

Community providers can receive timely and full reimbursement—often quicker than private insurers—by treating the authorization number like gold, using Medicare-compliant coding, and maintaining thorough documentation via HSRM or electronic 275 files.

Telehealth follows the same rules as in-person care—just with different place-of-service codes (02 or 10) and modifier 95.

Master this workflow, and your practice supports veterans effectively while keeping your revenue cycle running smoothly.

Need help? VeteransDesk.org offers free guides and a provider hotline to assist you every step of the way.

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