What Happens After Your VA Community Care Referral Is Approved

Getting referred to Community Care through the VA can feel overwhelming, but once you’re approved, there’s a clear path forward. Here’s a step-by-step guide to help you navigate what comes next—so you can focus on your health, not red tape.
Here’s a step-by-step guide to help you navigate what comes next

1. Your Referral Becomes an Authorization

Once your VA doctor refers you for Community Care, the VA creates an authorization in their system—this is your official green light to see a community provider. The details go into a system called HealthShare Referral Manager (HSRM) and include:

• What care is approved (CPT codes)
• How many visits are allowed
• The timeframe for your treatment

What You’ll Receive:

You’ll get an authorization letter by mail or electronically. This letter is important—it confirms your eligibility and outlines your approved services. If you schedule the appointment yourself, make sure to tell your VA care team within 14 days so your file stays up to date.

Quick Tip: Snap a photo of your authorization number or keep the letter handy. It helps avoid confusion at the clinic and puts you in control of your care.

2. Scheduling Your Appointment

VA partners with the Community Care Network (CCN), managed by either TriWest or Optum, depending on your region.

• Sometimes, the third-party scheduler (TriWest/Optum) will call you directly.
• Other times, your VA care team or the provider will handle scheduling.
• You can also schedule your appointment with an in-network provider—but don’t forget to inform VA within 14 days.

If you’re in a TriWest region and schedule yourself, try to do it within 21 days of their first contact, or your referral could be delayed.

Telehealth Options:
Many services are available via telehealth if your authorization covers it. The provider just needs to meet CCN requirements and bill using telemedicine codes.

3. The Day of Your Appointment: Stick to What’s Approved

Your community provider should only give the care listed in your authorization and within the allowed dates. If they think you need more visits or a new service, they must submit a request to VA for additional approval.

Tip:
If the clinic can’t locate your authorization, show them your letter and ask them to call VA or the TPA before proceeding.

4. Prescriptions and Medical Equipment

After your visit, prescriptions and durable medical equipment (DME) should be filled through VA-approved channels:

• Use in-network community pharmacies (find them using the VA Facility Locator).
• For equipment like walkers or braces, your local VA Prosthetics team or referring VA doctor will arrange delivery or pick-up.

5. What You’ll Pay (and What You Won’t)

You do not pay anything at the community provider’s office—not even a copay.

• If the care is not related to your service, you may receive a VA copay bill later (e.g., $15 for primary care, $50 for specialty).
• VA may bill your private insurance for non-service-connected care.

Warning: If you go to a community provider without authorization, you could be stuck paying the full cost.

6. After the Visit: What Happens Behind the Scenes

After your appointment:

• The provider sends their visit notes and a claim for payment.
• If authorized under CCN, the claim goes to TriWest or Optum.
• If under a Veterans Care Agreement (VCA), the claim goes directly to VA.

VA reviews the claim and will either accept, deny, or reject it:

• Accepted = Paid
• Denied = No authorization or doesn’t meet emergency rules
• Rejected = Needs corrections (like missing info)

7. Need More Visits or a New Service?

If your care needs to continue past the original authorization:

• The provider or VA must request an extension, a new specialty referral, or a change to your treatment plan.
• Don’t assume extra visits are covered—wait until it’s approved in the system.

8. What to Do if You Get a Bill

You should never be billed directly by the clinic for authorized services. But if you receive a bill or collections notice:

Call:
VA’s Office of Integrated Veteran Care (IVC)
📞 877-881-7618 (Option 1)

Before you call, gather your:

• Authorization letter
• Bill or notice
• Appointment and claim details

This helps VA resolve the issue faster.

9. Why You Might Still Get a Statement

Even though the clinic is paid directly:

• VA may send you a bill if a copay applies.
• VA may also bill your private insurance as required by law.

None of this affects your authorization status—it’s just how VA billing works.

You can view your VA copay balance or handle overpayments via the VA debt portal.

10. Who Does What? A Quick Breakdown

You (the Veteran):

• Bring your authorization letter to your appointments
• Notify VA within 14 days if you schedule on your own
• Use in-network pharmacies and DME providers.
• Call VA if you receive any bill related to your care.

Community Provider:

• Only provide what’s authorized
• Request approval for more visits/services if needed
• Submit claims to the right place (TriWest, Optum, or VA)

VA / TriWest / Optum:

• Manage your referral and authorization.
• Coordinate scheduling
• Process and pay claims

11. Telehealth Visits

If your authorization includes telehealth, your appointment can happen virtually. It’s billed the same way as an in-person visit. Just make sure:

• The provider meets CCN standards
• The authorization covers the service.

Note: VA also offers internal telehealth programs—but those are separate from Community Care.

Bottom Line

Once your VA Community Care referral is approved, your most important tasks are:

✅ Stick to the services and timeline in your authorization
✅ Keep your VA team informed if you schedule care yourself
✅ Let VA and the TPA handle billing
✅ Speak up if something seems off—especially if you get a bill

Have questions or billing issues?
📞 Call 877-881-7618 (Option 1) to protect your care—and your credit.