VA Community Information

What to do at your VA visit

VETERANADMIN AUGUST 28, 2023

VA Community Care: Veteran Patient Care

From Exam Room to Paid Claim:

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

What to do at your VA appointment to set up outside care the right way

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 (right there with your VA doctor)

Community Care lets you get certain medical services from providers outside the VA—but only if you meet specific eligibility criteria. The most common reasons are:

Wait time or drive time is too long

Primary care, mental health, extended care: No appointment available within 20 days, or you live more than 30 minutes away.
Specialty care: No appointment within 28 days, or the drive is over 60 minutes.(VA News, Veterans Affairs)

The service you need isn’t available at your VA site

It’s in your best medical interest (e.g., a 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 your clinician agrees, they’ll create a referral (called a consult) and select a Standardized Episode of Care (SEOC)—a set of covered services for your specific condition.
This info flows into the VA’s HealthShare Referral Manager (HSRM), where both VA and community providers can track and coordinate your care. (Veterans Affairs)

Ask your clinician for these details before you leave:

The name of the SEOC
The start and end dates of the referral
A quick summary of what’s covered (e.g., imaging, procedures, consults)

Step C: Know what your authorization letter includes (and why you need it)

Once your appointment is scheduled (more on that in Part 2), the VA will send you an authorization letter—this is your golden ticket for outside care. It lists:

Your referral number
The authorized services
Scheduling instructions

Pro tip:

Save a photo of this letter on your phone, and keep a paper copy. You’ll need that referral number later—for billing, for the clinic, and just in case something goes sideways.

Didn’t get your letter? Call your VA care team and ask for the authorization details.

Step D: Know what you pay (and what you don’t)

Here’s the bottom line: If care is VA-authorized, the clinic should not bill you. Ever.
If your condition is non-service-connected, you may owe a VA copay—but that will come directly from the VA, not the clinic.
If you ever see a bill that says “patient responsibility” or asks for a balance, stop and double-check with VA before paying.

Say to yourself:
“Copays—if any—come from VA. Clinics shouldn’t bill me directly for authorized care.”

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

How to schedule your community care without delays or billing headaches

Your goal in Part 2:
Get your appointment on the books quickly, stay within your referral dates, and make sure your claim gets paid without a hitch.

Step A: Schedule smart

There are two common ways your appointment gets scheduled:

VA books it for you using something called External Provider Scheduling (EPS), or
You schedule it yourself directly with the community provider

No matter who schedules it, you’ll get that authorization letter from Part 1.

If you schedule it yourself, tell your VA care team within 14 days—this keeps your chart and referral info in sync.

Before you lock it in, make sure:

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

Step B: Bring what you need to the appointment

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

Bring:

Your authorization letter (paper or phone screenshot)
Your photo ID
Any VA instructions or documents the clinic asked for

That authorization number connects your visit to the referral—like a tracking number for your claim.

Step C: Rescheduling? Stay inside the window

If you need to move the date—or if the clinic needs to add services not listed in the SEOC—they must request approval from VA first.

That means submitting VA Form 10-10172 through HSRM.(Veterans Affairs, ccracommunity.va.gov)

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

Step D: Know the exception—Urgent Care

Urgent care is different. No referral needed in advance if:

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

Use it for non-emergency issues when you can’t wait for a regular appointment.

Step E: Keep your paperwork tight

These small steps protect you if billing issues pop up later:

Save your authorization letter and appointment confirmations
Write down the clinic name, appointment date, and who you spoke to
After the visit, watch for a VA Explanation of Benefits (EOB)—it usually shows a $0 balance, and any copay (if applicable)

If you get a bill from the clinic for VA-authorized care, call your VA team immediately.

One-Page “Do / Don’t” for Parts 1 & 2

Do

Ask your VA doctor to document your Community Care eligibility and enter a referral
Get the SEOC name, dates, and services, and confirm it’s in HSRM
If you schedule yourself, notify your VA team within 14 days
Keep your authorization letter handy—especially for front desk check-in

Don’t

Don’t accept appointments outside your authorization window without the clinic first submitting an RFS (VA Form 10-10172)
Don’t pay a community clinic directly for authorized care—copays come from VA, not them

Why these steps matter (and how they connect to Parts 3 & 4)

Getting the referral right—along with the SEOC name, services, and valid dates—sets up everything that follows:

It ensures your provider’s claim matches the authorization, so it gets paid fast
It prevents billing errors or delays that can leave you chasing down surprise charges
It lets VA handle your copay (if any)—not the clinic

Bottom line:

A solid referral + proper scheduling = no bills, no stress, and smoother care.

Part 3 of 4 — From Exam Room to Paid Claim

How your Community Care visit becomes a properly paid claim

Your goal in Part 3:

Make sure the care you received is billed correctly and paid by the VA—without the bill ever landing in your lap.

The Big Picture

Community providers only get paid when the care they deliver matches your VA authorization—this includes the scope of services, approved billing codes, and the referral dates. If anything is missing or incorrect, the VA or the Third-Party Administrator (TPA) may deny the claim.

When that happens, providers may mistakenly send the bill to you. Understanding how the claim process works helps you catch problems early and prevent those billing surprises.

The Claim Lifecycle: What Happens After Your Appointment

Step 1: Care is provided within the approved referral

The services you receive must match what’s authorized in your referral. That includes the type of care, the dates it’s approved for, and the codes tied to the treatment. If your provider wants to add services, they need to request a new authorization before delivering that care.

Step 2: The provider sends your visit notes to VA

After the appointment, the clinic sends your medical records back to VA. This is usually done through the HealthShare Referral Manager (HSRM) system or by secure fax. Most VA facilities ask providers to do this within 30 days. If the VA doesn’t receive your records, the claim may not be paid.

Before you leave the appointment, it’s worth asking: “Will you be sending my notes to VA within the next 30 days?”

Step 3: The provider submits the claim

Where the claim goes depends on how your referral was issued:

If it’s a Community Care Network (CCN) referral, the provider submits the claim to the appropriate TPA—Optum or TriWest.
If it’s a local agreement or Veterans Care Agreement (VCA), the claim is sent directly to VA.

Authorized care must be billed within 180 days of the appointment date.

Step 4: The claim is reviewed

The TPA or VA reviews the claim to make sure everything matches:

Authorization number
Date of service
Approved codes
Supporting documentation

Any mismatch or missing information can delay or deny the claim.

Step 5: Provider receives a payment notice

For claims filed directly with VA, providers check status and remittance in the eCAMS Provider Portal (ePP).
For TPA claims, they track progress through the Optum or TriWest online portals.

Step 6: Payment is issued

All VA payments to community providers are made by Electronic Funds Transfer. No paper checks are issued. In some cases, if the provider has federal debts, payments may be reduced through the Treasury Offset Program. That does not affect you.

Step 7: Case is closed

Once everything is complete, your referral will be marked as closed. You may see this update in your VA.gov account or in the VA Health & Benefits mobile app. If anything seems off, contact your VA Community Care office for help.

What You Can Do to Help Keep Things on Track

At the clinic

Before you leave, ask:

“Did my visit match the VA referral? Will you be sending the documentation back to VA?”
If they can give you a visit or claim ID, write it down for your records.

At home

If you’re unsure how many visits remain, or if your referral is still active, call the VA Community Care line at 877-881-7618 (TTY 711). They can confirm your current status.
If the clinic billed VA directly, it’s their responsibility to track the claim, but you can still call VA if a bill shows up.

Warning Signs to Catch Early

If you receive a bill that says:

“Self-pay”
“Balance after insurance”
“Patient responsibility”

And you know your visit was authorized by VA, the provider may have submitted the claim incorrectly or billed the wrong payer.

Call VA Community Care immediately at 877-881-7618. They’ll help identify what went wrong and how to correct it.

Why Timing Matters

Even for authorized visits, if the provider doesn’t submit the necessary documents and file the claim within 180 days, the VA won’t pay—and the clinic may mistakenly send the bill to you.

Timely documentation and accurate claims protect both you and the provider from payment issues.

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

What to do if you receive a bill for authorized VA Community Care

Your goal in Part 4:
Stop billing issues quickly using VA’s official process—before they affect your finances or credit.

Step-by-Step: How to Handle a Bill for Authorized Care

Step 1: Don’t pay the bill right away

Even if it looks legitimate, hold off on paying. Paying prematurely can complicate the resolution process. Start by confirming that the care was authorized and that the provider billed the correct payer.

Step 2: Call the provider’s billing office

Explain that your care was authorized under VA Community Care. Ask the billing team to check whether they:

Sent the claim to the correct payer (Optum or TriWest for CCN, or VA for local agreements)
Included your authorization number and referral dates

If something was missed, ask them to correct the billing and resubmit the claim.

Step 3: Call VA Community Care

Call 877-881-7618 (TTY 711), Monday through Friday, 8 a.m. to 9 p.m. ET.
Let them know you received a bill for an authorized visit. VA can:

Confirm the referral and authorization
Identify the correct payer

Assist the provider in resolving the issue

Step 4: Provide documentation

If needed, send a copy of your VA authorization letter and any appointment confirmation to the provider’s billing department. Follow VA’s instructions for securely uploading or faxing the information.

Step 5: Track the resolution

Ask the clinic when they plan to resubmit the claim and when you can expect an update. Providers have access to claim tracking systems through the TPA or VA portals.

Step 6: Escalate if the issue isn’t resolved

If you’re not getting answers:

Use Ask VA (AVA) to submit a written inquiry and receive a reference number.
Call your VA facility’s Community Care office directly (check the official VA contact directory).
For emergency care bills, call VA Community Care at 877-881-7618.

How to Prevent Future Billing Issues

Stay inside your referral dates. If you need more visits, ask your provider to request an updated referral before the next appointment.
Before you leave the clinic, ask if your visit notes have been or will be sent to VA.
Save the right phone number in your contacts: VA Community Care Billing Help – 877-881-7618 (TTY 711)

Frequently Asked Questions

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

How can providers check the claim status?