What to do at your VA visit

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

Navigating care inside and outside the VA can feel overwhelming, especially when referrals, authorizations, and billing rules aren’t clearly explained during an appointment. Many Veterans assume that once a VA doctor recommends outside care, everything else happens automatically. In reality, small details—such as referral dates, approved services, and proper documentation—determine whether your visit is paid smoothly or turns into a billing issue later. Missed steps can lead to denied claims, delayed payments, or bills that should never reach you. This guide breaks the process into clear, manageable steps so you know exactly what to ask, what to save, and how to stay protected throughout your VA Community Care journey.

Your mission in Part 1:

Leave your VA visit knowing whether you qualify for Community Care—and with a properly documented referral if you do.

Step A: Confirm Eligibility with Your VA Clinician

Community Care allows Veterans to receive care outside the VA only when eligibility criteria are met, most commonly when:

• Wait times or drive times are excessive 
  • Primary care, mental health, or extended care: no appointment within 20 days, or drive time exceeds 30 minutes
  • Specialty care: no appointment within 28 days, or drive time exceeds 60 minutes. (VA News, Veterans Affairs)

• The service isn’t available at your VA facility 
• Best medical interest, such as specialized care not offered locally

What to say:

“Can you check and document whether I meet Community Care criteria—such as wait time, drive time, or best medical interest—and place a referral if I do?”

Step B: Make Sure the Referral Is Entered and Authorized

If approved, your clinician enters a consult and selects a Standardized Episode of Care (SEOC). This defines what services are covered and feeds into the HealthShare Referral Manager (HSRM) (Veterans Affairs)

Before leaving, ask for:

• The SEOC name 
• The start and end dates 
• A brief summary of what’s covered

Step C: Understand Your Authorization Letter

Once scheduled, you’ll receive an authorization letter—your proof of VA approval. It includes:

• Referral number 
• Authorized services 
• Scheduling instructions

Pro tip:
Save a photo on your phone and keep a paper copy. You’ll need this for check-in and billing questions.

Step D: Know What You Owe—and What You Don’t

If care is VA-authorized, the clinic should not bill you.

• Any VA copay (if applicable) comes from VA, not the clinic 
• If you receive a bill showing “patient responsibility,” pause and verify before paying

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

How to schedule care without delays or billing problems

Your goal:
Get scheduled quickly, stay within your authorization dates, and protect your claim.

Step A: Schedule Carefully

Appointments are scheduled either by:

• VA via External Provider Scheduling (EPS), or 
• You, directly with the provider

If you self-schedule, notify VA within 14 days.

Before confirming:

• Verify the provider is CCN-authorized 
• Confirm the appointment is within your SEOC dates 
• Ensure the clinic can see your referral in HSRM

Step B: Bring the Right Documents

Bring:

• Authorization letter (paper or digital) 
• Photo ID 
• Any requested VA paperwork

Your authorization number links the visit to payment.

Step C: Rescheduling or Added Services

If dates change or additional services are needed, the provider must submit VA Form 10-10172 in HSRM before care is delivered.

Step D: Urgent Care Exception

Urgent care doesn’t require a referral if:

• You’re enrolled in VA care, and 
• You’ve used VA or in-network care within the last 24 months

Step E: Stay Organized

• Save confirmations and letters 
• Note appointment details 
• Watch for your VA Explanation of Benefits (EOB)—usually showing a $0 balance

One-Page Do / Don’t (Parts 1 & 2)

Do

• Ask for eligibility documentation and a referral 
• Confirm SEOC details and dates 
• Notify VA if you self-schedule 
• Bring your authorization to check in

Don’t

• Accept care outside authorized dates 
• Pay clinics directly for authorized care

Part 3 of 4 — From Exam Room to Paid Claim

How authorized care becomes a paid claim

Your goal:
Ensure your visit is billed correctly so payment goes to the provider—not you.

The Claim Lifecycle

1. Care is delivered within the authorized scope and dates 
2. Provider sends visit notes to VA (usually within 30 days) 
3. The claim is submitted 
   • CCN referrals → Optum or TriWest 
   • Local agreements → VA directly 
4. Claim review checks authorization, codes, dates, and documentation 
5. Payment notice issued via VA or TPA portals 
6. Payment sent by electronic funds transfer 
7. Referral closed in VA systems 

Claims must be submitted within 180 days of service.

What You Can Do

Before leaving the clinic, ask:

“Will my visit notes be sent to VA?”

At home:

• Confirm referral status at 877-881-7618 (TTY 711) 
• Watch for unexpected bills labeled “self-pay” or “patient responsibility.”

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

What to do if a bill arrives for authorized care

Your goal:
Stop billing errors early—before collections or credit damage.

Step-by-Step Response

1. Don’t pay immediately 
2. Call the provider’s billing office 
   • Confirm the correct payer and authorization number 
3. Call VA Community Care 
   • 877-881-7618 (TTY 711) 
4. Send documentation if requested 
5. Track follow-up and resubmission 
6. Escalate if needed 
   • Use Ask VA (AVA) or contact your VA facility’s Community Care office 

Prevent Future Issues

• Stay within referral dates 
• Ask if documentation was sent 
• Save the VA Community Care Billing Help in your phone

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.

Why This Process Protects You as a Veteran

Following each step in this guide does more than prevent billing errors—it protects your time, finances, and access to care. Community Care works best when referrals, documentation, and timelines are handled correctly from the start. When Veterans understand how authorization, scheduling, and claims connect, they’re less likely to experience delays, denied payments, or collection notices. Being proactive also helps VA and community providers work more efficiently together. A few questions at the right time—and keeping key documents handy—can save weeks of follow-up calls and unnecessary stress later.

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.

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)