Community Care

VA is required by law to bill Third Party Payers (TPP) for care that is not related to a Veteran’s service-connected disability or Special Authority. This requires VA to call TPPs for precertification for patients who are VHA beneficiaries with other billable health insurance (OHI).
Please note: Claims for ancillary services will be processed in accordance with Medicare National Correct Coding Initiative (NCCI), Medically Unlikely Edits (MUE), and related edits.

To identify services that require VA precertification, refer to the referral packet which contains a form called Offline Referrals/Billing and Other Referral Information. Providers can refer to the View your Billing and Other Referral Information section to see if the Standardized Episode of Care (SEOC) in your VA referral has codes that require precertification.

The preferred method to notify VHA Revenue Operations (RO) for tests/procedures/admissions requiring precertification is via the HealthShare Referral Manager (HSRM) provider portal using the Task: PROVIDER PRECERT NOTIFICATION. Although this is the preferred method of notifying Revenue Operations of precertification, the request can also be submitted via fax.

Once the community care provider has notified VHA Revenue Operations that the test/procedure/admission requiring TPP precertification is scheduled, there is no requirement to wait for the TPP approval or response prior to performing the test/procedure/admission included as part of the SEOC referral.

The precertification process should not be used to request additional services or extensions for authorization duration. To request additional services or extend authorization durations please use the Request for Additional Services (RFS) Form, VA Form 10-10172, which should be submitted to local facility community care staff using the office fax or email indicated on the referral form.

If you are interested in more information about HealthShare Referral Manager, including how to register, please review our Care Coordination page.

Fax numbers by Consolidated Patient Account Center (CPAC) region are listed below:

Standardized Episodes of Care (SEOC) Billing Code Information

The VA SEOC Billing Code List provides preapproved billing codes associated with the services within each available SEOC. The list also contains billing codes that require TPP precertification, called "Precertification (Precert) Codes.” While the codes have been clinically approved in the referral by VA as part of the SEOC, an additional precertification request must be submitted by VHA Revenue Operations to the Veteran’s TPP for the precert codes.

Prior to viewing the VA SEOC Billing Code List, you must accept the terms and conditions defined
in the License for Use Of Current Procedural Terminology.

Additional Coding Information

Ancillary Codes: Please note that claims for ancillary services will be processed in accordance with CMS NCCI, MUE, and related edits.

If code(s) are not on SEOC: Services provided must be appropriate and necessary to accomplish the intent of the referring provider's order/consult request. The SEOC describes the most likely scope of care necessary, but other services may be allowed in certain circumstances if necessary for completing the referral.