Community Care

Most commonly, authorized care refers to medical or dental care that was approved and arranged by VA to be completed in the community. Emergency care can also be authorized by VA in certain circumstances when the VA is notified within 72 hours. To file a claim for services authorized by VA, follow instructions included in the “Submitting Claims” section of the referral form.

There are two routes for filing claims for authorized care which depend on your status in the VA network and how the care was authorized:

• Community Care Network (CCN)–If you are part of the CCN with TriWest Healthcare Alliance (TriWest) or Optum United Health Care (Optum), you must file the claim with the correct CCN Third Party Administrator (TPA) as per the authorization/referral.
  • For CCN Regions 1-3, file with Optum.
  • For CCN Regions 4-5, file with TriWest.
• Veterans Care Agreement (VCA)/Local Contract–If you have a Veterans Care Agreement (VCA) established with VA or are not part of one of VA’s formal networks, file claims with VA.

All non-urgent and non-emergent care requires authorization from VA in advance. Eligibility and claims submission information for emergent care will be provided after notification is made to the VA. Claims for emergent care not eligible for authorization upon notification, may be eligible for consideration as Unauthorized Care. If notification was not made to VA and you wish to have claims considered for payment, please submit claims and supporting documentation to VA as listed in the "Where to Send Claims" section below.

More Information

Emergency Care Claims–Information for Providers

Reference the table below to find which contract vehicle will process your claim:

Entities Responsible for Claims Processing

Affiliation/Authorization/Scenario	Responsible Entity
Community Care Network Region 1 (authorized)	Optum
Community Care Network Region 2 (authorized)	Optum
Community Care Network Region 3 (authorized)	Optum
Community Care Network Region 4 (authorized)	TriWest
Community Care Network Region 5 (authorized)	TriWest
Veterans Care Agreement (authorized)	VA
Local Contract (authorized)	VA
Unauthorized Emergent Care (unauthorized)	VA

Please review the Where To Send Claims and the "Where To Send Documentation" sections below for mailing addresses and Electronic Data Interchange (EDI) details. If you are submitting a paper claim, please review the "Filing Paper Claims" section below for paper claim requirements.

Medical Claim Submission Requirements

• Complete and accurate standard Center for Medicare & Medicaid Services (CMS) or electronic transaction containing false claims notice (such as CMS 1450, CMS 1500 or 837 EDI transaction).
• National Provider Identifier: Submit all that are applicable, including, but not limited to billing, rendering/servicing, and referring.
• For authorized care, the “referral number” listed on the “Billing and Other Referral Information” form.

Fact Sheet: Medical Document Submission Requirements for Care Coordination

Dental Claim Submission Requirements

• Dental claims must be filed via 837 EDI transaction or using the most current American Dental Association Claim Form, and must comply with American Dental Association (ADA) and specific VA requirements. Please visit the "File a Dental Claim" page for more information and tips for successful dental claim submissions.

The deadline for claims submission is dependent upon which program the care has been authorized through or which program the emergency care will be considered under.

Timely Filing Requirements

Program	Filing Deadline	Submit Claims To
Authorized Care (38 U.S.C. §1703)	180 days	For CCN, submit to TriWest or Optum For VCA or local contract, submit to VA
Unauthorized Emergent Care (38 U.S.C. §1728: Service-connected)	2 years	VA
Unauthorized Emergent Care (38 U.S.C. §1725: Nonservice‑connected)	90 days*	VA

*From the date the Veteran was discharged from the facility that furnished the emergency treatment; the date of death, but only if the death occurred during transportation to a facility for emergency treatment or if the death occurred during the stay in the facility that included the provision of the emergency treatment; or the date the Veteran exhausted, without success, action to obtain payment or reimbursement for treatment from a third party.

Electronic 837 claim and 275 supporting documentation submissions can be completed through the VA clearinghouse or through another clearinghouse of your choice.

EDI Referral/Authorization Annotation Information

• Prior Authorization Number is Loop = 2300, Segment = REF*G1, Position = REF02.
• Home Health Agencies billing with an OASIS Treatment number use the Prior Authorization segment for the TAC and the Referral Number segment on the 837I submission.

You are strongly encouraged to electronically submit claims and required supporting documentation. This improves claim accuracy and reduces the amount of time it takes for us to process claim determinations. Review the "Filing Electronically" section above to learn how to file a claim electronically.

Paper to Electronic Conversion

Paper claims and supporting documentation submitted to us are converted to Electronic Data Interchange (EDI) transactions. This improves our claims processing efficiency. The conversion happens before claims and records are accepted into our claims processing system.

As part of the process, claims and supporting documentation are scanned for compliance prior to conversion to electronic format. If the claims and records do not conform to the minimum requirements for conversion to the 837 or 275 electronic formats, they are rejected and sent back for correction.

If you submit a noncompliant claim and/or record, you will receive a letter from us that includes the rejection code and reason for rejection.

Learn how to prevent paper claim rejections

More Information

Review the "Where to Send Claims" section below to learn where to send claims. Review the "Supporting Documentation" section below to learn how to properly submit supporting documentation with your claim.

You can submit a corrected claim or void (cancel) a claim you have already submitted to VA for processing, either electronically or in paper. The instructions differ based on the type of submission.
NOTE: For specific information on submitting claims to Optum or TriWest, please refer to their resources.

Corrected/Void Claim Submissions

Correction	Void
Submit a corrected claim when you need to replace an entire claim previously submitted and processed. A corrected claim might include different procedure(s) or diagnosis codes or any other information that would change the way the claim was originally processed.	Submit a claim void when you need to cancel a claim already submitted and processed. A claim void must be identical to the original claim that it is intended to cancel.

More Information

Corrections and Voids

Reference the table below for information on where to send your claims:

Where To Send Claims

Provider Network	Submission Method
CCN Regions 1-3 Submit to Optum	Electronic Data Interchange (EDI): Payer ID for medical and dental claims is VA CCN. If electronic capability is not available, providers can submit claims by mail or secure fax. MEDICAL Mailing Address: VA CCN Optum P.O. Box 202117 Florence SC 29502 Secure Fax: 833-376-3047 DENTAL Mailing Address: Optum Serve ATTN: VA CCN Claims 3237 Airport Rd. La Crosse WI 54603 Secure Fax: 608-793-2143 (Specify VA CCN on fax)
CCN Region 4 Submit to TriWest	Electronic Data Interchange (EDI): Payer ID for medical claims is TWVACCN. Payer ID for dental claims is CDCA1. If electronic capability is not available, providers can submit claims by mail or secure fax. MEDICAL Mailing Address: TriWest VA CCN Claims P.O. Box 108851 Florence SC 29502-8851 DENTAL Mailing Address: Delta Dental of California VA Community Care Network P.O. Box 537007 Sacramento CA 95853-7007 Secure Fax: 916-851-1559
CCN Region 5 (Kodiak, Alaska, only) Submit to TriWest	Electronic Data Interchange (EDI): Payer ID for medical claims is TWVACCN. Payer ID for dental claims is CDCA1. If electronic capability is not available, providers can submit claims by mail or secure fax. MEDICAL Mailing Address: TriWest VA CCN Claims P.O. Box 108851 Florence SC 29502-8851 DENTAL Mailing Address: Delta Dental of California VA Community Care Network P.O. Box 537007 Sacramento CA 95853-7007 Secure Fax: 916-851-1559
Veterans Care Agreement Submit to VA	Electronic Data Interchange (EDI): Payer ID for medical claims is 12115. Payer ID for dental claims is 12116. If electronic capability is not available, providers can submit claims by mail. MEDICAL & DENTAL Mailing Address: VHA Office of Finance P.O. Box 30780, Tampa FL 33630-3780
Local Contract Submit to VA
Unauthorized Emergency Care Submit to VA

Authorized Care

While not required to process a claim for authorized services, medical documentation must be submitted to the authorizing VA medical facility as soon as possible after care has been provided.

There are multiple methods by which community providers may electronically provide VA with the required medical documentation for care coordination purposes. Those options are:

The electronic 275 transaction process may be utilized to supply Remittance Advice documentation for timely filing purposes. The 275 transaction process should not be utilized for the submission of any other documentation for authorized care.

Unauthorized Emergent Care

NOTE: The processes outlined below are exclusive to supplying documentation for unauthorized emergent care. With the exception of supplying remittance advice supporting documentation for timely filing purposes, these processes do not apply to authorized care.

While VA always encourages providers to submit claims electronically, on and after May 1, 2020, it is important that all documentation submitted in support of a claim comply with one of the two paper submission processes described. Any supporting documentation that VA is unable to link to a claim will be returned to sender to for additional information.

Providers who continue to elect to submit paper claims and paper documentation to support claims for unauthorized emergency care should be aware of the following:

• VA must be capable of linking submitted supporting documentation to a corresponding claim.
• Community providers have three options that allow for that linkage:
  1. Submit the claim electronically via 837 transaction and the supporting documentation via 275 transaction.
  2. Include the claim, or a copy of the claim, along with the supporting documentation that is mailed to the following address:

     VHA Office of Integrated Veteran Care
     P.O. Box 30780, Tampa FL 33630-3780

  3. Include a completed cover sheet with the supporting documentation that is mailed to the above address.
     

     P2E Documentation Cover Sheet, VA Form 10-10143f

Documentation in support of a claim may include:

*NOTE: Documentation not required includes flowsheets and medication administration

Follow the guidance below to avoid having your claim denied:

• Make sure you have received an official authorization to provide care or that the care is of an emergent nature.
• Submit the claim to the correct payer.
• Include the authorization number on the claim form for all non-emergent care.
• Make sure the services provided are within the scope of the authorization.
• Check the accuracy of billing codes.
• Include the 17 alpha-numeric (10 digits + "V" + 6 digits) VA-assigned internal control number (ICN) in the insured's I.D. field. Veteran's ICN can be found on the VA issued HSRM referral. The Veteran's full 9-digit social security number (SSN) may be used if the ICN is not available.

VA is the primary and sole payer when VA issues an authorization. VA is also the primary and sole payer for unauthorized emergent care approved under 38 U.S.C. §1725 or 38 U.S.C. §1728.

VA may be a secondary payer for unauthorized emergent claims under 38 U.S.C. §1725 when remaining liability to the Veteran is not a copayment or similar payment.

If billing electronically, please include "Other Payers Information" in Loop 2320, 2330A, 2330B, and 2430.

Community providers should remain in contact with the referring VA Medical Center to ensure proper care coordination. Questions about care and authorization should be directed to the referring VA Medical Center.

If you have questions about a claim, reference the contacts below:

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