Veteran Community Care: Filing Claims
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Veteran Community Care: Filing Claims


♪♪ At VA, our community partners
are key to making sure Veterans have access to timely,
high-quality health care. When VA refers a Veteran to a
community provider, a detailed authorization is issued by VA or
one of VA’s Third Party Administrators (TPAs). The
authorization allows the community provider to provide
care to the Veteran and for VA or the TPA to pay for the care. After a community provider
furnishes care to a Veteran based on the scope of services
in the authorization, a claim for reimbursement should be
filed with the appropriate authorizing party, either VA or
a TPA. Instructions for filing the claim are included in the
authorization. Filing claims and supporting documentation
electronically is recommended because it reduces the risk of
errors and speeds up reimbursement. While not
required to process a claim for authorized services, medical
documentation should be submitted to the authorizing VA
medical facility as soon as possible after care has been
provided. This is important because it allows VA to
incorporate it into the Veteran’s medical record. Please
note that for care authorized through a TPA, claims for
reimbursement can only be filed with the appropriate TPA that
generated the authorization. For community providers who
provide emergency care to a Veteran, VA must be notified
within 72 hours of the emergency room visit. Upon notification, and after
receiving supporting documentation, VA may generally
approve payment for emergency care based on whether the care
provided is related to a Veteran’s service-connected
condition, if the community provider is in VA’s network, and
whether or not VA was notified within 72 hours. If the emergency care is
approved after appropriate notification, an authorization
will be generated by VA or a TPA and provided to the community
provider. Claims for that care should be
filed according to instructions in the
authorization. In some cases, emergency care
may not be authorized. This generally occurs when the care
provided is not related to a Veteran’s service-connected
condition, the community provider is not in VA’s network,
and/or VA was not notified within 72 hours. When the community provider is
out-of-network and/or VA was not notified within 72 hours, claims
may be filed with the nearest VA medical facility for
reimbursement consideration. In addition, please note the
following about unauthorized emergency care claims: VA may
require and request medical documentation, and community
providers should use electronic claim and documentation
submission processes. After a claim has been filed and
processed, it will be classified as accepted (approved for
payment) or denied. Claims are denied when the care was not
authorized and when the Veteran does not meet eligibility
requirements. To avoid having a claim denied, make sure you have
received an official authorization to provide care
from either VA or the TPA, include the authorization number
with the claim, and make sure the care being requested for
reimbursement is within the scope of that authorization. Claims are also denied when they
cannot be paid due to billing errors or the need for more
information. To avoid having a claim denied, include the
authorization number in the referral/authorization field,
check the accuracy of billing codes, make sure claims are
submitted in accordance with nationally standardized billing
requirements, include the Veteran’s full nine-digit Social
Security number in the insured’s ID number field, send the claims
to the correct authorizing party (VA or TPA), and, for emergency
care claims, medical documentation may be required,
such as the ER report, and for inpatient care, history and
physical, discharge summary, and progress notes. To find out the status of a
claim filed with a TPA, contact the appropriate TPA. For claims
filed directly with the VA, community providers can check
VA’s Customer Engagement Portal, or CEP, at this website.
Registration is required. To learn more about filing
claims for Veteran community care, visit our website at this
address.

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