VHA Office of Community Care
Preauthorized Non-VA Inpatient/Outpatient Medical Care
This Care in the Community program provides payment authorization for eligible Veterans to obtain routine outpatient or inpatient medical services through community providers. An authorization may be granted when it has been determined that direct VA services are either geographically inaccessible or VA facilities are not available to meet a Veteran’s needs. All community services must be preapproved before a Veteran receives treatment.
However, it may not be possible to contact VA prior to treatment in emergency situations. Each individual Veteran’s eligibility status and medical care needs are reviewed to decide whether payment for community treatment can be approved. The VA also requires a 72-hour notification of emergency room care.
Individual eligibility determinations are difficult, and therefore outside the scope of this general information. Please contact your local VA health care facility for individual Veteran eligibility questions or concerns.
A local VA Medical Center may request medical documentation to support adjudication of a submitted claim from a community health care provider. In addition, standard billing forms such as the UB-04 CMS-1450* or CMS-1500 are required. Additional forms can be located at Forms.
*NOTE: Per the CMS website, the UB-04 CMS-1450 is provided as a sample only—providers cannot use the downloaded form to submit claims.
Basic authorities and payment methodologies to provide preauthorized medical care are contained in:
- 38 U.S.C. § 1703, Contracts for hospital care and medical services in non-Department facilities (PDF)
- 38 CFR § 17.52, Hospital care and medical services in non-VA facilities (PDF)
- 38 CFR § 17.53, Limitations on use of public or private hospitals (PDF)
- 38 CFR § 17.54, Necessity for prior authorization (PDF)
- 38 CFR § 17.55, Payment for authorized public or private hospital care (PDF)
- 38 CFR § 17.56, Payment for non-VA physician services associated with outpatient (PDF)