Preauthorized Non-VA Inpatient/Outpatient Medical Care
VA community care programs provide 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. During a medical emergency, VA encourages all Veterans to seek immediate medical attention without delay. A claim for emergency care will never be denied based solely on VA not receiving notification prior to seeking care. Notification should be made within 72 hours after receiving emergency care at a community emergency department. Each Veteran’s eligibility status and medical care needs will then be reviewed to decide whether payment for community treatment can be approved.
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 for VHA OCC programs are located on our Forms page.
UB-04 CMS-1450* CMS-1500 Additional VHA OCC Forms
NOTE: Providers cannot use the downloaded UB-04 CMS-1450 form to submit claims. Per the CMS website, the downloaded UB-04 CMS-1450 is provided as a sample only as it may not accurately replicate colors included in the form that are needed to enable automated reading of information.
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)