Community Care Medical Policy
VA publishes community care medical policies that describe standard VA health care services and procedures that community providers may recommend as necessary for a Veteran.
Note: While these policies are intended for community providers, VA staff should reference these policies when sending Veterans to the community and when reviewing a Request for Service.
Before providing care, community providers should refer to the policies to determine if a Veteran meets VA clinical criteria for the care. When additional services are requested, a VA clinical reviewer will refer to the appropriate community care medical policy for the service or procedure to determine approval.
Using the medical policies as a reference before providing care increases the speed at which VA processes requests for additional services from community providers. It also helps ensure the care being recommended meets VA clinical criteria.
Medical policies are based on the following:
Please note the following disclaimers:
- The policies are not intended to replace clinical judgment when determining care pathways; rather, they serve as a reference for non-VA providers.
- They do not guarantee benefits or constitute medical advice.
- They do not affect provider reimbursement for care provided at this time. Payment continues to be governed by existing contracts.
- Check this page regularly to ensure you have the most current policy.
Community Care Overview Community Care Network–Providers Precertification Requirements
Policy Factors
Each medical policy contains specific factors for services and procedures. They are subject to periodic updates based on:
- Clinical criteria requirements
- Medical necessity
- Evidence-based research
- Expert opinions of health care professionals
- Guidelines from nationally recognized health care organizations
NOTE: Individual policies should be referenced regularly as clinical criteria may change.
Definitions
Each medical policy contains the following terms and associated definitions:
- Effective date: Date the community care medical policy is effective.
- Exclusion criteria: Characteristics that disqualify prospective Veterans from care pathways or prescriptions.
- Experimental or Investigational: A treatment, procedure, equipment, drug, or service that has not been determined to be medically effective for the condition being treated but may be part of a research study to evaluate if the condition improves with use.
- Facility: The service is performed in a facility setting (i.e., hospital, ambulatory or surgical center).
- Facility type: Hospital or other institution where outpatient and inpatient services are performed.
- FDA approval: To receive U.S. Food and Drug Administration (FDA) approval, drug manufacturers must conduct testing and submit their data to FDA. FDA may approve the drug if the agency determines the benefits of the drug outweigh the risks for intended use.
- Locality description: Place of service locality (e.g., city, county).
- Medical necessity: Health care services that can be justified as reasonable, necessary and appropriate based on evidence-based clinical standards of care.
- Medicare carrier: Identification number assigned by Centers of Medicare and Medicaid Services (CMS) to a carrier (Medicare Administrative Contractor) authorized to process claims from a physician or supplier.
- Medicare locality: Identification number assigned by the CMS for a locality where care is received.
- Non-facility: The service is performed in a non-facility setting (i.e., physician’s office or outpatient clinic).
- Policy number: A unique ID code that combines an abbreviation of the name and version number.
- Procedure: Current Procedural Terminology (CPT) / Healthcare Common Procedure Coding System (HCPCS) codes are industry standard codes used to identify specific surgical, medical, or diagnostic interventions.
- Procedure code modifier: Supplemental information or “adjust care” descriptions to provide extra detail concerning a procedure or service.
Medical Policies
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Frequently Asked Questions
How do community care medical policies differ from Standardized Episodes of Care (SEOCs)?
VA community care medical policies provide guidance about specific treatments, services or devices. They also outline the clinical criteria requirements to determine the medical necessity of a treatment or service. In contrast, SEOCs allow VA to clearly request and deliver bundled health care services as part of a treatment plan within a specific period of time. VA issues SEOCs to community providers to clarify allowable services and procedures within a particular referral. You can view the SEOC billing code information on the Precertification Requirements page.
What if I cannot find the appropriate community care medical policies, or a device or procedure is not covered by an existing policy?
VA is in the process of creating more standard medical policies for community providers. If one is not available, please contact the Veteran’s local VA facility to obtain the clinical criteria for recommended care. If the clinical criteria still cannot be identified, submit your question pertaining to a published policy by completing the Community Care Medical Coverage Policy Question Submission Form, VA Form 10-322, and email it to the IVC Medical Policy Unit at the link below.
How often does VA publish new or updated community care medical policies?
VA reviews and updates the policies regularly. Please check this webpage for an updated version periodically. For the latest updates on VA community care, please sign up for the Provider Advisor newsletter.
Contacts
Questions? Email the IVC Medical Policy Unit with a completed VA Form 10-322.
NOTE: This email is only a means to submit the completed VA Form 10-322. VHA16IVCMedicalCoveragePolicy@va.gov
