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Precertification Requirements

VA is required by law to bill Third Party Payers (TPP) for care that is not related to a Veteran’s service-connected disability or Special Authority. This requires VA to call TPPs for precertification for patients who are VHA beneficiaries with other billable health insurance (OHI).
Please note: Claims for ancillary services will be processed in accordance with Medicare National Correct Coding Initiative (NCCI), Medically Unlikely Edits (MUE), and related edits.

To identify services that require VA precertification, refer to the referral packet which contains a form called Offline Referrals/Billing and Other Referral Information. Providers can refer to the View your Billing and Other Referral Information section to see if the Standardized Episode of Care (SEOC) in your VA referral has codes that require precertification.

The preferred method to notify VHA Revenue Operations (RO) for tests/procedures/admissions requiring precertification is via the HealthShare Referral Manager (HSRM) provider portal using the Task: PROVIDER PRECERT NOTIFICATION. Although this is the preferred method of notifying Revenue Operations of precertification, the request can also be submitted via fax.

Once the community care provider has notified VHA Revenue Operations that the test/procedure/admission requiring TPP precertification is scheduled, there is no requirement to wait for the TPP approval or response prior to performing the test/procedure/admission included as part of the SEOC referral.

The precertification process should not be used to request additional services or extensions for authorization duration. To request additional services or extend authorization durations please use the Request for Additional Services (RFS) Form, VA Form 10-10172, which should be submitted to local facility community care staff using the office fax or email indicated on the referral form.

If you are interested in more information about HealthShare Referral Manager, including how to register, please review our Care Coordination page.

HSRM Provider Portal: AccessVA website

Fax numbers by Consolidated Patient Account Center (CPAC) region are listed below:

Fax numbers by Consolidated Patient Account Center (CPAC) Region
CPAC / Fax number VISNs included
Northeast CPAC
VISN 1: Togus, ME; Manchester, NH; Central Western Massachusetts; Bedford, MA; Boston, MA; Providence, RI; White River Junction, VT; Connecticut

VISN 2: Western New York; East Orange, NJ; Bronx, NY; New York, NY; Northport, NY; Hudson Valley, NY

VISN 4: Pittsburgh, PA; Altoona, PA; Coatesville, PA; Erie, PA; Lebanon, PA; Wilkes-Barre, PA; Philadelphia, PA; Butler, PA; Wilmington, DE
Mid-Atlantic CPAC
VISN 5: Martinsburg, WV; Huntington, WV; Beckley, WV; Clarksburg, WV; Washington, DC; Baltimore, MD

VISN 6: Hampton, VA; Richmond, VA; Salem, VA; Asheville, NC; Fayetteville, NC; Durham, NC; Salisbury, NC

VISN 7: Birmingham, AL; Central Alabama, AL; Tuscaloosa, AL; Atlanta, GA; Dublin, GA; Augusta, GA; Charleston, SC; Columbia, SC
Florida/Caribbean CPAC
VISN 8: Orlando, FL; N Florida/S Georgia; Tampa, FL; Miami, FL; West Palm Beach, FL; Bay Pines, FL; San Juan, PR
Mid-South CPAC
VISN 9: Lexington, KY; Louisville, KY; Tennessee Valley, TN; Memphis, TN; Mountain Home, TN

VISN 16: Central Arkansas; Fayetteville, AR; Biloxi, MS; Jackson, MS; Shreveport, LA; New Orleans, LA; Alexandria, LA

VISN 17: North Texas; Amarillo, TX; Central Texas; El Paso, TX; West Texas; Houston, TX; South Texas; Texas Valley Coastal Bend
North Central CPAC
VISN 10: Battle Creek, MI; Saginaw, MI; Ann Arbor, MI; Detroit, MI; Marion, IN; Indianapolis, IN; Cleveland, OH; Columbus, OH; Cincinnati, OH; Dayton, OH; Chillicothe, OH

VISN 12: Iron Mountain, MI; Madison, WI; Milwaukee, WI; Tomah, WI; Chicago, IL; Hines, IL; North Chicago, IL; Illiana, IL
Central Plains CPAC
VISN 15: Heartland (E. Kansas; Wichita, KS; Columbia, MO); St Louis/Poplar Bluff, MO; Marion, IL

VISN 19: Montana; Cheyenne, WY; Sheridan, WY; Salt Lake City, UT; Eastern Colorado, CO; Grand Junction, CO; Muskogee, OK; Oklahoma City, OK

VISN 23: Fargo, ND; Minneapolis, MN; St Cloud, MN; Black Hills, SD; Sioux Falls, SD; Omaha, NE
VISN 20: Alaska; Puget Sound, WA; Spokane, WA; Walla Walla, WA; Boise, ID; Portland, OR; Roseburg, OR; White City, OR

VISN 21: Northern California (Sacramento & Martinez); Central California (Fresno); San Francisco, CA; Palo Alto, CA; Pacific Islands; Sierra Nevada, NV; Southern Nevada, NV

VISN 22: Los Angeles, CA; Long Beach, CA; Loma Linda, CA; San Diego, CA; Northern Arizona; Phoenix, AZ; Southern Arizona; New Mexico

Standardized Episodes of Care (SEOC) Billing Code Information

The VA SEOC Billing Code List provides preapproved billing codes associated with the services within each available SEOC. The list also contains billing codes that require TPP precertification, called "Precertification (Precert) Codes.” While the codes have been clinically approved in the referral by VA as part of the SEOC, an additional precertification request must be submitted by VHA Revenue Operations to the Veteran’s TPP for the precert codes.

Prior to viewing the VA SEOC Billing Code List, you must accept the terms and conditions defined
in the License for Use Of Current Procedural Terminology.

Additional Coding Information

Ancillary Codes: Please note that claims for ancillary services will be processed in accordance with CMS NCCI, MUE, and related edits.

If code(s) are not on SEOC: Services provided must be appropriate and necessary to accomplish the intent of the referring provider's order/consult request. The SEOC describes the most likely scope of care necessary, but other services may be allowed in certain circumstances if necessary for completing the referral.