Precertification Requirements
Precertification is the process of notifying VA before a specific service is delivered. Precertification supports high-value care for Veterans through effective services while maintaining health care quality.
All Community Care Network and Veterans Care Agreement providers who receive a VA-authorized referral are required to notify VA of services that require precertification before delivering these services to Veterans. Claims for precertification-required services will be denied if a precertification ID is not obtained prior to the date of service.
NOTE: Urgent and emergency care do not require precertification.
How to Submit a Precertification
Use the Precertification Portal to submit a precertification. Submit all precertifications through the portal. Fax and U.S. mail submissions are not accepted.
- Enter the Veteran’s demographics and VA authorization number.
- Enter a Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code to check if precertification is required.
- Upload medical documentation that justifies why the service is medically necessary.
After submitting, you’ll receive immediate confirmation and a unique precertification ID. You do not need to include this ID on claims, but it must be shared with any providers involved in the Veteran’s care (such as labs and imaging centers).
VA Precertification Code List
NOTE: Before accessing the VA Precertification Code List, you must review the terms and conditions defined in the CPT Data Files License End User Agreement.
Important notes:
- Other Health Insurance: Care authorized and paid for by VA cannot be submitted to a Veteran’s other health insurance by community providers.
- Requests for Additional Services: Do not use the precertification process to request more services or extend care. Visit the Request for Service webpage for instructions on how to submit those requests.
Standardized Episodes of Care Billing Code Information
This information is for community providers who bill VA for care delivered under Standardized Episodes of Care (SEOCs). The VA SEOC Billing Code List provides billing codes associated with each available SEOC.
View the VA SEOC Billing Code List
NOTE: Before viewing the SEOC Billing Code List, you must accept the terms and conditions defined in the License for Use of Current Procedural Terminology.
The SEOC Billing Code List identifies billing codes that require precertification, but the VA Precertification Portal (VAPP) must be used to validate that a code/service requires precertification and to submit a precertification request.
View Precertification Requirements
How to use the SEOC Billing Code List
SEOCs provide a high-level summary of the typical scope of care and commonly associated billing codes for a referral. The billing codes listed on an SEOC are not intended to represent every service that may be provided.
If a billing code is not listed on a SEOC, determine whether the service is within the scope and intent of the authorized referral, customary to the specialty, not investigational or experimental, and FDA-approved:
- Services within scope may be billed using appropriate codes, even if the specific code is not listed.
- Services outside the scope of the authorized referral require additional VA approval before care is provided.
When additional approval is needed, follow the Request for Service (RFS) process.
SEOC billing codes
VA generally follows standard Centers for Medicare and Medicaid Services (CMS) Medicare payment schedules and prospective payment system (PPS) methodology. Services coded on a SEOC typically use CMS Medicare codes.
Claims are processed in accordance with CMS National Correct Coding Initiative (NCCI), Medically Unlikely Edits (MUE), and other related payment edits.
Some billing code types are not included on SEOCs. Examples include:
- A-codes (supply codes)
- E- and K-codes (durable medical equipment [DME])
- J-codes (medications, pharmacy, and vaccines)
- L-codes (prosthetics)
- Q-codes (miscellaneous codes)
- Codes for intraoperative DME
A billing code may also not appear on a SEOC when it is not appropriate to the specialty, is considered bundled or inclusive, is an add-on code, is used for reporting purposes only, or represents unlisted, experimental, investigational, or non-FDA-approved services.
Non-CMS Medicare codes such as H-codes (CMS Medicaid codes), S-codes (commercial codes), and T-codes (category III codes for emerging technologies/investigational/experimental services) are included on SEOCs when the VA National Clinical Program Offices have made a determination of VA coverage. Visit the Clinical Determinations and Indications (CDI) webpage for more information about CDIs.
