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Community Care

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Information for Providers

icon stethoscopeThe VA is undergoing a significant transformation with how it purchases care in the community. The Veterans Health Administration Office of Community Care (VHA OCC) is committed to ensuring that its VA Community Care partners understand current processes, are informed of future enhancements, and receive excellent customer service. It is our intention to provide information that answers your questions accurately and clearly, and enables efficient and timely claims processing for all of the community care health plans we administer. VHA OCC verifies eligibility for benefits; authorizes benefits and services; and handles vendor certification, approval and payment methodologies for all of these health care programs.

Navigating the community care system can be complex, and this site is designed to give providers the information and contacts they need to collaborate with VA to deliver timely, quality care to Veterans and their dependents. Quick links to our key programs are provided below.

Hot Topics

Read about recent program news and updates

Provider resources toolkit

Online resource toolkit and key VHA OCC contacts

Provider Reference Library

Forms, fact sheets, guides, and training for providers

 
Programs for Veterans

Description of and links to our health care programs for Veterans

Family Member Programs

Description of and links to our programs
for dependents and family members


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Veteran Care

VHA OCC purchases health care for eligible Veterans when a VA medical center (VAMC), clinic or other federal facility is not feasibly available to furnish care. All VAMCs can use community care when needed. The different types of Veteran care include Patient-Centered Community Care (PC3)/Choice contracts, community emergency medical care, individual authorizations, and special programs.

The use of community care is governed by federal laws containing eligibility criteria and other policies specifying when and why it can be used. In most cases, a preapproval for treatment is required for community care unless the medical event is an emergency. Emergency events may be reimbursed on behalf of the Veteran in certain cases.

Programs for Veterans

Patient-Centered Community Care (PC3)/Choice Contract

When it is determined that neither VA nor its core partners can provide needed care, the primary method for VA to purchase care for Veterans is to utilize the PC3/Choice contract. The PC3 program and the Veterans Choice Program are executed through contracted third party administrators נcurrently Health Net Federal Services (Health Net) and TriWest Healthcare Alliance (Triwest).

Community Emergency Medical Care

When emergency care is necessary, preapproval is not required for emergency room/hospitalization at an approved non-VA facility or non-VA medical care service provider. VA payment or reimbursement may be authorized to a claimant for emergency treatment provided to a Veteran with a VA-adjudicated, service-connected condition, and for nonservice-connected conditions in certain circumstances.

Individual Authorizations

Preauthorized Inpatient/Outpatient Medical Care
When PC3 program contractors are unable to provide needed care, VA Community Care may authorize care for eligible Veterans to obtain routine outpatient or inpatient medical services through community providers. Preapproval is required.

Preauthorized Medical Care

Nationwide Dialysis Contract (NDC) Program
The purpose of the NDC Program is to provide authorized dialysis treatment to eligible Veterans when VA facilities are not capable of providing economical care due to geographical inaccessibility or the needed care is not available at a VA facility.

NDC Program Contacts and Resources

Home Health Services and Hospice Care
Home health care services are supportive medical services prescribed by and under the direction of a VA physician. There are five major categories of home health care authorized by VA CC: Skilled Home Health Care services, Home Health Aide services, Homemaker services, Respite Care services, and Hospice Care.

Home Health Services

Special Programs

State Home Per Diem (SHPD) Program
The SHPD Program is is a benefit administration and payment processing program that pays per diem for state-provided quality care for eligible Veterans in three different types of programs: nursing home, domiciliary, and adult day health care.

State Home Per Diem Program

Indian Health Service/Tribal Health Program (IHS/THP)
The VA IHS/THP Reimbursement Agreements Program provides a means for IHS and THP health facilities to receive reimbursement from the VA for direct care services provided to eligible American Indian/Alaska Native Veterans.

IHS/THP–Information for Providers

Foreign Medical Program (FMP)
The FMP is for Veterans who live or travel overseas. Under the FMP, the Department of Veterans Affairs will pay the VA allowable amount for the treatment of a service-connected disability.

Foreign Medical Program


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Family Member Care

VA provides a number of health care benefits programs for spouses and children of Veterans, depending on certain criteria. The largest of these programs is the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), a comprehensive health care program for the spouse or widow(er) and children of an eligible Veteran. The VA also has other health care programs for family members, including the children of Women Vietnam Veterans, and for the family members of Veterans who were potentially exposed to contaminated drinking water while stationed at Camp Lejeune Marine Corps Base, North Carolina, between Aug. 1, 1953 and Dec. 31, 1987.

Family Member Programs

CHAMPVA

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) was established in 1973 for dependents of permanently and totally disabled Veterans, survivors of Veterans who died from service-connected conditions or who, at the time of death, were rated permanently and totally disabled from a service-connected condition. Under CHAMPVA, costs of medical services and supplies are shared with eligible beneficiaries.

CHAMPVA–Information for Providers

CHAMPVA Program for the Primary Family Caregiver

CHAMPVA for the Primary Family Caregiver is a health care benefits program in which the Department of Veterans Affairs (VA) shares the cost of certain health care services and supplies with the Veteran's Primary Family Caregiver, who is not entitled to care or services under a health plan contract, including a health insurance plan, TRICARE, Medicare or Medicaid.

Caregiver Program

Camp Lejeune Family Member Program (CLFMP)

The CLFMP covers treatment costs for one or more of the 15 primary medical conditions listed in the Honoring Americaӳ Veterans and Caring for Camp Lejeune Families Act of 2012. Also covered are associated medical conditions that are caused or exacerbated by the listed conditions. (Example: hip fracture secondary to spread of breast cancer into the bones.) VA reimburses qualified family members as the last payer of medical claims for any of the covered illnesses or conditions.

CLFMP

Children of Women Vietnam Veterans (CWVV) Health Care Benefits Program

The CWVV Health Care Benefits Program provides health care benefits for children with certain birth defects born to women Vietnam Veterans.The CWVV Program is a Fee for Service (indemnity plan) program that provides reimbursement for medical care for conditions associated with certain birth defects for beneficiaries who have filed with the Veterans Benefits Administration and been found to have a covered condition.

CWVV Program

Spina Bifida Health Care Benefits Program

The Spina Bifida Health Care Benefits Program (SBHCBP) provides comprehensive health care benefits to birth children of Veterans of certain service in Korea and/or Vietnam who have filed for benefits with the Veterans Benefits Administration (VBA) and been found to have spina bifida.

SBHCP–Information for Providers

Pharmacy Benefits

Beneficiaries of the CHAMPVA, Spina Bifida and Children of Women Vietnam Veterans programs can access pharmacy benefits through the Catamaran network of retail pharmacies or through the Meds by Mail program.

Pharmacy Benefits