Emergency Medical Care–Information for Providers
Veterans seeking emergency care at a community medical facility should be treated immediately for the injury, illness, or symptom they are experiencing.
During a medical emergency, Veterans do not need to check with VA before going to an emergency department (ED) in their community or calling an ambulance.
Following treatment, providers should remind Veterans to promptly notify VA. The Veteran, a family member, friend, or provider staff member should contact the nearest VA medical facility as soon as possible, or within 72 hours of admission.
Once notified, VA staff will ensure that the Veteran is transferred to a VA medical center upon stabilization if the VA facility is feasibly available, and the Veteran receives any additional care, post discharge, without interruption. VA staff will also assist the Veteran and/or their representative(s) in understanding the extent to which, if any, VA can pay for the emergency medical treatment provided. Reimbursement by VA for emergency medical care provided to a Veteran depends on whether or not the treatment was for a condition related to the Veteran’s military service (a service-connected condition or nonservice-connected condition).
IMPORTANT: When a Veteran receives emergency medical care, notifying VA as quickly as possible is best. It ensures maximum VA coverage and assists VA in providing the Veteran with the care they need.
In general, VA may pay for emergency medical care at a local ED for a Veteran’s service-connected condition, or if the care is related to a Veteran’s service-connected condition. Specifically, emergency care provided related to a Veteran’s service-connected or related (adjunct) condition(s) is eligible for VA payment if VA is not reasonably available to provide the care.
VA may pay emergency care costs in the following situations:
- A Veteran receives emergency treatment of a service-connected, or adjunct condition* in a community emergency department; OR
- A Veteran who is Permanently and Totally disabled (P&T) as the result of a service-connected condition is eligible for emergency treatment of ANY condition; OR
- A Veteran who is participating in a VA Vocational Rehabilitation Program, and who requires emergency treatment to expedite their return to the program, is eligible for emergency treatment for any condition; AND (scenarios 1-3 must all meet #4)
- The emergency was of such a nature that the Veteran (or other prudent layperson without medical training) would reasonably believe that any delay in seeking immediate medical attention would cause their life or health to be placed in jeopardy.
A service-connected condition is one that has been adjudicated by the Veterans Benefits Administration (VBA) and a disability rating has been granted. An adjunct condition is one that, while not directly service-connected, is medically considered to be aggravating a service-connected condition. Legal authorities and payment methods for VA payment for emergency care for service-connected conditions are contained in Title 38 U.S.C. §1728, 38 CFR §17.120–§17.132.
VA may also pay for emergency medical care at a community ED for a Veteran’s nonservice-connected condition. However, there are several requirements and factors that affect the extent to which VA can cover those services. Specifically, emergency medical care for a Veteran’s nonservice-connected condition(s) is eligible for VA payment when all of the following six elements are true:
- Care was provided in a hospital emergency department (or similar public facility that provides emergency treatment to the public); AND
- The emergency was of such a nature that the Veteran (or other prudent layperson without medical training) would reasonably believe that any delay in seeking immediate medical attention would cause their life or health to be placed in jeopardy; AND
- A VA medical facility or another federal facility was not reasonably available to provide the care; AND
- The Veteran is enrolled and has received medical care under 38 U.S.C. Chapter 17 authority during the 24 months before the emergency care; AND
- The Veteran is financially liable to the provider of emergency treatment; AND
- If treatment was due to an injury accident, the claimant has exhausted without success all liability claims and remedies reasonably available to the Veteran or provider against a third party for payment of such treatment, and the Veteran has no contractual or legal recourse for extinguishing, in whole, the Veteran’s liability to the provider.
There are limitations on VA’s ability to provide coverage when a Veteran has other health insurance (OHI). If OHI does not fully cover the costs of treatment, VA may pay certain costs for which the Veteran is personally liable. By law, VA cannot pay copayments, coinsurance, deductibles, or similar payments a Veteran may owe to the provider as required by their OHI.
VA is also legally prohibited from providing coverage for Veterans covered under a health plan contract because of a failure by the Veteran or the provider to comply with the provisions of that health plan contract (e.g., failure to submit a bill or medical records within specified time limits, or failure to exhaust appeals of the denial of payment).
VA can pay for emergency medical care provided to a Veteran outside the United States if the emergency is related to the Veteran’s service-connected condition. For more information, including how to file a claim, contact the Foreign Medical Program office or visit the Foreign Medical Program page.
Foreign Medical Program Office: 877-345-8179
Claims for emergency medical care should be submitted to VA as soon as possible and within 180 days after care has been provided. This helps ensure that all required documentation is readily available and that provider payments are received in a timely manner.
Submit claims for services not preauthorized by VA to the VA medical facility closest to where the emergent treatment was provided.
- Submissions must include a standard billing form (such as CMS 1450 or CMS 1500) containing a false claims notice.
- Submit claims via Electronic Data Interchange (EDI) transaction (such as 8371 or 837P).
- Documentation related to the medical care may be required prior to claim processing.
Once a claim for emergency treatment is received by VA, the claim will be reviewed to determine Veteran eligibility. If the Veteran meets the eligibility criteria, the treatment documentation will then be reviewed by VA clinical staff to determine if the treatment received meets the clinical criteria necessary for VA to pay for the care. VA makes every effort to adjudicate claims for emergency treatment quickly and accurately.
For information about filing a claim for emergency medical care, please visit Filing A Claim for Veteran Care.
VA denies claims for emergency care when a Veteran or claim does not meet the legal requirements for payment. If you have received a denial for emergent care and you disagree with the decision, you or the Veteran may appeal the decision. Information regarding your right to appeal will accompany the denial decision letter.
VA rejects claims when the claim contains one or more errors or when VA needs additional information to process the claim for payment. If your claim has been rejected, please submit the corrected claim and/or required information to VA so your claim can be processed.
For additional information, please review Rejected Claims–Explanation of Codes.