Emergency Medical Care–Information for Providers - Community Care
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Emergency Medical Care–Information for Providers

During a medical emergency, Veterans should immediately seek care at the nearest medical facility. A medical emergency is an injury, illness or symptom so severe that without immediate treatment, an individual believes his or her life or health is in danger. If a Veteran believes his or her life or health is in danger, call 911 or report to the nearest emergency department right away.

Veterans do not need to check with VA before calling for an ambulance or going to an emergency department. During a medical emergency, VA encourages all Veterans to seek immediate medical attention without delay. It is, however, important to promptly notify VA within 72 hours of presenting to the emergency room.

72-Hour Notification

Providers, Veterans and representatives should report instances of a Veteran presenting to a community emergency room to VA within 72 hours of the start of emergent care.

Notifying VA within 72 hours is important because this:

  • Allows VA to assist the Veteran in coordinating necessary care or transfer,
  • Helps ensure that the administrative and clinical requirements for VA to pay for the care are met
  • May impact a Veteran’s eligibility for VA to cover the cost of emergency treatment

Case-specific details are necessary for care coordination and eligibility determinations. Providers, Veterans and representatives can utilize any one of the following options to report notification:

VHAEmergencyNotification@va.gov

844-72HRVHA (844-724-7842)

Appropriate VA official at the nearest VA medical facility

The person notifying VA should be prepared to supply the case specific information detailed in the Non-VA Hospital Emergency Notification, VA Form 10-10143g, when calling or emailing notification. If the person making the notification is unable to supply all information, VA will engage with the appropriate parties in attempt to collect the information.

Non-VA Hospital Emergency Notification, VA Form 10-10143g

The primary purpose of notifying VA of a Veteran presenting to a community provider in need of emergency treatment is to ensure proper care coordination. Notifying VA also allows covered Veterans who have presented to an in-network community facility to have their emergent treatment authorized by VA under 38 Code of Federal Regulation (CFR) §17.4020(c). The local VAMC will engage with community providers who report notification through the centralized notification process. However, if you have an urgent or emergent need to coordinate care and/or transfer a Veteran to a VAMC, please make immediate contact to the nearest VAMC.

Facility Contact Numbers for Care Coordination

IMPORTANT: Failure to timely notify VA of care rendered through an in-network community facility prevents VA from authorizing the emergency care and prevents claims and payments from being made through one of VA’s third-party administrators.

Veteran Eligibility for Emergency Care

VA has three legal authorities under which emergency treatment in a community facility may be paid for by VA:

  1. Authorized Emergency Treatment–38 Code of Federal Regulations (CFR) §17.4020(c)
  2. Unauthorized Emergency Treatment (Service-connected)–38 United States Code (U.S.C.) §1728
  3. Unauthorized Emergency Treatment (Nonservice-connected)–38 U.S.C. §1725

Each authority requires the following General Eligibility requirements be met:

  • Veteran is enrolled or exempt from enrollment in the VA health care system.
  • A VA health care facility or other federal facility with the capability to provide the necessary emergency services must not have been feasibly available* to provide the emergent treatment and an attempt to use them beforehand would not be reasonable.
  • The medical situation is of such a nature that a prudent layperson would reasonably expect that a delay in seeking immediate medical attention would be hazardous to life or health.
  • Generally, emergency treatment is only covered until such time as the Veteran can be safely transferred to a VA or other federal facility.

Additional Requirements for Authorized Emergency Treatment (38 CFR §17.4020(c)):

In addition to the General Eligibility requirements, in order to be authorized for emergent care under 38 CFR
§17.4020(c), all of the following criteria must also be met:

  • In-Network Status: The treatment was rendered at a community emergency facility that is in VA’s community care or PC3 network.
  • 72-Hour Notification to VA: VA must be notified of the treatment within 72 hours. If VA is not timely notified, the treatment cannot be authorized under this section.

Additional requirements for retroactive payment approval for unauthorized emergency treatment for service-connected Veterans (38 U.S.C. §1728):

In addition to the General Eligibility requirements, for payment to be retroactively approved for emergent care under 38 U.S.C. §1728, one of the following criteria must also be met:

  1. Emergency treatment of a service-connected*, or adjunct condition* in a community emergency department; OR
  2. 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
  3. A Veteran who is participating in a VA Vocational Rehabilitation Program and requires emergency treatment to expedite their return to the program is eligible for emergency treatment for any condition.

NOTE: Legal authorities and payment methods for VA payment for emergency care for service-connected conditions are contained in 38 U.S.C. §1728, 38 CFR §17.120 and 38 CFR §17.132.

Additional requirements for retroactive payment approval for unauthorized emergency treatment for nonservice-connected Veterans (38 U.S.C. §1725):

In addition to the General Eligibility requirements, for payment to be retroactively approved for emergent care under 38 U.S.C. §1725, all of the following 5 criteria must also be met:

  1. Care was provided in a hospital emergency department (or similar public facility held to provide emergency treatment to the public); AND
  2. The Veteran has received care within a VA facility during the 24 months before the emergency care; AND
  3. The Veteran is financially liable to the emergency treatment provider; AND
  4. If the treatment was due to an injury or 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; AND
  5. The Veteran is not eligible for reimbursement under 38 U.S.C. §1728 for the emergency treatment.

There are limitations on VA’s ability to provide coverage when a Veteran has other health insurance (OHI). If a Veteran has OHI but the OHI does not fully cover the costs of treatment, VA may pay certain costs for which the Veteran is personally liable, unless payment by the Veteran’s OHI was barred because the Veteran or provider failed to comply with the provisions of that health plan contract or third party payer; for example, failure to submit a bill or medical records within specified time limits, or failure to exhaust appeals of the denial of payment.

NOTE: Legal authorities and VA payment methods for emergency care for non-service-connected conditions are contained in 38 U.S.C. §1725 and 38 CFR §17.1000.

How Network Status Impacts Eligibility, Authorization and Claims Submission
How Network Status Impacts Eligibility, Authorization and Claims Submission

If care was rendered at an in-network facility and notification was received by VA within 72 hours, the following assessments will be made by VA:

Care At An In-Network Facility
  • Is Veteran enrolled or exempt from enrollment?
  • Was care determined to be emergent?
  • Was VA unable to provide the care?

If the answer to all question is “Yes”, VA will authorize payment and the provider should submit claims to TPA (Optum or TriWest).

If the answer to any question is “No”, VA will not authorize payment and the provider should submit claims to another payer (OHI or Veteran).

If care was rendered in an in-network facility and notification was not received by VA within 72 hours, eligibility assessments will mirror those of an out-of-network facility (below).

Care At An Out-of-Network Facility

If care was rendered in an out-of-network facility the following assessments will be made by VA:

  • Is Veteran service-connected 0% or more?
    • If yes, initial consideration for payment approval will be under 38 U.S.C. §1725 and 38 U.S.C. §1728 and claims should be submitted to VA for retroactive evaluation and determination.
    • If no, does the Veteran have other health insurance?
      • If no, initial consideration for payment approval will be under 38 U.S.C. §1725 and 38 U.S.C. §1728 and claims should be submitted to VA for retroactive evaluation and determination.
      • If yes, claims should be submitted to other health insurance for primary payment.
Filing a Claim

Please refer to File a Claim for Veteran Care for information on how to file a claim and the timelines in which claims must be filed.

Supporting Documentation

It is essential that medical documentation and other supporting material for all care received by Veterans in the community is provided to the referring VA for incorporation into the Veteran’s electronic health records. Medical documentation is also an important component to assessing the patient’s condition and making determinations related to care coordination and eligibility. During the care coordination process, the local VA medical center will communicate with the community provider about information needed to support the coordination. There are multiple methods by which community providers may electronically provide the referring VA with the required medical documentation for care coordination purposes:

Join the Veterans Health Information Exchange (VHIE) which enables bi-directional sharing of Veteran Health Information

Utilize HealthShare Referral Manager (HSRM) for referrals, authorizations and documentation exchange.

Use Azure Rights Management Services (Azure RMS) for encrypted email.

E-fax: Documentation sent via email to Veterans Affairs Medical Center (VAMC) fax machine. Please contact the referring VAMC for e-fax number.

For information on how to file documentation in support of a claim for reimbursement, please visit File a Claim for Veteran Care, and refer to the Supporting Documentation section.

Receiving Payment

VA and VA’s third-party administrators make every effort to adjudicate claims for emergency treatment quickly and accurately. When further information or clarification is needed, claims processing may be delayed.

If a Veteran is charged for emergency treatment received in the community and believes the charges should be covered by VA, they should contact the VA Office of Community Care (OCC) National Call Center. VA staff will assist the Veteran in understanding eligibility and determining whether the bill received is appropriate. VA will assist the Veteran and work to resolve any billing issues with the community provider.

VA OCC National Call Center: 877-881-7618, Monday-Friday, 8 a.m. to 8 p.m. Eastern Standard Time

If you are a provider and have a question about a claim you have submitted for payment, please contact the entity to which the claim was submitted:

  • TriWest: 855-722-2838
  • VA: 877-881-7618
  • Optum Region 1: 888-901-7407
  • Optum Region 2: 844-839-6108
  • Optum Region 3: 888-901-6613

Reimbursement Rates

 Reimbursement RateEmergent Care Payer
Authorized Emergency Treatment
38 CFR §17.4020(c)
Generally, 100% Medicare
(refer to the terms of your contract)
Authorizing Third Party Administrator (Optum or TriWest)
Unauthorized Emergency Treatment
(Service-connected)
38 USC §1728
Generally, 100% Medicare VA
Unauthorized Emergency Treatment
(Nonservice-connected)
38 USC §1725
Generally, 70% Medicare VA
Emergency Care in Foreign Countries

VA can pay for emergency medical care outside the United States if the emergency is related to a Veteran’s service-connected condition. Contact the Foreign Medical Program for more information.

Foreign Medical Program: 877-345-8179

*Definitions

Prudent Layperson: Any medical or behavioral condition of recent onset and severity that would lead an individual who possesses an average knowledge of health and medicine to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part, or in the case of behavioral condition placing the health of such person or others in serious jeopardy. This prudent layperson definition of emergency medical condition focuses on the patient’s presenting symptoms rather than the final diagnosis when determining whether to authorize medical claims for payment

VA Feasibility: VA’s capability to provide the emergency services at the time a Veteran is in need of such services. Travel time to the nearest VA capable of servicing those emergent needs, the severity of symptoms and the mode of arrival will all be evaluated in assessing VA feasibility.

Service-connected Condition: A condition that has been adjudicated by the Veterans Benefits Administration (VBA) and granted a disability rating.

Adjunct condition: A condition that, while not directly service-connected, is medically considered to be aggravating a service-connected condition.