Provider Reference Library - Community Care
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Community Care

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Provider Reference Library

Welcome to the Community Care Provider Reference Library! Here you will find key information and links to other information to make it easier for you to do business with VA.

Fact sheets, program guides and forms located throughout the Community Care provider website are housed on this page and cross linked with the topic.

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Community Care Program Fact Sheets

The fact sheets listed below provide specific information that may help providers and office staff who have questions about participating in Community Care programs.

VHA OCC fact sheets for providers
ProgramFact Sheet Title
General Community Care Network
Community Care Network–Regions 1-4
How to Become a VA Community Provider
How to Become a VA CCN Dental Community Provider
State Home Per Diem (SHPD) Program Overview
State Home Program Application for Veteran Care Medical Certification
Map depicting VAMCs of jurisdiction for State Homes
Veterans Care Agreements
IHS/THP Reimbursement Agreement Program
Handout for Providers: In Vitro Fertilization Treatment
Eligibility Veteran Community Care–Eligibility
Appointments
and Care
Veterans Community Care–Appointments and Getting Care
Care Coordination HSRM Single Sign-On External (SSOE) Quick Reference
HSRM Desk Support Information
HSRM Account Creation Information Sheet
HSRM Community Provider Information Sheet
Community Viewer for Community Providers and Staff
Azure RMS Encryption Software
Emergency Care VA Community Emergency Care–Information for Veterans
Centralized Community Emergency Treatment Reporting and Care Coordination
VHA OCC Ambulance Transportation
Urgent Care Veteran Community Care–Urgent Care
Infographic: How to Access Urgent Care
Infografía: Cómo acceder a la atención de urgencia
Billing and Claims Veterans Care Agreement
Billing and Payment Information for Veterans
Medical Document Submission Requirements for Care Coordination
IHS/THP Reimbursement Agreement Program
ADA Dental Claim Form and Completion Instructions
Paper Claims Submission Process
Preventing Paper Claims Rejections
Electronic Claims Adjudication Management System (eCAMS)
Geriatrics and Extended Care (GEC) Fee Schedule
How to File a Foreign Medical Program Claim
Foreign Medical Program (FMP)–Information for Outpatient Providers and Office Managers

Education
and Training
MISSION Act Community Provider Training
How to Create an Account in VHA TRAIN
Community Providers–Utilizing VHA TRAIN MISSION Act Training
Opioid Safety Initiative

Contact Lists and Locator Links

The following contact lists, customer call center phone numbers and locator links are valuable tools for providers when looking for additional information or answers to questions.

VHA OCC contact lists and locator links
Item TypeItem Title/Information
Contact Lists Emergency and Urgent Care Facility Contact List
Facility Contact Numbers for Care Coordination
VA Facility Points of Contact for Community Viewer
Customer Service
Call Centers
VA Claims: 877-881-7618
Region 1, Optum Claims: 888-901-7407
Region 2, Optum Claims: 844-839-6108
Region 3, Optum Claims: 888-901-6613
Region 4 and PC3, TriWest Claims: 855-722-2838
Locator Links VA Facility Locator
CVS Caremark Pharmacy Locator

Forms and Guides

Specific forms are used to request information or provide information as requested. Guides give more detailed information that may be needed to sign up for a program or use a specific tool.

VHA OCC forms for providers
Item TypeItem Title/Description
Fillable PDF Forms Non-VA Hospital Emergency Notification, VA Form 10-10143g
P2E Documentation Cover Sheet, VA Form 10-10143f
Community Care Provider Request for Service (RFS),VA Form 10-10172
Veterans Care Agreement Form, VA Form 10-10171
FMP Claim Cover Sheet, VA Form 10-7959f-2
Third Party Payer Precertification Form
State Home Program Recognition Checklist
HSRM End User Tracker Template  (Excel download)
Refusal of Transfer to VA Health Care Facility, VA Form 10-8001

VA Form 10-8001 is used when a Veteran refuses to transfer to a VA Health Care Facility.
VA-FSC Vendor File Request Form, VA Form 10091

VA Form 10091 enables all vendors to apply for payment via Electronic Funds Transfer (EFT), or to submit changes/updates to their Financial Management System Vendor Record in order to receive VA payments that comply with the 1996 Debt Collection Improvement Act.

For questions regarding VA Form 10091, please contact the Nationwide Vendor File Division via email or phone listed below.

877-353-9791

Print-Only Forms Medical Billing Claim Form, UB-04 (CMS‑1450) Institutional Paper Claim Form

The CMS-1450 form can be used by an institutional provider to bill a Medicare fiscal intermediary when a provider qualifies for a waiver from the Administrative Simplification Compliance Act requirement for electronic submission of claims. It is also used for billing of institutional charges to most Medicaid State Agencies.

PLEASE NOTE: You can download a sample CMS-1450 from the CMS.gov website. However, copies of the form should not be downloaded for submission of claims, since they may not accurately replicate colors included in the form. These colors are needed to enable automated reading of information on the form.

CMS.gov information on CMS-1450

Health Insurance Claim Form (CMS-1500)

The CMS-1500 Claim Form is the basic paper claim form prescribed by many health care payers for claims submitted by physicians, other providers, and suppliers, and in some cases, for ambulance services.
Guides Community Viewer User Guide
CV Quick Start Guide: Viewing Patient Information
Dialysis Provider Portal User Guide
HIPAA Transaction Standard Companion Guide (275 TR3)
HSRM Account Creation Information Sheet
HSRM Community Provider Quick Reference Guide
HSRM Community Provider User Guide
IHS/THP Provider Guide
TriWest Provider Claims and Reimbursement Quick Reference Guide
VA Manual VHA Directive 1108.08, VHA Formulary Management Process (PDF download)