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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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 Network programs.

Fact sheets for providers
ProgramFact Sheet TitleAssociated Page
General Information
Community Care Network Community Care Network Community Care Network
Community Care Network–Regions 1-5
How to Become a VA Community Provider
How to Become a VA CCN Dental Community Provider
Veterans Care Agreements Veteran Care Agreements
Veteran Care Program Handout for Providers: In Vitro Fertilization Treatment In Vitro Fertilization
Indian Health Services/Tribal Health Programs (IHS/THP) Reimbursement Agreement (RA) Program IHS/THP RA Program–Information for Providers
Eligibility
Community Care Network Veteran Community Care–Eligibility General Community Care
Appointments and Care
Community Care Network Veterans Community Care–Appointments and Getting Care General Community Care
Care Coordination
Community Care Network Azure RMS Encryption Software Azure Rights
Management Services
Community Viewer for Community Providers and Staff Community Viewer
HSRM Community Provider Information Sheet HealthShare Referral Manager (HSRM)
HSRM Account Creation Information Sheet
HSRM Single Sign-On External (SSOE) Quick Reference
HSRM Desk Support Information
Emergency Care
Veteran Care Program VA Community Emergency Care–Information for Veterans Emergency Medical Care–Information for Providers
Centralized Community Emergency Treatment Reporting and Care Coordination
VHA OCC Ambulance Transportation
Urgent Care
Veteran Care Program Veteran Community Care–Urgent Care Urgent Care–Information
for Providers
Infographic: How to Access Urgent Care
Infografía: Cómo acceder a la atención de urgencia
Billing and Claims
Community Care Network Billing and Payment Information for Veterans File a Claim for
Veteran Care
Preventing Paper Claims Rejections
Medical Document Submission Requirements for Care Coordination
Veteran Care Program Geriatrics and Extended Care (GEC) Fee Schedule VA Fee Schedule
IHS/THP Reimbursement Agreement Program IHS/THP RA Program–Information for Providers
Foreign Medical Program (FMP)–Information for Outpatient Providers and Office Managers
Other Types of Care–Information for Providers

Forms & 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.

CCN forms and guides for providers
Item Type
Item Title / Description
Associated Page / Website
Fillable PDF Forms
Community Care Provider Request for Service (RFS),VA Form 10-10172 Request and Coordinate Care–Request for Service (RFS) Requirements
FMP Claim Cover Sheet, VA Form 10-7959f-2 Other Types of Care–FMP
HSRM End User Tracker Template (Excel download) Request and Coordinate Care–HSRM 
P2E Documentation Cover Sheet, VA Form 10-10143f File a Veteran Claim–Supporting Documentation 
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.

Emergency Medical Care–Information for Providers
Third Party Payer Precertification Form Precertification Requirements
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

Provider Payments

Claims Status
Veterans Care Agreement Form, VA Form 10-10171 Veteran Care Agreements
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 Centers for Medicare & Medicaid Services (CMS) 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-1450 on CMS.gov
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.

CMS 1500 on CMS.gov
Guides
Community Viewer User Guide Request and Coordinate Care–Community Viewer
CV Quick Start Guide: Viewing Patient Information
Dialysis Provider Portal User Guide Claims Status 
HIPAA Transaction Standard Companion Guide (275 TR3) File a Veteran Care Claim
HSRM Account Creation Information Sheet Request and Coordinate Care–HSRM
HSRM Community Provider Quick Reference Guide
HSRM Community Provider User Guide
IHS/THP Provider Guide IHS/THP RA Program–Information for Providers
VA Manual
VHA Directive 1108.08, VHA Formulary Management Process DME Requirements / Pharmacy Requirements

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.

CCN contact lists and locator links
Item TypeContact Information
Contact Lists Office of Community Care Contact Us page
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
PC3, Regions 4 and 5, TriWest Claims: 877-226-8749
Locator Links VA Facility Locator
CVS Caremark Pharmacy Locator
Third Party Administrator (TPA) websites Optum–CCN Regions 1, 2, and 3
TriWest Health Care Alliance–CCN Regions 4 and 5