Provider Reference Library
Fact sheets, program guides and forms located throughout the Community Care provider website are housed on this page and cross linked with the topic.
On This Page...
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.
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.
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.
|Veterans Care Agreement Form, VA Form 10-10171||Veteran Care Agreements|
|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|
|CV Quick Start Guide: Viewing Patient Information||Request and Coordinate Care–Community Viewer|
|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|
|VHA Directive 1108.08, VHA Formulary Management Process||DME Requirements / Pharmacy Requirements|
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.
|Item Type||Contact Information|
|Contact Lists||Office of Community Care Support page|
|Emergency and Urgent Care Facility Contact List|
|Facility Contact Numbers for Care Coordination|
|VA Facility Points of Contact for Community Viewer|
|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|