File a Claim for Veteran Care
VA accepts both electronic and paper claim submissions. Electronic claim submissions will be automatically routed to the correct VA location for processing. Paper claims must be submitted to the claims processing unit responsible for the referring VA Medical Center.
The process for submitting claims for health care provided to Veterans is different depending on how VA authorized the care.
For claims authorized and provided through Patient-Centered Community Care (PC3) networks or the Veterans Choice Program (VCP), you should file your claim directly with VA’s Third Party Administrator (TPA), TriWest Healthcare Alliance (TriWest). Please note: VCP ended on June 6, 2019.
For emergent care claims that have not been preauthorized through the Community Care Network, claims and records should be submitted to the payment processing unit associated with the VA medical facility nearest to where the emergent services were provided.
Filing Directly with TriWest
Claims for care provided through PC3, or previously through the VCP, must be sent to and processed by TriWest Healthcare Alliance (TriWest). You can find specific instructions and contact information in the TriWest Claims and Reimbursement Quick Reference Guide.
TriWest Claims and Reimbursement Quick Reference Guide
Health Net Federal Services Information
Health Net Federal Services (Health Net) was a TPA for VA’s PC3 networks and the VCP. Health care provided to Veterans through Health Net ceased in June 2018, and VA’s contract with Health Net ended on September 30, 2018. The deadline for community providers to file initial claims for Health Net-authorized services with Health Net was March 26, 2019.
For questions and more information, please call the Health Net provider service line or visit the Health Net website.
Claims for care previously provided through a VCP Provider Agreement should be sent directly to VA. Once you have provided care to a Veteran, you can submit a claim directly to VA electronically or by mail. VA encourages filing electronically for prompt processing and payment.
National Provider Identifier (NPI)
The VHA OCC requires the use of the NPI on all inbound medical, dental, and pharmacy transactions. If you are a HIPAA-covered health care provider who electronically bills for services to VA programs, or submits other electronic transactions through our clearinghouse, you need an NPI. NPIs that should be sent include, but are not limited to, rendering, referring, and prescribing NPIs.
More information on the use of NPIs can be found on the National Plan and Provider Enumeration System (NPPES) website.
VA now requires a referral/authorization number to be submitted on all 837 Electronic Data Interchange (EDI) and paper claim submissions that are for preauthorized services. The compliance date for this is June 2019, so please begin adjusting processes and systems now. This additional claim data will enable faster claims processing for authorized care.
- For paper claims, include this information in field 23 on a HCFA 1500 or field 63 on a UB-04.
- For EDI 837, Referral Number is Loop = 2300, Segment = REF*9F, Position = REF02 or Prior Authorization, Loop = 2300, Segment = REF*G1, Position = REF02.
- If you are a Home Health Agency billing with an OASIS Treatment number, you will continue to place the Treatment Authorization Code (TAC) in field 63a on UB-04 and the VA referral/authorization number in field 63b.
- For EDI 837I (Institutional Health Care Claim), use the Prior Authorization segment for the TAC and the Referral Number segment for the VA referral/authorization number.
Claims Where VA May be Secondary Payer
For claims where VA may be secondary payer, provide a copy of the Explanation of Benefits (EOB) from the primary payer documenting the balance remaining is not due to a copayment, cost-share, deductible, or other similar patient liability. Please include a copy of the reverse side of the EOB if a definition/explanation of codes is listed on the back.
Claims processing can be cut down by weeks when you submit electronically. VA accepts HIPAA-compliant, 837 EDI institutional, professional, and dental claims through our clearinghouse, Change Healthcare.
Providers must complete an enrollment form at Change Healthcare to receive an ERA from VA. You should enroll to receive both regular network ERAs as well as ERAs created from claims that are received from Medicare crossover through the Coordination of Benefits contractor. The form can be found on the Change Healthcare Enrollment Services website.
For all compliant EDI claims sent to us through Change Healthcare, an 835 electronic remittance advice (ERA) will be provided in addition to a Preliminary Fee Remittance Advice Report (PFRAR) and, if paid, an EOB.
Where to Send Electronic Claims
All compliant EDI claims will automatically be sent electronically to VA through the Change Healthcare clearinghouse. VA will reimburse you for authorized services provided to Veterans.
To check the status of a claim, see Check Claim Status.
VA encourages providers to submit claims electronically. VA does accept paper claims, but the processing time is 20 days longer on average. Paper claims submitted to VA will be subject to the Paper to Electronic Claims process.
When filing a paper claim, the following information must be submitted:
- Itemized billing statement on either a CMS-1500 form or UB-04 form
- Full name, address, National Provider Identifier (NPI), and tax ID number of the provider
- Veteran’s Social Security Number
- Remit to address
- Rendering facility address
- Provider professional status
(doctor, nurse, physician assistant, etc.)
- Specific date of each service provided
- Itemized charges for each service
- Appropriate code for each service
(ICD-10, CPT, HCPCS)
Where to Send Paper Claims
Information about where to send paper claims for care provided through a VCP Provider Agreement or community care can be found in the authorization document. If you provided care through a different community care program, please review the Contact List for information and addresses for where to send your claim.
Converting Paper Claims to EDI (P2E)
To improve efficiency, VA is transitioning paper claims for community care to an electronic format. Currently, VA sends paper claims to a centralized location for scanning and conversion to an electronic 835 format.
As part of this process, the paper submission intake system automatically scans for noncompliant form fields based on national standards. Claims submitted that do not comply with nationally standardized billing requirements will be rejected before passing to VA’s clearinghouse and claims processing system. This front-end claim evaluation process ensures that providers who have submitted incomplete claims are notified as quickly as possible about the need for correction. The acceptance of complete claims reduces processing time since fewer corrections to noncompliant fields will be needed during claims processing.
When emergency care is necessary, Veterans should call 911 or go to the nearest emergency room immediately. Notification of emergent treatment must be provided to VA as soon as possible and within 72 hours of treatment. VA reimbursement for the emergent care may be authorized if clinical and administrative criteria are met.
Expanded Eligibility for Emergency Care
On January 9, 2018, VA began processing claims for reimbursement for reasonable costs that were only partially paid by a Veteran’s other health insurance (OHI). Those costs may include hospital charges, professional fees, and emergency transportation such as ambulances. VA applied the updated regulations to claims pending with VA on or after April 8, 2016, and to new claims. VA’s Payment Limitation regulation (Title 38 CFR §17.1005) establishes the methodology used to process and pay these claims.
Claims for emergency medical care should be submitted to VA as soon as possible after care has been provided. The deadline for filing a claim depends on whether care was provided for a service-connected condition or a nonservice-connected condition. The following chart describes filing requirements, deadlines, and payment rates.
|What Do I Submit?|
|Veterans or their personal representatives may file a claim for reimbursement of emergency treatment costs that they have incurred and paid to the provider.
||Submit claims for services not preauthorized by VA to the VA medical facility closest to where the emergent treatment was provided.
|Claim Filing Deadlines|
|Service-Connected Condition||Nonservice-Connected Condition|
|Claims must be submitted to VA within two (2) years of the date emergency medical care was received. However, filing the claim as soon as possible after care has been provided is highly recommended because it helps ensure that all required documentation is readily available and that providers receive their payment in a timely manner.||Claims must be submitted to VA within 90 days of the date of discharge, or 90 days from the date that all attempts to receive required payments from a liable third party are completed and not successful in eliminating the Veteran’s personal liability to the provider. A liable third party includes other health insurers, worker’s compensation, civil litigation, etc.|
|Service-Connected Condition||Nonservice-Connected Condition|
|Generally, 100% Medicare rates||Generally, 70% Medicare rates|
For more information about emergency care claims, call your nearest VA medical facility. The VA Facility Locator can help find a facility and key staff information.
By law, non-emergent care provided by community providers must be formally authorized by VA prior to care being rendered for VA to assume financial responsibility for that care.
If you are authorized to provide care to a Veteran, paid for by VA, you will receive a hard-copy authorization. Unlike other Federal payers, such as Medicare, Tricare, and in some cases CHAMPVA, VA must authorize the care in advance to ensure the Veteran meets the clinical and administrative eligibility requirements.
VA is the primary and sole payer when VA issues an authorization. In rare instances, VA may become secondary payer for nonservice-connected emergency care. VA is legally prohibited from paying Veteran copayments, deductibles, co-shares, and co-insurance.
It is extremely important for you to contact the VA medical center closest to where the emergency care is provided as soon as possible and within 72 hours so that:
- Veteran receives continuity of care
- VA can assist with transfer to a VA medical facility once the Veteran is stable for transfer
- VA may evaluate the Veteran’s eligibility and issue an authorization if the Veteran meets the eligibility criteria for approval under 38 USC §1703
To determine which VA medical center is nearest, please use the VA Facility Locator to help find a facility and key staff information.
The community provider should reach out to the VA Medical Center that issued the authorization. If the care was emergent and not preauthorized, please reach out to the VAMC nearest to where the care was rendered.
Yes, the authorization number is required on claims for preauthorized care submitted to VA for payment. This additional claim data will enable faster claims processing for authorized care. The criteria for adding the authorization number is located above.
See the Authorization Annotation Requirement listed above.
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