Emergency Medical Care - Community Care
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Emergency Medical Care

During a medical emergency, you should immediately seek care at the nearest emergency department (ED). A medical emergency is an injury, illness or symptom so severe that a delay in seeking immediate medical attention would be reasonably expected to be hazardous to life or health. If you believe your life or health is in danger, call 911 or go to the nearest emergency department right away.

During a medical emergency, VA encourages all Veterans to seek immediate medical attention without delay.

IMPORTANT: An emergency department is a facility that is staffed and equipped to provide emergency treatment and does not include community facilities that only provide medical treatment in situations other than emergencies.

Notify VA Immediately

Inform the emergency care provider to report your emergency treatment to VA’s Centralized Emergency Care Reporting Center as soon as possible after your treatment starts by:

Using the VA Emergency Care Reporting portal, OR

Calling 844-72HRVHA (844-724-7842)

You, or someone acting on your behalf, can also report the emergency treatment to VA. VA should only be notified once and ideally that notification is from the community emergency facility where treatment is being conducted. If you have an urgent or emergent need to coordinate care or transfer to a VAMC, contact the nearest VAMC immediately.

Notifying VA of an emergency event allows covered Veterans to have their emergency treatment authorized by VA. Failure to report emergency care to VA within 72 hours of the start of the emergency treatment may impact your eligibility for VA to cover the cost of treatment. However, even if the notification to VA did not occur timely, the emergency treatment may still be eligible for VA reimbursement.

Eligibility

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

  • Unauthorized Emergency Treatment (Service-Connected): 38 United States Code (U.S.C.) §1728
  • Unauthorized Emergency Treatment (Nonservice-connected): 38 U.S.C. §1725
  • Authorized Emergency Treatment: 38 Code of Federal Regulations (CFR) 17.4020(c)

Each authority requires the following:

  1. You must be enrolled in the VA health care system or have a qualifying exemption from enrollment.
  2. A VA health care facility or other federal facility with the capability to provide the necessary emergency services must not be feasibly available* to provide the emergency treatment.
  3. 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.
  4. The claim is timely filed.

NOTE: Emergency treatment is only covered until you can be safely transferred to a VA or other federal facility. If you refuse to be transferred to a VA or other federal facility after your emergency condition is stabilized, you may be liable for the cost of care beyond the point of stabilization.

The single exception to this rule is if VA is contacted and unable to accept the transfer. If this happens,
it is important that any attempt to transfer you be documented by the community emergency treatment facility.

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

In addition to the general eligibility requirements, the following criteria must also be met under 38 CFR 17.4020(c):

  1. In-Network Status: The treatment was provided at a community emergency facility that is in VA’s Community Care Network (CCN) or Patient-Centered Community Care (PC3) network.
  2. 72-Hour Notification to VA: VA must be notified of the treatment within 72 hours of your arrival at the emergency treatment facility. If VA is not notified within that window, the treatment cannot be authorized under this section.

NOTE: Failure to notify VA within 72 hours will not automatically result in a denial of the emergency care claim; however, it will affect the eligibility criteria that must be met for the claim to be processed under separate payment authorities. (See the following eligibility requirements for 38 U.S.C. §1728
and §1725).

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, one of the following criteria must also be met under 38 U.S.C. §1728:

  1. You receive emergency treatment of a service-connected* or adjunct condition* in a community emergency department; OR
  2. If you are permanently and totally disabled (P&T) as the result of a service-connected condition, you are eligible for emergency treatment of ANY condition; OR
  3. If you are participating in a VA Vocational Rehabilitation Program and you require emergency treatment to expedite your return to the program.

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, all of the following criteria must also be met under 38 U.S.C. §1725 for payment to be retroactively approved for emergency care:

  1. Care was provided in a hospital emergency department (or similar public facility held to provide emergency treatment to the public); AND
  2. You received care from a VA facility (or via other community care authorities approved by VA) during the 24 months before the emergency care; AND
  3. You are financially liable to the emergency treatment provider; AND
  4. The treatment was due to an injury or accident; the claimant has exhausted, without success, all liability claims and remedies reasonably available to you or your provider against a third party for payment of such treatment; and you have no contractual or legal recourse for extinguishing your whole liability to the provider; AND
  5. You are not eligible for reimbursement under 38 U.S.C. §1728 for the emergency treatment.

Other Health Insurance limitations under 38 U.S.C. §1725

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

NOTE: When OHI is present, VA is prevented from reimbursing your copayments under the terms of the OHI policy.

File a Claim

Please refer to File a Claim–Information for Veterans page for information on how to file a claim and timelines for filing.

Payments

VA and VA’s third-party administrators make every effort to adjudicate claims quickly and accurately. If you are charged for emergency treatment received in the community and believe the charges should be covered by VA, VA’s Community Care Call Center is available to help. VA staff will explain your eligibility and determine whether the bill you received is appropriate. VA will also help resolve billing issues with the community provider.

Community Care Call Center: 877-881-7618, Monday-Friday from 8 a.m. to 8 p.m. Eastern time

Emergency Care in Foreign Countries

VA can pay for emergency medical care outside the United States if the emergency is related to your service-connected condition. More information can be found through the Foreign Medical Program (FMP) resources listed below.

Call toll free at 877-345-8179

Definitions

Prudent Layperson: An individual possessing an average knowledge of medicine and health. This definition focuses on the patient’s presenting symptoms rather than the final diagnosis when determining whether to authorize medical claims for payment.

VA Feasibly Available: VA’s capability to provide the necessary emergency services at the time a Veteran is in need of such services. Travel time to the nearest VA medical facility capable of servicing those emergency care needs, the severity of symptoms, and the mode of arrival are all evaluated in assessing whether VA services were feasibly available.

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

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

Resources

Fact Sheet: Community Emergency Treatment Reporting and Care Coordination

Facility Locator
For additional information, please reach out to the nearest VA medical center responsible for processing the claims.