The process for filing a claim for services rendered to a Veteran in the community varies depending upon whether or not the services were referred by VA and by the entity through which the services were authorized–VA or one of the VA Third Party Administrators (TriWest Healthcare Alliance or Optum United Health Care). The following information should help you understand who to submit claims to and the requirements you must follow when submitting claims.
For those VA community providers serving our Veterans, please follow the guidelines at the link below.
Authorized CareMost commonly, authorized care refers to medical or dental care that was approved and arranged by VA to be completed in the community. Emergency care can also be authorized by VA in certain circumstances when the VA is notified within 72 hours. To file a claim for services authorized by VA, follow instructions included in the “Submitting Claims” section of the referral form.
There are two routes for filing claims for authorized care which depend on your status in the VA network and how the care was authorized:
All non-urgent and non-emergent care requires authorization from VA in advance. Eligibility and claims submission information for emergent care will be provided after notification is made to the VA. Claims for emergent care not eligible for authorization upon notification, may be eligible for consideration as Unauthorized Care. If notification was not made to VA and you wish to have claims considered for payment, please submit claims and supporting documentation to VA as listed in the "Where to Send Claims" section below.
Reference the table below to find which contract vehicle will process your claim:
| Affiliation/Authorization/Scenario | Responsible Entity |
|---|---|
| Community Care Network Region 1 (authorized) | Optum |
| Community Care Network Region 2 (authorized) | Optum |
| Community Care Network Region 3 (authorized) | Optum |
| Community Care Network Region 4 (authorized) | TriWest |
| Community Care Network Region 5 (authorized) | TriWest |
| Veterans Care Agreement (authorized) | VA |
| Local Contract (authorized) | VA |
| Unauthorized Emergent Care (unauthorized) | VA |
Please review the Where To Send Claims and the "Where To Send Documentation" sections below for mailing addresses and Electronic Data Interchange (EDI) details. If you are submitting a paper claim, please review the "Filing Paper Claims" section below for paper claim requirements.
The deadline for claims submission is dependent upon which program the care has been authorized through or which program the emergency care will be considered under.
| Program | Filing Deadline | Submit Claims To |
|---|---|---|
| Authorized Care (38 U.S.C. §1703) | 180 days | For CCN, submit to TriWest or Optum For VCA or local contract, submit to VA |
| Unauthorized Emergent Care (38 U.S.C. §1728: Service-connected) | 2 years | VA |
| Unauthorized Emergent Care (38 U.S.C. §1725: Nonservice‑connected) | 90 days* | VA |
*From the date the Veteran was discharged from the facility that furnished the emergency treatment; the date of death, but only if the death occurred during transportation to a facility for emergency treatment or if the death occurred during the stay in the facility that included the provision of the emergency treatment; or the date the Veteran exhausted, without success, action to obtain payment or reimbursement for treatment from a third party.
Filing ElectronicallyElectronic 837 claim and 275 supporting documentation submissions can be completed through the VA clearinghouse or through another clearinghouse of your choice.
You are strongly encouraged to electronically submit claims and required supporting documentation. This improves claim accuracy and reduces the amount of time it takes for us to process claim determinations. Review the "Filing Electronically" section above to learn how to file a claim electronically.
Paper claims and supporting documentation submitted to us are converted to Electronic Data Interchange (EDI) transactions. This improves our claims processing efficiency. The conversion happens before claims and records are accepted into our claims processing system.
As part of the process, claims and supporting documentation are scanned for compliance prior to conversion to electronic format. If the claims and records do not conform to the minimum requirements for conversion to the 837 or 275 electronic formats, they are rejected and sent back for correction.
If you submit a noncompliant claim and/or record, you will receive a letter from us that includes the rejection code and reason for rejection.
Review the "Where to Send Claims" section below to learn where to send claims. Review the "Supporting Documentation" section below to learn how to properly submit supporting documentation with your claim.
Corrections and VoidsYou can submit a corrected claim or void (cancel) a claim you have already submitted to VA for processing, either electronically or in paper. The instructions differ based on the type of submission.
NOTE: For specific information on submitting claims to Optum or TriWest, please refer to their resources.
Submit a corrected claim when you need to replace an entire claim previously submitted and processed.
Submit a claim void when you need to cancel a claim already submitted and processed.
Reference the table below for information on where to send your claims:
Electronic Data Interchange (EDI): Payer ID for medical and dental claims is VA CCN. If electronic capability is not available, providers can submit claims by mail or secure fax.
MEDICAL
Mailing Address:
VA CCN Optum
P.O. Box 202117
Florence SC 29502
Secure Fax:
833-376-3047
DENTAL
Mailing Address:
Optum Serve
ATTN: VA CCN Claims
3237 Airport Rd.
La Crosse WI 54603
Secure Fax: 608-793-2143
(Specify VA CCN on fax)
Electronic Data Interchange (EDI): Payer ID for medical claims is TWVACCN. Payer ID for dental claims is CDCA1. If electronic capability is
not available, providers can submit claims by mail or secure fax.
MEDICAL
Mailing Address:
TriWest VA CCN Claims
P.O. Box 108851
Florence SC 29502-8851
DENTAL
Mailing Address:
Delta Dental of California
VA Community Care Network
P.O. Box 537007
Sacramento CA 95853-7007
Secure Fax: 916-851-1559
CCN Region 5
(Kodiak, Alaska, only)
Submit to TriWest
Electronic Data Interchange (EDI): Payer ID for medical claims is TWVACCN. Payer ID for dental claims is CDCA1. If electronic capability is
not available, providers can submit claims by mail or secure fax.
MEDICAL
Mailing Address:
TriWest VA CCN Claims
P.O. Box 108851
Florence SC 29502-8851
DENTAL
Mailing Address:
Delta Dental of California
VA Community Care Network
P.O. Box 537007
Sacramento CA 95853-7007
Secure Fax: 916-851-1559
Electronic Data Interchange (EDI): Payer ID for medical claims is 12115. Payer ID for dental claims is 12116. If electronic capability is not available, providers can submit claims by mail.
MEDICAL & DENTAL
Mailing Address:
VHA Office of Finance
P.O. Box 30780, Tampa FL 33630-3780
While not required to process a claim for authorized services, medical documentation must be submitted to the authorizing VA medical facility as soon as possible after care has been provided.
There are multiple methods by which community providers may electronically provide VA with the required medical documentation for care coordination purposes. Those options are:
HealthShare Referral Manager (HSRM) for referrals, authorizations and documentation exchange.
E-fax: Documentation sent via email to Veterans Affairs Medical Center (VAMC) fax machine. Please contact the referring VAMC for e-fax number.
Request and Coordinate Care: More information about submitting documentation for authorized care.
The electronic 275 transaction process may be utilized to supply Remittance Advice documentation for timely filing purposes. The 275 transaction process should not be utilized for the submission of any other documentation for authorized care.
NOTE: The processes outlined below are exclusive to supplying documentation for unauthorized emergent care. With the exception of supplying remittance advice supporting documentation for timely filing purposes, these processes do not apply to authorized care.
While VA always encourages providers to submit claims electronically, on and after May 1, 2020, it is important that all documentation submitted in support of a claim comply with one of the two paper submission processes described. Any supporting documentation that VA is unable to link to a claim will be returned to sender to for additional information.
Providers who continue to elect to submit paper claims and paper documentation to support claims for unauthorized emergency care should be aware of the following:
Documentation in support of a claim may include:
*NOTE: Documentation not required includes flowsheets and medication administration
Follow the guidance below to avoid having your claim denied:
VA is the primary and sole payer when VA issues an authorization. VA is also the primary and sole payer for unauthorized emergent care approved under 38 U.S.C. §1725 or 38 U.S.C. §1728.
Is VA ever a secondary payer?VA may be a secondary payer for unauthorized emergent claims under 38 U.S.C. §1725 when remaining liability to the Veteran is not a copayment or similar payment.
If billing electronically, please include "Other Payers Information" in Loop 2320, 2330A, 2330B, and 2430.
Who do I contact if I have a question about an authorization?Community providers should remain in contact with the referring VA Medical Center to ensure proper care coordination. Questions about care and authorization should be directed to the referring VA Medical Center.
Who do I contact if I have a question about a claim?If you have questions about a claim, reference the contacts below:
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