Overview

This page provides information about types of community care that may require additional guidance when you are providing care, checking Veteran eligibility, or submitting claims.

Working with VA

VA works with community providers in different ways, depending on the type of care and the arrangement with VA. To learn more about options such as Community Care Network and other agreements, visit the Community Care partnerships page.

Urgent care

VA offers urgent care services to eligible Veterans at in-network urgent care clinics for minor, non-life-threatening injuries and illnesses such as colds, strep throat, sprains, skin infections, and ear infections.

Urgent care must be provided by in-network providers in the VA Community Care Network (CCN).

Intake and checking eligibility

When a Veteran arrives for urgent care, you must check their eligibility for their urgent care benefit. This step also activates their pharmacy benefit. Check a Veteran’s eligibility by calling the third-party administrator for your region.

• For CCN Regions 1-3: Contact Optum at 888-901-6609
  A dedicated Provider Services support team is available Monday through Friday, 8 a.m. to 6 p.m. local time, excluding federal holidays.
  
  
• For CCN Regions 4 and 5: Contact TriWest at 833-483-8669
  This is an automated service that is available 24 hours a day, 7 days a week.

Covered services

VA does not publish a list of covered services for urgent care. In general, preventive and dental services and any items not included in the VA medical benefits package are excluded.

Only eligible Veterans may use this benefit. Family members are not covered. There is no limit to how many times a Veteran may use urgent care in a year. For clarification about what services are covered, contact your regional third-party administrator (TPA).

Care coordination

Submit medical documentation within 30 calendar days to the Veteran’s home VA medical center. Use an approved method, such as the Veterans Health Information Exchange (VHIE) or secure fax.

If the Veteran needs follow-up care, notify VA as soon as possible.

To find the right VA medical center, use the Veteran’s home ZIP code to locate the appropriate VA medical center. Then, look up care coordination contacts at that facility.

Prescriptions

Visit the Prescribing medications page for information on urgent care prescriptions and billing information.

Filing an urgent care claim

After you provide urgent care, submit a claim within 180 calendar days to the TPA for your region. The TPA processes and pays claims on behalf of VA.

Support

• Region 1: Call 888-901-7407
• Region 2: Call 844-839-6108
• Region 3: Call 888-901-6613

Resources

Urgent care: 38 Code of Federal Regulations (C.F.R.) § 17.4600

Emergency care

If a Veteran presents at your emergency department with a medical emergency, treat them immediately. You do not need to wait for VA approval. VA may pay for the care depending on the Veteran’s eligibility. 

There are two categories of emergency care for Veterans:

• Emergent suicide care: Emergent suicide care may be covered under the COMPACT Act (Veterans’ Comprehensive Prevention, Access to Care, and Treatment Act of 2020), which provides broader eligibility and follow-up support for Veterans experiencing an emergent suicidal crisis.   
  
  
• All other emergency medical care: This guidance applies to emergency care at an emergency department. An emergency department is a facility that has the staff and equipment to provide emergency care (like a hospital or free-standing emergency department). 
  • Urgent care facilities don’t qualify as emergency departments.  
  • VA may reimburse emergency ambulance transport if the Veteran meets specific eligibility requirements for transportation coverage.

Emergent suicide crisis care (COMPACT Act)

The COMPACT Act allows VA to provide, pay for, or reimburse emergent suicide crisis care for eligible Veterans at a VA or community facility, at no cost to the Veteran. 

This may include emergency transportation and certain authorized follow-on crisis services after the emergency period. Covered follow-on care may include inpatient care, outpatient care, prescription medications, or crisis residential care when clinically appropriate and authorized by VA. 

Refer to the emergency care process for notification requirements, claims information, and care coordination instructions.

Emergency care in countries outside the U.S.

VA can only pay for emergency care outside the U.S. under certain circumstances. If you have questions, view the foreign medical care section or call the Foreign Medical Care program office.

Emergency care process

1. Treat the Veteran immediately.  Do not wait for VA authorization. 
   
   
2. Notify VA as soon as possible.  After notification, VA will inform you if the care is authorized and where to submit claims.  
   IMPORTANT: CCN providers must notify VA within 72 hours. Late notifications may affect how claims are processed, but still need to be submitted.
   • Online: Emergency Care Reporting 
   • Phone: 844-724-7842
     
     
3. Coordinate follow-on care or transfer with the local VA medical facility.
   • The local VA medical facility may reach out to community providers administering emergent treatment to a Veteran. If you have an urgent or emergent need to coordinate care and/or transfer a Veteran, please contact the nearest VA medical facility immediately.
     • Look up facility contact numbers for care coordination
       
       
4. File a claim. 
   
   
5. Send medical documentation to the coordinating VA facility. 
   • Medical documentation must be submitted to the coordinating VA medical facility as soon as possible after the initiation of treatment. 
   • There are multiple ways to electronically provide VA with the required medical documentation for care coordination purposes.  
     
     

Filing an emergency care claim

After notifying VA, you will receive instructions on where to file a claim.

• If VA authorized the care, submit claims in accordance with the authorization decision.
• If VA did not authorize the care, submit claims to VA.

How VA determines eligibility for non-VA emergency care 

After filing an emergency care claim, VA reviews the claim and determines if the care is eligible for coverage. VA uses three legal authorities to make this determination:

1. Authorized Emergency Treatment: 38 Code of Federal Regulations (C.F.R.) §17.4020(c)
2. Unauthorized Emergency Treatment (Service-connected): 38 United States Code (U.S.C.) §1728
3. Unauthorized Emergency Treatment (Nonservice-connected): 38 United States Code (U.S.C.) §1725

Prescribing medications

This page is for community providers who prescribe medications for Veterans through the Community Care Network (CCN). It explains how to send prescriptions to VA or an in-network retail pharmacy, including guidance for electronic prescriptions, routine and maintenance medications, urgent or immediate-need medications, and immunizations.

• Electronic prescriptions
• Routine/maintenance prescriptions
• Urgent/Immediate need prescriptions
• Immunizations
• VA Formulary

Electronic prescriptions (eRx)

VA now accepts electronic prescriptions from community providers for all eligible Veteran medications including controlled substances. Controlled substances include opioids, stimulants, and others.

VA will still accept and fill paper prescriptions (or fax where applicable); however, electronic prescriptions are recommended due to their ease and compliance with all state regulations.

• Use the published name of the VA pharmacy for e-prescribing. The published name is typically the town where the VA pharmacy is located, followed by “VAMC Pharmacy.” For example “Buffalo VAMC Pharmacy.”
• If you cannot electronically submit a prescription to a VA pharmacy, fax and hard copy prescriptions are accepted. Please contact the Community Care representative at the referring VA medical facility for the VAMC pharmacy fax number.

Routine/maintenance prescriptions

Routine/maintenance prescriptions must be sent to the referring VA medical facility’s pharmacy. If you do not have the ability to electronically submit prescriptions to pharmacies, please contact the Community Care representative at the referring VA medical facility for their pharmacy FAX number.

The following information must be included for the referring VA medical facility pharmacy to fill a prescription:

Prescriptions must generally be filled for no more than a maximum three-month (90-day) supply of medication. However, exceptions can be made for non-controlled medications and supplies to avoid breaking commercial package size, and for oral contraceptives if requested by the Veteran and their provider.

No prescription may exceed 12 months of therapy (including refills). For some prescriptions, a one-month (30 days) or less limitation may be established; these include controlled substances or any agent with a restriction not to exceed 30 days as specified by the VA National Formulary.

Urgent/immediate need prescriptions

Medications that are needed immediately can be sent to an in-network retail pharmacy or VA pharmacy. If choosing a retail pharmacy, ensure the medication is on the VA Urgent Emergent Formulary by using the VA Formulary Advisor.

Urgent/immediate need prescription instructions

• Up to a 14-day supply with no refills of the urgent care medication may be authorized
  • If more than a 14-day supply of the medication is needed, the prescription must be sent to the referring VA medical facility pharmacy for fulfillment.
• A seven-day maximum supply for opioids, or up to the opioid prescribing limit allowed by state law — whichever is less — is authorized.
• Prescriptions can be filled at an in-network pharmacy, at VA, or at a non-network pharmacy. If a non-network pharmacy is used, Veterans must pay for the prescription and then file a claim for reimbursement with their local VA medical facility.
• Only eligible Veterans can use this benefit. The urgent care benefit is nontransferable and does not extend to family members.

Choosing a pharmacy location

The Veteran must fill their urgent care prescription in the same state as their urgent care visit to avoid any issues. 

• For a list of participating retail pharmacies, please use the VA Facility Locator.

• For telephone assistance finding an in-network, in-state pharmacy, contact the third party administrator that manages the region.

Urgent/immediate need prescription billing information

Frequently asked questions

How do I determine which pharmacy to send a prescription for fulfillment (VA or retail)?

Medications needed urgently can be sent to an in-network retail pharmacy or VA pharmacy. Urgent care prescriptions are listed on the VA Urgent/Emergent Formulary.

Routine/maintenance prescriptions must be sent to the referring VA medical facility’s pharmacy. If you do not have the ability to electronically submit prescriptions to pharmacies, please contact the Community Care representative at the referring VA medical facility for their pharmacy FAX number.

Does VA allow me to provide drug samples or coupons to Veterans?

No. The use of drug samples or drug coupons is prohibited.

Immunizations

Free flu shot

Eligible Veterans can get a No-Cost Flu Shot from a nearby VA facility or an authorized community care location during flu season. Please refer to the VA Facility Locator for authorized locations. For more information, review the VA Community Care Pharmacy Billing Card.

Process for administering free flu-shots

Other adult immunizations

Eligible Veterans with an existing approved community care referral are authorized to receive VA approved vaccines (Tdap, Shingrix, RSV and Pneumococcal) at in-network retail pharmacies. A prescription is required for all adult immunizations.

If a Veteran needs one of the VA approved adult immunizations, community care providers should send a prescription for the vaccine directly to an in-network, retail pharmacy for administration. If the Veteran does not have a community care referral, have them contact their local VA medical facility for additional guidance.

Process for administering adult immunizations

Once it has been established that a Veteran requires a vaccine prescription (ONLY Tdap, zoster, pneumococcal, and RSV), VA providers should follow existing internal processes to obtain these vaccinations for Veterans.

For community providers, please follow the steps below:

1. Ask the Veteran for their preferred pharmacy. Ensure the pharmacy is in‑network. You can use the VA Locator to confirm the Veteran’s preferred pharmacy is in network.
2. Ensure the medication is on the Urgent/Emergent Formulary. You can use the VA Formulary Advisor to search for the medication.
3. Send a prescription to the pharmacy or provide the Veteran with a paper prescription.
4. Inform the Veteran to bring the Community Care Pharmacy Billing Card to the pharmacy.

Resources

• Community Care Pharmacy Billing Card
• VA National Formulary
• VA Formulary Advisor
• VA Facility Locator

VA Formulary

The VA Formulary for Community Care is a comprehensive list of all medications listed alphabetically by generic name and can be found on the Pharmacy Benefits Management Services website. This site includes downloadable files for the VA National Formulary including a link to the VA Urgent/Emergent Formulary, VA Criteria for Use (CFU) and Clinical Guidance Documents, and a searchable VA Formulary Advisor tool.

Frequently asked questions

How do I request a medication from VA that has a criteria for use or is non-formulary?

All providers must follow the Veterans Health Administration (VHA) Directive 1108.08, VHA Formulary Management Process, including provisions for requesting medications with Criteria for Use. Criteria for Use can be found by searching for the medication in the VA Formulary Advisor and downloading the appropriate PDF if applicable.

Criteria for Use documents must be completed and submitted to the referring VA medical facility for review. If you need to submit a Criteria for Use document or non-formulary request for a medication, please contact the Community Care representative at the referring VA medical facility to obtain VA pharmacy contact information.

Community providers are encouraged to communicate results of prior authorization denials to the Veteran and determine appropriate next steps.

VHA Directive 1108.08, VHA Formulary Management Process

Criteria for Use and Clinical Guidance Documents

How do I request a non-formulary or prior authorization medication at a VA pharmacy?

All providers must follow the Veterans Health Administration (VHA) Directive 1108.08, VHA Formulary Management Process, which includes provisions for requesting non-formulary drugs. If you need to submit a non-formulary request for a medication, please contact the Community Care representative at the referring VA medical facility to obtain their non-formulary request form.

VHA Directive 1108.08, VHA Formulary Management Process

Can I request medications not on the Urgent/Emergent formulary at in-network retail pharmacies?

All medications that are not on the urgent/emergent formulary must be sent to a VA pharmacy for processing.

Ambulance transport 

 VA-covered ambulance transportation for Veterans falls into two categories:

• Authorized ambulance transport refers to non-emergency transportation that must be preauthorized by VA. To arrange preauthorized, non-emergency ambulance transportation, contact your local VA Beneficiary Travel Office.

• Unauthorized ambulance transport refers to emergency transportation that was not preauthorized. In some cases, VA may reimburse these transports after the fact if the Veteran meets eligibility requirements and the transport is connected to a covered emergency. Whether VA can pay, and how much VA can pay is based on the Veteran’s status and emergency treatment coverage.

Claim filing requirements

• Submit only one ambulance trip per claim.
• Include the pickup and drop-off locations using valid USPS addresses.
• Include the ambulance trip report.

Ambulance transport claim submissions 

Ambulance transport claims must be submitted directly to VA. For maximum benefit eligibility, submit claims within 30 days.

• Paper claims

• Electronic claims
  Electronic 837 claim and 275 supporting documentation submissions can be completed through the VA clearinghouse, PNT Data, or through another clearinghouse of your choice.
  • Payer ID: 12115 

American Indian and Alaska Native Veteran care

This program allows VA to reimburse eligible Indian Health Service, Tribal Health Program, and Urban Indian Organization facilities for care they provide to eligible American Indian and Alaska Native Veterans.

Learn more about the program works including, how to start an agreement, veteran eligibility, claims and billing, and operational updates.

Bowel and bladder care

Bowel and bladder providers play an important role in caring for Veterans at home and in the community. Providers who have been approved to provide bowel and bladder care to an eligible Veteran will be issued a VA referral that contains pertinent clinical information to include the services that have been authorized for payment.

There are two types of bowel and bladder providers: Individual (health care services provided by a family member, friend, or a caregiver) and agency providers.

Dental care

VA provides dental care services to eligible Veterans at VA medical facilities and in-network dental clinics. Some of the services offered include regular teeth cleaning, x-rays, fillings, crowns, bridges, dentures, and oral surgery. 

Preauthorization

All dental care in the community must be preauthorized by a VA provider. Community providers must follow the authorized care per the treatment plan developed by the VA dentist. The community provider must only provide the services on the consult order including the specific ADA Current Dental Terminology (CDT) code and appropriate area of the oral cavity.

Covered services

The Oral Appliance Therapy (OAT) Standard Episode of Care (SEOC) covers the medical benefit, not routine dental care. The OAT SEOC covers the care done by a dentist but is billed with medical codes including evaluations, fitting, procurement of the oral device, and follow up.

• Sleep-related breathing disorders (SRBD)
  Sleep-related breathing disorders (SRBD) are diagnosed and treated by a licensed independent provider (LIP). The medical LIP is responsible for evaluating, diagnosing, and managing the treatment of SRBD. Oral appliance therapy for conditions such as sleep apnea is part of the medical benefits package and the medical LIP may prescribe OAT when treating a patient with a sleep disorder.
  
  If services within the local VA dental clinic are available, the medical LIP can request OAT with a consult. If services are unavailable within the local VA, the medical LIP can request the service through community care via the Oral Appliance or Mandibular Repositioning Device SEOC.
  
  
• Dental Orthodontics
  Orthodontics treatment is not authorized unless there is specific documentation of service-connected trauma resulting in a malocclusion or if there is evidence that a congenital disease or defect increased beyond its natural progression as a result of military service. Dental Orthodontics Phase SEOC is only used for correction of a malocclusion due to a dental-facial deformity. Malposed teeth are considered a developmental abnormality and a pre-existing condition relative to the start of military service.

Additional dental services

When additional services are needed for a Veteran receiving community care, the performing dentist must submit a request detailing the type of care and receive prior approval for reimbursement. Submit requests by sending a completed ADA Dental Claim form.

The VA Form 10-10172, Community Care Provider—Request for Services (RFS), is not required for dental RFS but may be submitted in addition to the ADA Dental Claim form, if preferred. 

Dental care claims

View the Dental Care Claims page for information on how to file a dental care claim.

Foreign medical care

VA’s Foreign Medical Program (FMP) is a health care benefits program for Veterans with VA-rated, service-connected disabilities who live or travel abroad. FMP covers certain health care services, medications, and durable medical equipment needed to treat a service-connected disability or a condition associated with a service-connected disability.

Providing medical care

Approvals and preauthorization are not required for referrals, medical services or diagnostic tests related to treating service-connected disabilities. Eligible Veterans will have a FMP benefits authorization letter outlining their covered, service-connected disabilities.

Veterans are encouraged to communicate directly with FMP through Ask VA.gov to obtain a treatment predetermination screening. This process will provide reasonable assurance on whether a claim will be paid, if billed appropriately.

Prescription coverage

Prescription and over-the-counter medications are covered if the drug is appropriate for the treatment of a service-connected disability, or any condition associated with a service-connected disability that VA determines makes the disability worse (or “aggravates” it). All medications must be approved by the U.S. Food and Drug Administration (FDA).

FMP claims

Home Health services and Hospice care

VA provides supportive medical services to help chronically ill or disabled eligible Veterans of any age remain in their home. These services are referred to as home health care and are considered extended care services prescribed by and under the direction of a VA physician.

VA provides several types of home health care including:

For more information about home health care, please visit the Geriatrics and Extended Care website or contact your local VA medical facility.

Contact

Contact the AN98 Support Group for AN98 non-contracted, skilled home health and hospice care payment methodology questions.

In vitro fertilization

Veterans with certain service-connected conditions that result in infertility may be eligible for in vitro fertilization (IVF), another form of assisted reproductive technology (ART), or other infertility services. VA may provide these services to Veterans if:

• The Veteran has a service-connected condition that causes infertility
• The Veteran is legally married
• Male spouses can produce sperm
• Female spouses have an intact uterus and ability to produce eggs

VA provides infertility treatment and services through Reproductive Endocrinology and Infertility (REI) community providers who are part of VA’s Community Care network. REI providers play an integral part in making sure Veterans get the infertility treatment they need.

VA does not cover the costs associated with donor sperm, donor eggs, donor embryos, or gestational surrogacy. In addition, VA does not cover the cost of IVF related to donor sperm, donor eggs, donor embryos, or gestational surrogacy.

State Veterans homes

State Veterans homes are facilities that provide eligible Veterans with nursing home, domiciliary, or adult day care. These facilities are owned and operated by state governments. Each state establishes eligibility and admission criteria for its homes and some State Veterans Homes may admit non-Veteran spouses and gold star parents. The VA State Home Program provides an economical alternative to constructing, maintaining, and operating facilities for the provision of care to eligible Veterans.

VA also provides per diem payments to states for the care of eligible Veterans in state homes. There are several policies and regulations that affect the State Home Per Diem Program. For more information about State Veterans Homes and to see a list of current regulations, laws, policies and handbooks relating to the program, please visit the VA Geriatrics and Extended Care (GEC) State Veterans Home Program website.

Transplant guidance

VA provides integrated care of acute and chronic diseases for which transplantation may be an option. Management of such advanced diseases (e.g., heart failure, cirrhosis) is coordinated among referring VA medical centers (VAMC), and regional referral VA medical centers, VA Transplant Centers (VATC), and/or community specialists as appropriate.