When a veteran arrives at a community practice for care arranged through the Department of Veterans Affairs, the billing question is different from the one most front desks are used to. It is not “which commercial plan is this?” It is “which VA vehicle authorized this care, and who do we bill for it?” Send a CCN claim to VA directly, or a VCA claim to a network administrator, and the claim can stall even when the care was fully authorized.
This guide follows the order a practice actually encounters VA billing: authorization, payer route, claim packet, deadlines, and denials.
The authorization comes first — always
Community care is authorized care. Before the appointment, VA issues a referral and authorization naming the veteran, the provider, the approved services, the number of visits or units, and the dates covered. That document is the billing contract for the episode: it decides what can be billed, to whom, and by when.
Check it before the visit, not after. A service not on it is not covered by it, however reasonable it seemed in the exam room. A follow-up the provider recommends still needs its own authorization if the current one does not cover it; a new referral request, not a note in the chart, is what extends coverage. Keep the authorization number attached to everything downstream — scheduling, the claim, and the documentation sent to VA.
There is one genuine exception: care furnished in an emergency without prior authorization, filed with VA rather than with a network administrator. It is an exception for emergent, unauthorized care, not a second route for ordinary visits, and urgent care has its own VA rules.
Three routes, three different payers
VA community care reaches a practice through more than one vehicle, and the vehicle decides the payer on the claim.
Community Care Network (CCN) care. Most community care flows through the CCN, a contracted network run in five regions by third-party administrators (TPAs). CCN claims go to the regional TPA named on the authorization — Optum for Regions 1–3 and TriWest for Regions 4–5 — not to VA directly, and the authorization number must be on the claim. Because TPA assignments have changed before, and VA has announced a rebid of the CCN contracts, confirm the TPA on the referral itself.
Veterans Care Agreement (VCA) or local-contract care. Where a provider serves veterans under a VCA with a local VA facility rather than through the CCN, claims go to VA directly, following the authorization or referral. One timing rule matters: no payment is due for care furnished before the agreement is established and signed.
Emergent, unauthorized care. Filed with VA, not with a TPA — the exception that proves the authorization rule, not a route for ordinary scheduled care.
Before the first VA referral, the network-participation step must be complete. Our credentialing and enrollment service covers that step; this guide picks up at the first authorized visit.
What a clean claim carries
A clean claim here is a checklist. For CCN claims, route the claim electronically to the TPA and include the approved referral and authorization number. For claims filed directly with VA, include the veteran’s 17-character VA internal control number (ICN) in the insured’s ID field — the full Social Security number only if the ICN is unavailable — and use the right payer ID: VA medical 12115 or VA dental 12116. CCN claims use payer ID VACCN through the TPA.
Documentation travels with the claim, not behind it. Medical documentation must go to VA and to the referring provider, with the approved referral number on the cover page so the record can be matched to the authorization. Build that step into the same workflow that submits the claim — see our claims management approach. And bill only what the authorization describes: services, dates, and visit counts outside it need a new authorization first.
Two timely-filing clocks — do not mix them
For CCN claims, the TPA guide sets timely filing at 180 calendar days from the date of service or from the date VA issues the referral to the provider. Note the second trigger: a referral arriving weeks after the visit does not silently eat the filing window.
The frequently quoted two-year rule is something else entirely. Under 38 CFR 17.126, two years applies to claims for care that was not previously authorized — a different vehicle, with its own requirements. It is not a fallback deadline for an ordinary CCN claim.
One protection is worth knowing. If a claim was filed on time but sent to VA or to the wrong TPA in error, the provider can refile with the correct TPA together with proof of timely filing — a VA explanation of payment or another TPA’s remittance advice — within 180 calendar days of the denial. That covers a routing mistake, not a late claim.
Never bill the veteran — or their other insurance — for authorized care
For care covered by an approved referral, the practice may not bill the veteran and may not bill the veteran’s other health insurance. The TPA’s payment for the authorized services is payment in full. Collecting a copayment at checkout “like any other payer” is a compliance error in community care, not a courtesy.
Any copayment the veteran owes for non-service-connected care is assessed by VA at the end of the billing process, not collected by the community provider at the point of care. Amounts vary by year and priority group, so this guide deliberately names no dollar figure. The same rule holds for Veterans Care Agreement care.
When a claim is denied or short-paid
Denials go back through the payer that processed the claim, not through a VA benefits appeal — the two processes are different, and sending a claim dispute down the benefits-appeal path wastes the filing window. For CCN claims processed by Optum, the guide draws a useful distinction. A medical claim inquiry asks for a review of a paid service — for example, whether the paid amount matches the fee schedule — and is due within 12 months of the date on the provider remittance advice. A reconsideration is the formal process for a claim denied in whole or in part, due within 90 calendar days of that date, with supporting documentation attached.
Before choosing between them, match each denied line to the authorization: was the service on it, within its dates and visit count, with the right referral number? Most VA denials trace back to one of those four mismatches, and a reconsideration that does not fix the underlying mismatch will be denied again. If the authorization itself was too narrow, the remedy is a new referral request, not a louder appeal. Our denial management service follows that sequence.
Staying inside the authorization: episodes of care and reauthorization
Some VA authorizations are issued as a Standardized Episode of Care (SEOC): a preapproved list of services for a defined episode. Services billed inside a SEOC must match the episode’s preapproved code list, so check the current SEOC list before billing. Where additional care is needed beyond the original authorization, request additional or extended care from VA — preferably through the HealthShare Referral Manager or an equivalent interface — which produces a new or extended authorization if approved.
The discipline is this: the authorization is the claim’s boundary. Work inside it, request a new one when care goes beyond it, bill the payer it names, file on its clock, and never collect from the veteran for what it covers.
Frequently asked questions
Who do we bill for VA Community Care Network care? The regional third-party administrator named on the authorization — Optum for Regions 1–3 and TriWest for Regions 4–5 — not VA directly.
What if we billed VA directly for a CCN claim? The claim went to the wrong payer. Refile with the correct TPA together with proof of timely filing, such as the VA explanation of payment or the other TPA’s remittance advice, within 180 days of the denial.
Can we collect a copayment from the veteran at checkout? No, not for authorized community care. Any copayment owed is assessed by VA at the end of the billing process, and the veteran’s other insurance must not be billed for authorized care either.
How long do we have to file a CCN claim? 180 calendar days from the date of service or from the date VA issues the referral to the provider. The two-year rule in 38 CFR 17.126 covers care that was not previously authorized and is not a fallback for CCN claims.
How do we challenge a denied CCN claim? Through the TPA that processed it, not through a VA benefits appeal. For Optum-processed claims, a reconsideration of a denied or partially denied claim is due within 90 days of the remittance advice date; a review of a paid service is due within 12 months of that date.
What if the veteran needs more visits than the authorization allows? Request additional or extended care from VA, which produces a new or extended authorization if approved. Do not bill the extra visits under the old authorization, and do not collect them from the veteran.
If VA community care is becoming a regular part of your schedule — or denied VA claims are already sitting in your aging — a review of your authorization-to-claim workflow usually finds the break quickly. Request a free billing assessment and we will walk through your VA referrals, claim routing, and denial patterns with you.
