Third Party Payer Precertification Education for Community Providers

VA is making the precertification process for community providers easier to understand and use.

How does it relate to the VHA third party payer revenue process?

Precertification is the process in which a community provider is required to notify the VA when scheduling services for a Veteran of a VA-approved referral that requires third-party payer (TPP) precertification. VA has worked to make the process simple and accessible. This notice is critical for VA to conduct effective TPP billing activities.

Can it delay patient care? No. But precertification notification can help offset a Veteran’s co-pay responsibility and provide funds to VA facilities.

Because it is important?

Federal Title 38 law requires VA to bill TPPs for nonservice-connected/special authority care, including community care services. VA requires timely notification of care that requires TPP precertification and timely clinical documentation of the medical record.

VA must qualify like any other service provider that expects to collect reimbursement from the third-party payer.

As you know, some veterans are required to pay VA copays. The TPP reimbursement is applied to your VA copay responsibility, which reduces the Veteran’s out-of-pocket expense.

How does a provider know if a referral requires precertification?

Providers can find precertification information and instructions using the HealthShare Referral Manager (HSRM) Community Provider Portal by clicking the Offline Reference link. Providers should review the updated VA Offline Reference page to determine if the requested reference includes billing codes that require review for VA precertification.

If the referral includes billing codes that require VA precertification, providers can access the VA requirements here: https://www.va.gov/COMMUNITYCARE/providers/PRCT_requirements.asp.

Checking codes

Providers may review the codes for Standardized Episodes of Care (SEOC) as authorized in the approved referral they have selected to determine if the SEOC includes codes that require prior certification by TPPs. These codes are highlighted in red and have been reviewed and identified by VA. ​Precertification notification is only required for scheduled care.

If the provider does not have access to the HealthShare Referral Management (HSRM) Provider Portal, please notify VA by completing and submitting the Third Party Payer Precertification Form.

Completed forms must include the SEOC Reference ID/Authorization Number and be sent to the appropriate fax number based on regional location. Locations and fax numbers can be reviewed here: https://www.va.gov/COMMUNITYCARE/providers/PRCT_requirements.asp.

To request additional services that were not authorized on initial referral/SEOC, community providers should use the Request for Additional Services form found in HSRM.

You may also contact the Revenue Operations Nursing Executive Team via email at VHA104ROCPACNurseExecutive@va.gov.