Community care referrals and schedule appointments
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Before you schedule an appointment with a non-VA provider in our community care network, you must get a referral. Your VA health care team must approve your care. Keep reading on this page to learn how to get community care referrals and schedule appointments.
Follow this process to get care with an in-network community provider
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1. Find an in-network community provider.
You can search for a provider yourself. Or ask your VA health care team to find a provider for you.
Ask your VA health care team for help in either of these cases:
You can’t find an in-network community provider who meets your needs, or
The community provider you want to go to isn’t in our network
2. Get a referral from your VA health care team.
Ask your VA health care team for a referral to the community provider.
We’ll review your request to make sure you’re eligible. Then we’ll contact you to confirm that you want to get community care and the type of appointment you need. We’ll then prepare your referral.
This part of the process can take up to 14 days.
3. Schedule your appointment.
After you have your referral, you can schedule your appointment yourself. Or you can ask your VA health care team to schedule for you.
If you schedule yourself, tell your VA health care team within 14 days. Your team will put this information in your chart so they can work with your community provider.
4. Make sure you have your authorization letter.
After you schedule an appointment, we’ll send you your authorization letter. This letter is your approval for community care.
Your letter will provide this information:
An authorization number
Information about your approved in-network community provider
A description of the care you can get
How long you can continue to get care without needing another referral
5. Go to your appointment.
We’ll share your medical records with the community provider. But be sure to bring copies of any images (like CT scans or MRIs) that the provider asks you to bring with you.
6. Keep track of ongoing appointments and referrals.
If we approve you for continued care, you can schedule follow-up appointments with the provider. But keep track of how many appointments you go to and how long you’re approved to get care. We won’t cover services that your authorization letter doesn’t include.
If you need more care, you or your community provider can request a new referral.
7. Request for Referral and Precertification Requirements
WALKES, JON CECIL M
0.5 miles
1900 North Loop W Ste 180
Houston, TX 77018
Main number: 281-888-0809
If you don’t have a referral, contact your local VA medical center.
ALABI, NATHANIEL B
0.5 miles
1900 North Loop W Ste 180
Houston, TX 77018
Main number: 281-888-0809
VA Form 10-10172 is the form to fill out with your provider to request a community care provider for specialty care.
Community Care Provider – Request for Service VA Form 10-10172
Precertification Requirements
(Care Not Related to Veterans Service-Connected Disability)
VA is required by law to bill Third Party Payers (TPP) for care that is not related to a Veteran’s service-connected disability or Special Authority. This requires VA to call TPPs for precertification for patients who are VHA beneficiaries with other billable health insurance (OHI).
Please note: Claims for ancillary services will be processed in accordance with Medicare National Correct Coding Initiative (NCCI), Medically Unlikely Edits (MUE), and related edits.
To identify services that require VA precertification, refer to the referral packet which contains a form called Offline Referrals/Billing and Other Referral Information. Providers can refer to the View your Billing and Other Referral Information section to see if the Standardized Episode of Care (SEOC) in your VA referral has codes that require precertification.
The preferred method to notify VHA Revenue Operations (RO) for tests/procedures/admissions requiring precertification is via the HealthShare Referral Manager (HSRM) provider portal using the Task: PROVIDER PRECERT NOTIFICATION. Although this is the preferred method of notifying Revenue Operations of precertification, the request can also be submitted via fax.
Once the community care provider has notified VHA Revenue Operations that the test/procedure/admission requiring TPP precertification is scheduled, there is no requirement to wait for the TPP approval or response prior to performing the test/procedure/admission included as part of the SEOC referral.
The precertification process should not be used to request additional services or extensions for authorization duration. To request additional services or extend authorization durations please use the Request for Additional Services (RFS) Form, VA Form 10-10172, which should be submitted to local facility community care staff using the office fax or email indicated on the referral form.
Third Party Payer Precertification Form
Sources:
https://www.va.gov/resources/how-to-get-community-care-referrals-and-schedule-appointments/
VA In Network Providers at Texas Heart and Vein Multispecialty Group
https://www.va.gov/COMMUNITYCARE/providers/PRCT-requirements.asp
