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 where a community provider is required to notify VA when scheduling services for a Veteran from an approved VA referral that requires third-party payer (TPP) precertification. VA has worked to make the process simple and accessible. This notification is critical for VA to perform effective TPP billing activities.

Can it delay patient care? No. But notification of precertification can assist in offsetting a Veteran’s copayment responsibility and provide funds to VA facilities.

Why is it important?

Title 38 federal law requires VA to bill TPPs for non-service connected/special authority care, including community care services. VA requires timely notification of care requiring TPP precertification and timely clinical medical record documentation.​

VA must comply with the requirements as any other provider of service expecting to collect third-party payer reimbursement. ​

As you know, some Veterans are required to pay VA copayments. Reimbursement from TPPs is applied to their VA copayment responsibility, thus reducing 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 on the Offline Referral link. Providers should review the updated VA Offline Referral page to determine if the referral requested includes bill codes that require review for VA precertification.

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

Reviewing codes

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

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

Completed forms must include the referral ID/SEOC authorization number and be submitted 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 the initial referral/SEOC, community providers should use the Request for Additional Services form found in HSRM.

You can also contact the Revenue Operations Nurse Executive Team via email message to VHA104ROCPACNurseExecutive@va.gov.