Billing the VA Community Care Network: Referrals, Auth, and Denials in 2026

:::info Quick answer You cannot treat a VA patient without an approved referral, known as a Standard Episode of Care (SEOC). Check the HealthShare Referral Manager (HSRM) for active auths before the visit. Submit claims directly to the regional TPA (Optum or TriWest) within your contracted timely filing limit. :::

Getting paid by the Department of Veterans Affairs requires strict adherence to one fundamental rule: never touch a patient without an active referral in hand.

If you bill for an independent practice, you already know that treating Veterans is both highly rewarding and administratively punishing. The VA does not operate like a traditional commercial payer. Instead of dealing directly with the government for community care, you work through Third-Party Administrators (TPAs) that manage the VA Community Care Network (CCN).

Now that we are in the final quarter of 2026, the VA has fully entrenched its digital workflows. The days of faxing referral requests and hoping for a callback from a local VA Medical Center (VAMC) are dead. Everything runs through centralized portals, standardized episode codes, and strict electronic data interchange (EDI) mandates.

Here is how to manage the paperwork, secure your authorizations, and submit clean claims without getting caught in the VA's bureaucratic crossfire.

How This Payer Works: Optum, TriWest, and the VA Network

The VA does not process your CCN claims. When the VA determines it cannot provide timely care to a Veteran at a local facility—either because wait times are too long, the drive is too far, or the specific specialty is unavailable—it outsources that care to the commercial sector via the CCN.

The United States is divided into regions managed by two massive TPAs:

• Optum Public Sector Solutions: Manages Regions 1, 2, and 3. This covers the East Coast, the Midwest, and the South.
• TriWest Healthcare Alliance: Manages Regions 4 and 5. This covers the West Coast, the Southwest, Alaska, and Hawaii.

When you contract with the CCN, you are signing a contract with Optum or TriWest, not the VA directly. Your fee schedule, your clearinghouse routing, and your provider representative all belong to the TPA.

The basic workflow looks like this: A VAMC physician decides a Veteran needs outside care. The VAMC generates a referral. That referral goes to the regional TPA. The TPA routes the referral to an in-network provider (you). You accept the referral, treat the patient, upload your clinical notes back to the VA, and then bill the TPA for the encounter. The TPA cuts your check based on the Medicare Physician Fee Schedule (MPFS), which is the standard baseline for CCN reimbursement.

Mastering Referrals: SEOCs, SARs, and HSRM

It is impossible to overstate this: you can memorize all the VA Community Care prior authorization requirements in the world, but if your front desk fails to verify the expiration date on the referral document before the patient walks in, you will be providing free care.

The cornerstone of VA billing is the Standard Episode of Care (SEOC). An SEOC is not just a generic approval for "physical therapy" or "cardiology." It is a hyper-specific, bundled authorization that dictates exactly which CPT and HCPCS codes you are allowed to bill, how many visits the patient is approved for, and the exact date range in which those visits must occur.

For example, an SEOC for physical therapy might approve 12 visits over 90 days, explicitly listing evaluation codes (97161-97163) and standard therapeutic exercise (97110). If your therapist decides to incorporate dry needling (20560) and that code is not on the SEOC, the TPA will deny that line item. You cannot bill the Veteran for the balance. You simply eat the cost.

To manage these authorizations, your practice must use the HealthShare Referral Manager (HSRM). This is the VA's web-based portal where all referrals live.

The Secondary Authorization Request (SAR)

What happens when a patient hits their visit limit but still needs care? You submit a Secondary Authorization Request (SAR) through HSRM.

You must submit the SAR before the current SEOC expires or the visit limit is reached. In 2026, VAMCs are taking anywhere from 7 to 14 days to process a SAR. If you submit a SAR on a Tuesday, and see the patient on a Wednesday before the SAR is approved, that Wednesday visit will be denied for lack of authorization.

Always attach clinical justification to your SAR. The VAMC reviewing the request wants to see recent progress notes, diagnostic reports, and a clear medical reason why the initial SEOC was insufficient.

The 72-Hour Emergency Care Rule

Emergency care is the one exception to the prior authorization rule. If a Veteran presents to your independent freestanding ER or urgent care, you do not need an SEOC before treating them. However, you must notify the VA within 72 hours of the Veteran presenting for care.

Notification is done through the VA's Emergency Care Reporting (ECR) portal. If you miss the 72-hour window, getting the claim paid becomes a monumental administrative struggle requiring retrospective reviews and appeals that rarely break in the provider's favor.

Enrollment and Credentialing for the CCN

You do not credential with the VA. You credential with Optum or TriWest.

The basic requirements align with standard commercial credentialing: a valid NPI, an active state license, a clean DEA certificate (if applicable), and no active Medicare/Medicaid sanctions. Both Optum and TriWest rely heavily on CAQH ProView to pull your data.

As of the early 2026 network updates, both TPAs have tightened their roster management rules. If a solo practitioner adds a Nurse Practitioner (NP) or Physician Assistant (PA) to their tax ID, that mid-level provider cannot automatically start seeing VA patients under the primary physician's NPI. The new provider must be formally added to your CCN roster and individually credentialed by the TPA.

If you bill a claim with a rendering NPI that is not explicitly linked to your CCN contract, it will hit a hard denial for "Provider Not Eligible." Keep your CAQH profiles updated and audit your TPA rosters quarterly.

Claim Submission and Timelines

Once the care is complete, you bill the TPA, not the VA.

Before you drop the EDI 837 file, you have a critical administrative step: clinical documentation return. The VA requires community providers to upload the clinical notes for the encounter into HSRM. If you bill the TPA, and the TPA audits the claim only to find that the VAMC never received the clinical notes for the visit, they will recoup the payment.

For electronic claim routing, ensure your practice management system is pointing to the correct clearinghouse Payer IDs.

• Optum Payer ID: VACCN
• TriWest Payer ID: TWG1

Timely Filing and Processing Deadlines

Timely filing limits depend on the specific contract you signed with the TPA, but they generally follow strict federal guidelines.

Coordination of Benefits (COB) and Other Health Insurance (OHI)

One of the biggest headaches in VA billing is Other Health Insurance (OHI).

If the Veteran is receiving care for a service-connected disability, the VA is the sole payer. You bill the TPA directly, and you are done.

If the care is non-service-connected, and the Veteran has commercial insurance (like Blue Cross or Aetna), the commercial carrier is legally primary. You must bill the commercial payer first, receive the Explanation of Benefits (EOB), and then submit the claim to the CCN TPA with the primary EOB attached.

How do you know if the care is service-connected? You don't have to guess. The SEOC generated by the VA will explicitly state whether you should bill the TPA as primary or if you need to chase the commercial payer first.

Denials and Appeals

When a VA Community Care claim denies, you need to identify exactly who denied it and why before you start firing off appeals.

Common Denials

1. Service Not Authorized (CO-24) This happens when you bill a CPT code that was not listed on the SEOC, or you billed for a date of service that fell outside the SEOC's active window. Fix: Check the SEOC. If the code wasn't approved, you have no recourse. If the code was approved and the TPA simply misread the authorization, you must file a reconsideration with the TPA and attach a copy of the HSRM approval.

2. Missing Clinical Notes The TPA suspended or denied the claim because the local VAMC reported that they never received the post-visit documentation. Fix: Upload the notes to HSRM immediately, screenshot the upload confirmation, and submit a corrected claim or reconsideration to the TPA.

3. Provider Not on Roster The billing NPI is contracted, but the rendering NPI is not loaded into the TPA's system. Fix: You cannot appeal this until the credentialing department fixes the roster. Contact your Optum or TriWest network representative, get the rendering provider credentialed, and then submit a corrected claim.

The Appeals Process

If you have a legitimate medical necessity or authorization dispute, you appeal to the entity that processes your claims: Optum or TriWest. Do not send appeals to the local VAMC; they do not control the money once the SEOC is issued.

The first step is a Provider Dispute Resolution (PDR) or reconsideration. You generally have 90 days from the date of the denial to file this. It must be submitted via the TPA's provider portal (or by mail using their specific dispute form) and must include the original claim, the denial EOB, the SEOC proving authorization, and the clinical notes.

If the reconsideration fails, you can escalate to a formal appeal. Be warned: appealing a lack of authorization retroactively is nearly impossible in 2026. The VA's mandate is strict. If you provided elective or non-emergent care without an SEOC, neither the TPA nor the VA will bail you out. Your only defense in a VA audit or appeal is a paper trail showing you had approval before the patient crossed your threshold.

Frequently asked questions

Can I treat a VA patient in an emergency without prior authorization?

Yes, emergency care does not require a prior authorization. However, you must report the visit to the VA through the Emergency Care Reporting (ECR) portal within 72 hours of the patient presenting to your facility to guarantee payment.

Do I bill the VA directly or the TPA?

Under the Community Care Network (CCN), you bill the regional Third-Party Administrator (TPA) that holds your contract. This will be either Optum for Regions 1-3 or TriWest for Regions 4-5.

What is a Standard Episode of Care (SEOC)?

An SEOC is the VA's bundled authorization document. It details exactly which CPT and HCPCS codes you are approved to bill, the maximum number of visits allowed, and the date range during which the care must be provided.

How do I request more visits for a VA patient?

If a patient needs care beyond what the initial SEOC allows, you must submit a Secondary Authorization Request (SAR) along with supporting clinical documentation through the HealthShare Referral Manager (HSRM) before the current authorization expires.

What is the timely filing limit for VA CCN claims?

While federal statutes generally allow up to 180 days, your specific timely filing limit is dictated by your network contract with Optum or TriWest. Always consult your TPA agreement, as some corrected claims require submission within 90 days.