VA Community Care: the referral decides everything that follows.

1. The payer and the patient

The payer is the Department of Veterans Affairs, acting through the Veterans Health Administration. The patient is a veteran who is enrolled in, or eligible for, VA health care. The program is the Veterans Community Care Program, created by the VA MISSION Act, which was signed on June 6, 2018 and consolidated several older purchasing programs into one. Its rules are in 38 CFR 17.4000 through 17.4040.

Two things must be true before a veteran can be sent to a community provider. The veteran must be enrolled in or eligible for VA health care, and the veteran must have approval from the VA care team before receiving the care, except in cases such as urgent or emergency care. Then at least one of six eligibility conditions has to apply. In outline: the veteran needs a service no VA facility offers; the veteran lives in a state or territory without a full-service VA medical facility; the veteran qualified under the older 40-mile rule and still meets its conditions; VA cannot furnish the care within its designated access standards; the veteran and the referring clinician agree that community care is in the veteran’s best medical interest; or VA has found that its own service line does not meet its quality standards.

The access standards are numbers in the regulation. For primary care, mental health care and non-institutional extended care services, the standard is a 30-minute average drive time or an appointment within 20 days of the request. For specialty care it is a 60-minute average drive time or 28 days. Home health, homemaker and respite services sit in the extended care group. VA decides all of this. The agency sees the result, which is a referral.

2. Two ways to become a provider

The Community Care Network. VA calls the network its preferred national vehicle for purchasing community care. It is five regional contracts covering every state and territory, each run by a third-party administrator that builds the network, credentials its members and pays their claims. VA.gov lists Optum as the administrator for Regions 1, 2 and 3 and TriWest Healthcare Alliance for Regions 4 and 5. Providers are not enrolled automatically. An agency signs up with the administrator for its region and is credentialed through that administrator.

The Veterans Care Agreement. This is an agreement made directly between a community provider and a VA medical facility. VA describes it as used in limited situations, where network services are either not provided or not sufficient. The regulation says VA may use one only when care is not feasibly available through a VA facility, a contract or a sharing agreement. To hold an agreement the agency must be certified by VA. Certification runs for three years; VA decides an application within 120 calendar days where practicable; and a provider must apply for recertification at least 60 calendar days before the current certification expires. Credentialing for an agreement is done through VA’s contracted credentials verification organization.

Under either route, VA bars participation by providers on the federal exclusion lists: the List of Excluded Individuals and Entities kept by the Health and Human Services inspector general, and the exclusions in the System for Award Management. VA also states that keeping required training current is essential to continue receiving referrals.

3. What an agency actually delivers

VA groups care at home under extended care services prescribed by and under the direction of a VA physician. Its provider pages list skilled home health care, home health aide services, homemaker services, respite care, hospice care, palliative care and remote monitoring care.

Skilled Home Health Care is described by VA as short-term care for veterans moving from a hospital or nursing home back home, delivered by a community home health agency that has a contract with VA. VA’s description includes nursing care such as wound or catheter care, physical, occupational and speech therapy, patient education, home safety evaluation, social work support and IV antibiotics. That last item is where infusion nursing at home appears in VA’s description.

Homemaker and Home Health Aide Care sends a trained aide to help the veteran with daily activities such as bathing, dressing, grooming, eating and moving about. VA states that the aide works for an organization that has a contract with VA and is supervised by a registered nurse who helps assess the veteran’s daily living needs. How long it continues depends on the veteran’s need.

Respite Care pays for care for a short time so that a family caregiver can rest, run errands or travel. At home it is delivered by an aide who comes to the veteran’s residence.

For all three, VA states the same eligibility rule: every enrolled veteran is eligible if he or she meets the clinical criteria for the service and is eligible for community care. The veteran arranges each of them through a VA social worker or case manager.

4. How the referral arrives

The sequence starts inside VA. A VA clinician enters a consult, which is the clinical order for the service. The facility’s community care team receives it, confirms eligibility, and authorizes the care. VA manages referrals and authorizations in a web-based system called HealthShare Referral Manager, where a participating provider can receive and track referrals, see the veteran’s clinical summary and submit requests online.

What reaches the agency is a referral packet for a specific Standardized Episode of Care. VA’s provider fact sheet says the packet includes the episode, its title and its content, including a start and end date and a specified number of visits or services. The approved referral itself tells the agency where to send the claim. The episode summarizes the typical scope of care and the billing codes commonly associated with it. VA is explicit that those codes are not a list of everything that may be provided, and that a service may be billed when it is within the scope and intent of the authorized referral.

The consult and the authorization are two different records. VA tells providers to look at the consult or order itself to see which services were specifically requested, and not to assume that everything listed in the episode was ordered for this veteran. The clinical order says what the veteran needs. The authorization says what VA will pay for, how many times, and between which dates. Intake has to hold both, tied to the same referral, and should not treat the arrival of one as proof of the other. A visit made on a clinical order with no authorization behind it is a visit VA has warned it may not reimburse.

The length of an authorization is whatever the referral states. In August 2025 VA announced yearlong authorizations for 30 standardized types of specialty care, noting that some referrals had previously been reevaluated every 90 to 180 days. Home health, homemaker and respite services are not on that list, so an agency reads the dates and the visit count from each referral.

5. Asking for more: the Request for Services

When the veteran needs more than the referral allows, the agency submits a Request for Services on VA Form 10-10172. VA requires the form for additional visits or time beyond an active referral, for example when an authorization is expiring; for a new specialty referral; and for a procedure or service not included in the original episode. Each service request needs its own form, signed by the requesting provider by electronic or wet signature, with supporting records such as provider notes, care plans and results.

The request goes to the local VA community care office through HealthShare Referral Manager, secure email, direct messaging, fax or mail. VA states that it processes requests within 3 business days and notifies the provider by the provider’s preferred method. Until an approval comes back, the earlier authorization’s dates and counts still govern, so the request has to go early enough for the answer to arrive before the last authorized visit.

6. Returning documentation to VA

VA coordinates the veteran’s care and keeps the veteran’s record, so the agency’s documentation is expected back at the referring facility. VA’s care coordination model ends with the facility confirming that services were provided and closing the consult, which depends on the agency’s records. Documentation can be returned through HealthShare Referral Manager, secure email, health information exchange or fax. For a home care agency that means the assessment, the plan of care, visit notes and aide supervisory notes. The records that support a Request for Services are the same records, sent sooner.

7. Filing the claim

The claim goes to the payer the referral names. For network care that is the regional administrator. For care under a Veterans Care Agreement it is VA, by electronic data interchange or by mail. VA accepts electronic 837 claims, and 275 transactions for supporting documentation, through clearinghouses, and publishes its payer identifiers for medical and dental claims. A claim is filed on the standard institutional format or the standard professional format according to how the agency bills the service, and the administrator’s provider handbook says which one applies to a given service type.

Three things have to be right on every claim. The authorization or referral number must be on the claim for all non-emergent care. The veteran must be identified by the VA-assigned control number or the Social Security number. And the services billed must be within the scope of the authorization, inside its dates and counts.

There is a filing limit. VA’s provider fact sheet states that claims for authorized care must be submitted within 180 days after the date care was provided. The clock runs from each date of service, so an agency with weekly aide visits over many months cannot safely bill far in arrears.

8. How the claim is paid

The regulation sets a ceiling: payment will not exceed the applicable Medicare fee schedule or prospective payment system amount for the period of service. It then lists exceptions. Rates may be higher in highly rural areas, defined as counties with fewer than seven residents per square mile. VA may depart from the ceiling where it finds the limit impracticable in light of patient needs, market analysis or provider qualifications. Services in Alaska follow the contract or VA’s Alaska fee schedule. The same structure applies to Veterans Care Agreements.

In practice VA describes an order of rates. A contract-negotiated rate is used if one exists. If not, the Medicare rate applies. Where Medicare has no rate for the service, the VA Fee Schedule applies. If nothing else applies, VA pays a percentage of billed charges. The schedule is published by calendar year; the 2026 schedule applies to services from January 1 through December 31, 2026.

VA’s network fact sheet says providers will be paid within 30 days of submitting a clean claim to their administrator. Payment is electronic by federal law.

The veteran is not billed. VA states that veterans should not pay anything out of pocket to a community provider, that providers cannot balance bill the veteran, and that providers cannot charge the veteran’s other insurance, Medicare or Medicaid for amounts VA does not cover. Where a copayment applies to extended care services, VA determines it and bills the veteran itself.

9. What VA and the administrator look at

VA is not a surveyor in the way a state is, but it inspects the same things from the payer’s side. Was there an authorized referral before the first visit. Were the services inside its scope, dates and counts. Did the documentation come back. Is the provider still credentialed, trained and absent from the exclusion lists. Under an agreement, the regulations set a formal dispute process for the scope of an authorization or a claim for payment, opened by written notice within 90 calendar days.

10. What ends or renews the episode

An episode ends when its end date passes or its visits are used, whichever comes first. If the veteran still needs care, continuation depends on an approved Request for Services and a new or extended referral. For long-running aide services the cycle repeats many times for the same veteran, and each cycle is its own authorization with its own counts.

What software has to do

The referral is the governing record for this line. Software that treats it as an attachment leaves people to enforce its dates and counts from memory. Each of the six engines has a specific job.

One operating chain

An agency that serves veterans almost never serves only veterans. The same nurse sees a Medicare patient in the morning and a veteran in the afternoon. The patient, the order, the clinician, the visit, the evidence, the obligation and the money are views of the same event, and VA Community Care changes only who authorized it and who pays. The authorization is the same idea as a Medicaid service authorization in units, the claim is the same billing record in a different format, and the personnel file that satisfies an administrator’s credentialing is the file a state surveyor reads.

Payer and program models →   Medicaid home and community care →   How Medicare home health operates →   From referral to revenue →