A Guide for VA Authorizations & Referrals
Veteran Affairs (VA) authorizations and referrals are a complex web of documents, deadlines, and compliance benchmarks. Requests for care must move from VA physicians to community care providers, followed by a strict approval process and highly specific care parameters. Every caregiver interaction must be perfectly aligned with the VA’s approved scope, ensuring the services provided are eligible for reimbursement.
Central to this process is the Community Care Network (CCN), which connects VA partners with private providers in veterans’ communities. This guide will connect the dots between every stakeholder in the referral chain, explore the most common challenges surrounding authorizations, and illuminate the most important pillars of the VA billing process.
What VA Authorizations Mean for Care Providers
A VA authorization legally approves a veteran’s care plan. It is a binding agreement between the Department of Veterans Affairs and a home care agency, granting them the ability to deliver a set of medically necessary services to an eligible veteran for a predetermined period.
Authorizations are also necessary documentation for ensuring financial reimbursement and regulatory compliance. They indicate the approved scope, frequency, and duration of a veteran’s care, as determined by a VA physician. As long as services align with the authorized Standardized Episode of Care (SEOC) outlined in the veteran’s referral, they are eligible for billing under programs like the Community Care Network (CCN). Services that fall outside of this scope require additional authorization before they can be delivered and billed.
How Referrals & Authorizations Work Together
Referrals and authorizations play a prescriptive role in how the VA pays for home care. The process begins with the veteran’s primary care provider at the VA identifying a medical or non-medical need that cannot be met by the VA’s offering. The provider then issues a referral to a home- or community-based service, like a home care agency, that can bridge the gap.
The referral document is simply a request; the VA authorization is the administrative green light. It specifies the type of care that’s been approved, the frequency of visits, and the specific date range for which the VA will subsidize a veteran’s care. A caregiver can only enter a veteran client’s home if an authorization has been inked.
Once services have been delivered and accurately logged, billing teams can use this information to create a claim for the VA. This alignment between original authorization and the data captured by your home care platform ensures every billed hour is pre-validated, drastically reducing the risk of a claim rejection while protecting the agency’s revenue cycle.
Connecting With the VA Community Care Program
The CCN is a framework used by the VA to purchase care from community providers. Third-party administrators (TPA) manage the CCN and maintain these referral networks for easy, direct access when required, spanning a wide range of medical and supportive services beyond just home and community-based care (HCBS).
To satisfy eligibility requirements, a veteran must meet at least one of the six following criteria:
- They must live more than 30 minutes away from a VA primary care facility, or 60 minutes away from a specialized care facility.
- The VA must not have any available appointments within 20 days for primary care, or 28 days for specialty care.
- The veteran must require a type of service that is not offered at any VA facility.
- The local VA service does not meet the VA’s own quality standards.
- The veteran and their VA physician agree that a community provider will deliver the best possible health outcome.
- The veteran is grandfathered into the program via the previous 40-mile rule.
To join the CCN, agencies must sign a contract with the TPA that serves their region. They must also undergo a vetting process to confirm they meet the VA’s quality and safety standards for community providers. Once they’ve been accepted into the network, agencies may receive service requests from VA physicians through a secure portal.
These referral networks greatly increase veterans’ access to a broad spectrum of healthcare services, while giving them even more flexibility to choose providers that align with their personal preferences. While the VA delivers many clinical services directly, certain types of care, including in-home support services, are often coordinated through community providers in the CCN.
In-home and community-based support is also essential for individuals with limited mobility, eliminating the need to travel to and from a VA facility. Agencies also benefit by expanding their reach into a large referral pool, generating inbound leads and diversifying their client base while receiving predictable payments from a trusted source.
How To Manage VA Authorizations Efficiently
The main pipeline through which agencies receive referrals is the HealthShare Referral Manager. They may also receive a fax from their VA Regional Medical Center.
Before accepting, the agency must verify that they can provide the type of care that’s been requested, which is specified using specific service codes. For example, if you provide skilled nursing visits but the VA has only offered to cover home health aide hours, the VA will deny your claim for the nursing services and leave you to cover the cost.
If the veteran ends up needing additional services or care hours that exceed the original allowance, agencies need to submit VA Form 10-10172 to extend the scope. Only administer the additional services once the request has been approved; you can monitor its status via the HealthShare Referral Manager (HSRM). To close the compliance loop on each appointment, upload any clinical notes or discharge summaries to HSRM. That way, the VA can verify that the visit has satisfied the associated authorization requirements.
Navigating Common Authorization Challenges
Coordinating care with the VA requires its fair share of documentation, leaving plenty of room for information to slip through the cracks — or errors to slip in.
Sometimes, it’s as simple as a missed document field or delayed paperwork submission that can place care into total gridlock. Agency admin teams may also run into issues if the referral is vague about the specific number of hours or service types, leaving teams confused about which interventions are eligible for reimbursement.
Reviewing the VA’s SEOC for clarity and completeness as soon as it’s received can prevent misunderstandings down the road.
Even if an agency has their paperwork in order, the VA operates on its own timeline. Requests for extensions or additional hours can sit pending for weeks, leaving veterans hanging in the balance. Authorizations are typically issued in 6-month periods, and agencies should proactively request renewals 45 to 60 days before the authorization end date to avoid gaps in care. This updated timeline, implemented in 2025, helps ensure continuity while reducing last-minute delays.
Claim denials are one of the largest threats to an agency’s cash flows and should be avoided at all costs. They often occur due to overservicing beyond authorized hours, inaccurate or incomplete demographic information, submitting claims with incorrect service codes, or attempting to bill without an active authorization in place. A simple pre-billing audit should catch the majority of these issues, double-checking that visits are exactly the same as the VA’s approved authorization numbers and codes.
Best Practices for Providers Working With VA Referrals
A proactive approach will keep agencies ahead of the most common VA referral challenges, instead of finding themselves on their back foot.
When a referral comes through, it’s in their best interest to begin care as soon as possible to incorporate VA payouts into their cash flows. However, agencies often wait days for faxes or mailed authorization letters, which delays the start of their care with a new client. The HSRM portal is an easy way around snail-mail and hard-copy paperwork issues, enabling real-time viewing and downloading as soon as an authorization is ready.
If an RFS must be submitted to continue serving a given veteran, expect the process to take some time. Waiting for a continuation of care approval can lead to gaps in service, so be sure to submit the documentation 45 to 60 days in advance of the current authorization’s expiration date. For services such as home health aide, homemaker, and respite care, authorizations are typically issued in 6-month periods, making early renewal requests essential to maintaining continuity of care.
Interacting with the VA requires a good bit of specialized knowledge. If possible, designate a specific staff member to become your VA expert, training them on the specific nuances of government portals and TPA software. That way, you’ll have a single point of contact for troubleshooting issues and navigating the complex world of claims submissions.
For caregivers out in the field, using clear, objective language is the best way to prove that the care being provided aligns with the care that was requisitioned. They should always use terminology that upholds the VA’s “medical necessity” requirements, backed by detailed documentation that documents the veteran’s progress (or need for further care) and paves the way for authorization renewal.
Manage VA Authorization & Referrals With AxisCare
AxisCare is a trusted partner for agencies across the United States that have partnered with the VA. As a full-service vendor, we take care of every step, from setting up your clients’ billing tabs to filing submissions and appeals on your behalf. Request a free demo to learn more about how we can support your referral journey and keep your cash flows protected.
