A VA community care referral lets you see a private-sector provider at the VA’s expense when a VA facility can’t meet your needs. To get one, you have to meet at least one of six eligibility conditions in federal regulation, and your VA provider has to create an internal consult that clears both a clinical eligibility check and administrative authorization before you schedule anything outside. Skipping that sequence is the single biggest way veterans end up personally responsible for a bill they thought the VA would cover.
Who Qualifies for a Community Care Referral
Federal regulation at 38 CFR 17.4010 sets out the conditions under which the VA must offer community care to an enrolled veteran who asks for it.1eCFR. 38 CFR 17.4010 – Veteran Eligibility You only need to meet one. There are six pathways.
Drive-Time and Wait-Time Access Standards
This is the pathway most veterans use. The VA’s designated access standards at 38 CFR 17.4040 set maximum drive times and wait times, and exceeding either one qualifies you.2eCFR. 38 CFR 17.4040 – Designated Access Standards
- For primary care, mental health, and non-institutional extended care, the nearest VA provider must be within a 30-minute average drive and able to see you within 20 days of your request.
- For specialty care, the nearest VA provider must be within a 60-minute average drive and able to see you within 28 days.
Drive time is calculated using geographic information system software based on your home address, not straight-line distance.2eCFR. 38 CFR 17.4040 – Designated Access Standards The wait-time clock starts on the date you or your provider makes the request.
Service Not Offered at Any VA Facility
If the VA does not offer the service you need at all, you qualify regardless of drive time or wait time. Maternity care and in vitro fertilization are common examples.3U.S. Department of Veterans Affairs. Eligibility for Community Care Outside VA
Best Medical Interest
You and your VA provider can agree that an outside provider would produce a better outcome for your situation. This typically comes up when a medical condition makes traveling to a VA facility unreasonably difficult, such as severe nausea from cancer treatment, or when you need recurring care the VA can’t supply in a timely way even within the formal wait-time limits.3U.S. Department of Veterans Affairs. Eligibility for Community Care Outside VA Both you and your provider have to concur.
Hardship
Geographic or environmental challenges can make travel to a VA facility impractical even when the drive is technically within the standard. Mountainous areas that become impassable in winter, or remote regions with limited transportation, can meet the hardship criterion.3U.S. Department of Veterans Affairs. Eligibility for Community Care Outside VA
Quality Standards
When a VA facility falls below federally established quality benchmarks for a particular service, veterans at that facility gain community care eligibility for that service. The performance thresholds and how they translate to individual eligibility are managed internally by the VA.
Grandfathered Eligibility
Veterans who qualified under the older Veterans Choice Program’s 40-mile distance rule on the day before the MISSION Act took effect (June 6, 2018) may retain eligibility if they still live in a qualifying location.4U.S. Department of Veterans Affairs. Veteran Community Care Eligibility In practice, this pathway now applies only to veterans in the five states with the lowest population density from the 2010 Census: Alaska, Montana, North Dakota, South Dakota, and Wyoming. For veterans in other states, the grandfather provision expired on June 6, 2020.
A Note on Urgent Care
Urgent care is not a referral pathway. You do not need a referral or prior authorization to walk into a participating urgent care provider.5U.S. Department of Veterans Affairs. Getting Urgent Care at VA or In-Network Community Providers You do need to be enrolled in VA health care and to have received care at a VA or in-network provider within the past 24 months.
How the Referral Moves Through the VA
A community care referral doesn’t start with a phone call to a private doctor. It starts inside the VA, and the request has to follow a specific sequence before anyone schedules an outside appointment.
Your Provider Creates a Consult
When your VA provider decides you need care that may qualify for community delivery, they create what the VA calls a consult. That’s the formal internal request that starts the referral.6U.S. Department of Veterans Affairs. Understanding the Community Care Process VA staff review it for accuracy before it moves forward. If you already have a community provider in mind, say so during the conversation so it goes in the consult.
The Decision Support Tool Checks Eligibility
Once the consult is created, VA staff run it through a software system called the Decision Support Tool. The DST pulls your home address from the enrollment system, calculates drive time to nearby VA facilities offering the service, checks average wait times, and flags any pre-existing eligibility codes you hold, such as grandfathered status or hardship. It then produces a determination about whether community care is appropriate.7U.S. Department of Veterans Affairs. Decision Support Tool User Guide Your provider then picks the referral destination: the local VA facility, another VA via inter-facility consult, or a community provider.
Administrative Review and Your Authorization Letter
After the clinical team approves the consult, it moves to the administrative side for final authorization and funding. The VA verifies the service is a covered benefit and confirms the community provider is in good standing with the network. You’ll get a letter with your authorization number, a description of the approved care, and the timeframe you’re authorized to receive it in.6U.S. Department of Veterans Affairs. Understanding the Community Care Process The VA will also call you to walk through the approval.
Scheduling With the Community Provider
Once you have an approved consult, you can schedule the appointment yourself or ask the VA to schedule it for you.8U.S. Department of Veterans Affairs. How to Get Community Care Referrals and Schedule Appointments If you self-schedule, call the community provider directly or use VA Online Scheduling. If you want the VA to handle it, the appointment is coordinated through the VA or its Third-Party Administrator.
Whichever path you choose, give the community provider your authorization number before the appointment. That number is how they bill the VA instead of you. Without it, the billing can get tangled, and you can end up with a bill you shouldn’t owe.
How Long the Authorization Lasts
Authorization durations vary by service. The VA has expanded yearlong authorizations for roughly 30 types of standardized care, giving veterans 12 full months of uninterrupted treatment before reauthorization is needed.9U.S. Department of Veterans Affairs. VA Offers Yearlong Community Care Authorizations for 30 Services Your authorization letter states the exact timeframe. Care received after the authorization expires won’t be covered, so watch the end date.
Adding Services to an Existing Referral
If your community provider decides you need care beyond what was originally authorized, whether more visits, a new specialty referral, or an added procedure, the provider submits a Request for Service (VA Form 10-10172) to the local VA facility.10U.S. Department of Veterans Affairs. Request and Coordinate Care Supporting medical documentation has to come with it: progress notes, lab results, imaging reports. Requests without documentation are denied. The VA processes these within three business days.
What You May Still Pay
Community care is not always free. You may owe the same copayment you’d pay for care at a VA facility, depending on whether the condition is service-connected and your assigned priority group.11U.S. Department of Veterans Affairs. Veteran Community Care – Billing and Payments Fact Sheet Care for service-connected conditions generally carries no copay. Care for conditions unrelated to your military service may trigger copays based on your priority group, just as it would inside a VA hospital.
Urgent care copays follow their own schedule. Veterans in priority groups 1 through 5 pay nothing for the first three urgent care visits each calendar year, and $30 for each visit after that. Veterans in priority groups 7 and 8 pay $30 for every visit. Group 6 veterans pay nothing when the visit relates to a special authority condition, such as combat exposures or military sexual trauma, and $30 per visit otherwise.12U.S. Department of Veterans Affairs. Current VA Health Care Copay Rates
Emergencies Don’t Use the Referral Process
Emergency care at a non-VA facility is handled separately from community care referrals. The VA can still cover the cost, but you or the ER has to notify the VA within 72 hours of when care begins.13U.S. Department of Veterans Affairs. Getting Emergency Care at Non-VA Facilities You can report by calling 844-724-7842 or using the VA’s online emergency care reporting portal.14U.S. Department of Veterans Affairs. Emergency Medical Care – Information for Providers Missing the 72-hour window doesn’t automatically kill the claim, but it puts you under stricter “unauthorized emergency care” rules, which are harder to meet.
If Your Referral Is Denied
The clinical appeals process is how you push back on a denied community care request. Start by contacting the patient advocate at the VA facility that made the decision, and submit a written appeal explaining which decision you disagree with, why, and any medical evidence supporting your position.15U.S. Department of Veterans Affairs. Clinical Appeals of Medical Treatment Decisions You’ll get a letter confirming the appeal was received. The facility’s chief medical officer, or a designee, reviews the appeal along with your records.
If you disagree with that decision, you can escalate by writing to the patient advocate for your Veterans Integrated Service Network (VISN), which is the regional body overseeing your facility. The VISN chief medical officer conducts a separate review and issues a final decision.15U.S. Department of Veterans Affairs. Clinical Appeals of Medical Treatment Decisions Contact information for both advocates appears in any denial or appeal decision letter you receive.
Coming Prepared to the Referral Conversation
Veterans who walk into the referral conversation prepared tend to get through faster. Before your appointment with your VA provider, write down the condition needing treatment, the type of specialist you think you need, any symptoms or prior treatments that show why the VA’s current resources aren’t adequate, and whether you’ve hit drive times or wait times that exceed the access standards. If you already have a community provider in mind, look them up on the VA’s online facility locator or the community care provider directory and note their name and National Provider Identifier number.
The strongest requests pair a clear clinical need with concrete access data. Telling your provider that the next available cardiology appointment at the VA is eight weeks out is more effective than a general complaint. If you have a scheduling estimate in writing or through My HealtheVet, bring it. The Decision Support Tool runs its own calculations, but real scheduling data in your consult record only helps.