VA denied my community care claim saying I wasn't referred — who do I contact to fix this?

When a community care claim is denied because the VA says no referral or authorization existed, this is usually a records or coding problem rather than a final determination that you weren't eligible for care. Under the VA MISSION Act and the Veterans Community Care Program (38 CFR 17.4020 and related sections), veterans are only supposed to be billed by community providers when the VA authorized the care in advance, except in emergency situations covered separately under 38 CFR 17.4100. If you have documentation in your VA records showing a referral was discussed or processed, that is strong evidence the authorization existed but may not have been properly linked to the claim when it was submitted for payment.

The first step is not the community care claims/payment office itself, since they only pay based on what authorization is on file. Instead, contact the VA Community Care office at the VA medical facility that made the referral, sometimes called the Non-VA Care Coordination or Community Care Referral office. Ask them to confirm whether an authorization number was generated for your appointment and provide that authorization number in writing. If one exists but wasn't transmitted correctly to the payment processor (often TriWest or Optum, depending on region and time period), the facility can resubmit or correct the authorization so the claim can be reprocessed.

It also helps to request copies of the specific referral documentation from your records, including any consult notes or referral orders, and provide these directly to the community care office, not just to the outside clinic. Ask for a case manager or the community care liaison by name if possible, since general phone lines often can't resolve linkage errors between referrals and claims.

If the local Community Care office cannot resolve it, veterans can also file a complaint with the VA Patient Advocate at the facility, who can help escalate authorization disputes. Keep all communications in writing or documented, and do not pay the outside clinic while the dispute is active, since under the authorization rules the VA, not the veteran, is responsible for payment for authorized community care.

As a concrete next step, contact the VA Community Care office at the referring facility, provide the referral documentation from your records, and request written confirmation of the authorization number so the claim can be corrected and reprocessed.