Veterans Affairs health care and community care denials

Department of Veterans Affairs (VA) health care has its own appeal system, and it does not use the same steps as private insurance or Medicare. The first thing to work out is what kind of decision you are disputing. The reference page is Veterans Affairs health care.

What this means

There are two tracks.

• Clinical appeal. Use this when you disagree with a medical treatment decision by your VA care team, for example whether a medicine or therapy should be prescribed.
• Decision review. Use this when you disagree with a health care benefit decision, such as enrollment or eligibility, payment or reimbursement of community care or emergency care claims, travel reimbursement, or family member programs. This system was created by the Veterans Appeals Improvement and Modernization Act of 2017.

One rule cuts across both. A VA decision about whether you qualify to receive care in the community, under Title 38 of the United States Code (U.S.C.), section 1703(d) or (e), is reviewed only through the clinical appeal process. By statute it “may not be appealed to the Board of Veterans’ Appeals”. A payment decision about community care goes through decision review.

What to do: clinical appeal

1. Talk to your care team first (you). VA’s patient advocate page suggests this order: your treatment team, then the provider’s supervisor or chief of service, then the patient advocate. The patient advocate at each VA facility is a VA employee whose job is to help resolve concerns and to help file a clinical appeal.
2. Send a written appeal to the patient advocate (you). The facility’s chief of staff, or a designee, decides. VA’s public page says to send the appeal as soon as you can. The directive sets no hard filing deadline, but if the appeal arrives 60 or more calendar days after the decision, VA starts with a re-evaluation by the original decision maker before the appeal continues.
3. If you disagree, send a second and final appeal (you). It goes in writing to the regional network office, called the Veterans Integrated Service Network. The chief medical officer decides.
4. Know VA’s own time limits (the VA). Appeals about community care eligibility must be decided and communicated within 3 business days of receipt by the patient advocate. All other clinical appeals must be decided within 45 business days, or 60 business days at the network level if an external review is needed.

What to do: decision review for a benefit or payment decision

1. Find the date on the decision notice (you). You have one year from that date to ask for a higher-level review or a Board appeal.
2. Choose a lane (you).
   • A Higher-Level Review (VA Form 20-0996) asks VA to look again without new evidence. VA’s page lists community care claims among the decisions it can review, with a separate mailing address from disability claims.
   • A Board appeal (VA Form 10182) goes to the Board of Veterans’ Appeals. You can choose direct review (no new evidence, no hearing, with a Board goal of 365 days), evidence submission (new evidence within 90 days of filing), or a hearing with a Veterans Law Judge (evidence at the hearing and within 90 days after).
   • A Supplemental Claim is for new and relevant evidence. It can be filed at any time, but must be filed within one year to keep the claim continuously pursued.
3. Watch the payment deadlines (you and the community provider). VA must be notified within 72 hours of the start of emergency treatment at a non-VA facility for it to be authorized as community care. A claim for emergency care for a condition not connected to military service must be filed within 90 days. We did not confirm what starts the 90 days, so ask the facility. A claim for unauthorized care related to a service-connected condition must be filed within 2 years.

Check the date on your notice, which controls.

The rule

A decision about whether a veteran qualifies for care in the community is reviewed only through the clinical appeals process and may not be appealed to the Board of Veterans’ Appeals. (38 U.S.C. 1703(f))

Watch for

• What this site has not verified. The form number for a Supplemental Claim, which part of the federal regulations formally governs reviews of health care benefit decisions, and VA’s decision timeframes for a Higher-Level Review are not confirmed here. Use the form and timeframes shown on VA’s own pages.
• An overdue directive. The directive that sets the 3-business-day and 45-business-day clinical appeal times passed its scheduled recertification date of 30 September 2025. A replacement could change those times, so ask the patient advocate what applies now.
• Older rules. The older reconsideration and appeal rules in Title 38 of the Code of Federal Regulations (CFR), sections 17.132 and 17.133 apply only to claims decided before the 2019 system.
• Addresses change. Re-read mailing addresses on VA’s pages before you send anything.
• The Indian Health Service. Purchased/Referred Care through the Indian Health Service has a different three-step appeal. See Indian Health Service Purchased/Referred Care.

What next

• TRICARE appeals covers the military health program.
• Ask for your claim file helps you gather records before you appeal.
• Legal aid lists free legal help.
• Military, veteran and federal employee coverage lists every page in this group.