Medical Record Requirements for the VA

Summary of the Medical Record Requirements for the VA:

  • PREAUTHORIZED OUTPATIENT CARE under 38 U.S.C. 1703:
    • VA does not routinely require accompanying medical documentation for VA to process a claim. We still require the records; we simply will not hold up claims processing for the records.
  • UNAUTHORIZED OUTPATIENT AND INPATIENT CARE under 38 U.S.C. 1728 and 1725:
    • VA will attempt to process the claim without the records; however; when records are needed to determine the treatment provided, medical necessity for emergency services and point of stabilization the minimum records are: (1) ER/ED notes, (2) Daily progress notes for inpatient and (3) Discharge Summary.
  • Notes:
    • VA reserves the right to request additional information when determined to be necessary by a VA clinician
    • This list applies only to the VA, not VAChoice/PC3, which is managed by HealthNet
    • Additional information and updates can be found here.

    Virtual Lifetime Electronic Record (VLER)
    • VLER allows the VA to partner with community providers to view/move clinical documentation. Per our meeting in Georgia, we heard many providers who were frustrated with the mailing of clinical documentation to our VAMCs, scanning delays, repeated requests, etc. If you would like to become partners in utilizing VLER to make their records available electronically, please contact Mr. Tim Wong, Virtual Lifetime Electronic Record Coordinator, at edward.wong3@va.gov.
    • Additional information about VLER can be found here.