Medical records and documentation are required for all provided services. Providers are required to submit medical documentation directly to the authorizing VAMC, preferably via upload to the HSRM.
Standard, Urgent and High-Priority timeframes may apply based on the type of care provided. However, submit urgent and emergent care documentation as soon as it is complete. Referrals to screen for cancer or to treat a suicidal Veteran are other examples of higher priority medical documentation to return quickly.
All medical documentation must be signed (written or electronic), and/or initiated by the submitting provider or practitioner.
VA requires providers submit medical documentation to the authorizing VAMC within the following timeframes:
- Initial medical documentation for outpatient care – 30 days of the initial appointment
- Final outpatient medical documentation – 30 days of the completion of the SEOC
- Medical documentation for inpatient care – 30 days and will consist of a discharge summary
- Any medical documentation requested by VA for urgent follow up – upon request
Requirements vary by type of care. In general, documents should include legible notes and recommendations on further testing or follow-up care, which should match the coding billed on the claim. VA requires that all medical documentation include the following on each page, at minimum:
- Veteran Unique Identifier
- Veteran Full Name (including suffix)
- Veteran Date of Birth
- Referral Number
- Provider/Practitioner Authentication (signature either electronic or on paper) – Alaska only
- Include typed name and provider phone number
- THP Facility name (where applicable) – Alaska only
As for how often to submit, VA requires providers submit the following medical documentation for each episode of care:
- Initial medical documentation – associated with the first appointment of a SEOC.
- Final medical documentation – covers the entire SEOC.
VA defines critical findings as a test result, value or interpretation that, if left untreated, could be life-threatening or place the Veteran at serious risk.
- Providers are required to report Critical Findings to VA within the earlier of two (2) business days of the discovery or the timeframe required to provide any necessary follow-up treatment to the Veteran.
- Communication shall be either verbal or written.