Content outline, version 1.0
Six domains, published in full. Every item on the examination maps to one domain and one task statement below.
The weightings are fixed for the life of this version and are published so candidates can prepare against the standard rather than against a rumor of it. Published September 20, 2026; effective for every administration from the first 2027 testing window.
| Domain | Title | Weight | Scored items |
|---|---|---|---|
| D1 | VA Community Care referral and authorization | 25% | 19 |
| D2 | TRICARE East and West | 20% | 15 |
| D3 | CHAMPVA and other-health-insurance primacy | 15% | 11 |
| D4 | Divergence from Medicare and commercial | 15% | 11 |
| D5 | Documentation and record standards | 15% | 11 |
| D6 | Denials, appeals and remediation | 10% | 8 |
| Total | 100% | 75 |
The task statements describe what a certified practitioner can do, in the form item writers write to and preparation programs are evaluated against. A Pathway B program must cover every domain; it is evaluated by whether its syllabus reaches these tasks, not by who owns it.
VA Community Care referral and authorization
Referral origination, Standardized Episode of Care (SEOC) limits and duration, authorization versus referral, and routing among the third-party administrators, Veterans Care Agreements and local contracts.
- D1.1Determine whether a Veteran's care is authorized under the Community Care Network, a Veterans Care Agreement or a local contract, and route intake, documentation and the claim accordingly.
- D1.2Read a VA referral to identify the Standardized Episode of Care, the services it includes, its visit limits and its expiration date.
- D1.3Distinguish a referral from an authorization, and confirm that authorization is in place before care is scheduled or rendered.
- D1.4Identify the third-party administrator responsible for a referral by region, and the portal or contact used for referral status, secondary authorization and claims.
- D1.5Prepare a Request for Service when needed care falls outside the SEOC, including the clinical documentation VA requires to decide it.
- D1.6Apply the notification and documentation requirements for emergency and urgent care delivered outside a standing referral.
- D1.7Return required medical documentation to VA within the contract's timeframes and record evidence that it was received.
TRICARE East and West
Prior authorization versus referral by plan and beneficiary category, point-of-service rules, and the differences in process between the regional contractors.
- D2.1Identify a beneficiary's plan and category — Prime, Select, For Life, Reserve Select, active duty, family member or retiree — and derive what that category requires before care.
- D2.2Determine, by plan and service, when a primary care manager referral is required, when a prior authorization is required, and when neither is.
- D2.3Apply the point-of-service option and explain its deductible and cost-share consequence to a Prime beneficiary who self-refers.
- D2.4Apply the military treatment facility right of first refusal and the routing rules that apply to active duty service members.
- D2.5Read a referral or authorization letter to confirm the approved provider, service, visit count and validity dates before scheduling.
- D2.6Identify the regional contractor and portal responsible for referral status, authorization requests and claims, and the process differences between regions.
- D2.7Apply TRICARE's other-health-insurance rules and timely-filing limits when preparing a claim.
CHAMPVA and other-health-insurance primacy
Eligibility, coordination with other health insurance and order of payment, and the documentation that decides who pays first.
- D3.1Confirm CHAMPVA eligibility and distinguish it from TRICARE eligibility, which is mutually exclusive with it, before intake.
- D3.2Identify the services that require preauthorization from the CHAMPVA program office and how preauthorization is obtained.
- D3.3Determine order of payment when a beneficiary also holds Medicare, an employer plan, Medicaid or a supplemental policy, and identify the plans CHAMPVA pays after.
- D3.4Prepare a CHAMPVA claim with the other-health-insurance explanation of benefits attached, within the timely-filing limit.
- D3.5Apply the deductible, cost-share and catastrophic-cap rules to estimate a beneficiary's responsibility for a service.
- D3.6Recognize when a beneficiary's Medicare Part B enrollment affects CHAMPVA coverage.
Divergence from Medicare and commercial
Where federal payer rules depart from Medicare and commercial practice, and the assumptions carried over from commercial work that most often produce a denial.
- D4.1Identify the payer and the payment rules that govern an encounter from the authorization on file, rather than from the insurance card the patient presents.
- D4.2Explain why a community provider never bills a Veteran for authorized VA community care, and how VA copayments are handled.
- D4.3Distinguish federal referral and authorization requirements from commercial prior authorization, including the absence of retroactive authorization as a routine remedy.
- D4.4Compare timely-filing, balance-billing and provider-authorization rules across VA community care, TRICARE, CHAMPVA, Medicare and commercial plans.
- D4.5Recognize commercial and Medicare habits — advance beneficiary notices, patient financial-responsibility waivers, billing a secondary plan — that are inapplicable or prohibited under a federal program.
- D4.6Determine when a provider's Medicare enrollment status is, and is not, relevant to payment under a federal program.
Documentation and record standards
What must accompany an authorization at each stage, retention expectations, and the source records a payer treats as authoritative when records disagree.
- D5.1Assemble the documentation that must accompany an authorization at intake, scheduling, rendering and claim submission for each program.
- D5.2Match claim data elements — authorization number, referring provider, NPI and tax identifier, dates and place of service — to the authorization so the claim cannot fail on an avoidable mismatch.
- D5.3Return clinical documentation to VA within the required timeframes and keep evidence of receipt.
- D5.4Identify which record a payer treats as authoritative when the practice's record and the payer's record disagree.
- D5.5Apply record-retention requirements, and the longest applicable period when more than one applies.
- D5.6Exchange protected health information with contractors only under the practice's HIPAA program and business-associate agreements.
Denials, appeals and remediation
Reading a denial to its actual cause, the appeal levels and their deadlines, and the sequence that prevents a second rejection on identical grounds.
- D6.1Read a rejection or denial to its actual cause using the payer's reason and remark codes and the authorization on file.
- D6.2Distinguish a rejected claim from a denied claim, and a corrected resubmission from an appeal, and choose the correct action.
- D6.3Identify, for each program, the reconsideration or appeal level, the body that decides it, and its filing deadline.
- D6.4Sequence remediation so the underlying cause is corrected before resubmission and the second submission cannot fail on the same ground.
- D6.5Recognize a claim sent to the wrong program or contractor and redirect it without losing timely filing.
- D6.6Document the denial, the actions taken and the outcome so the record supports a later appeal.
What the examination does not test
The examination does not test code assignment and contains no CPT, ICD-10-CM or HCPCS code-selection items. It does not test clinical judgment, contract law, or the content of any single vendor's software. Candidates are not permitted reference materials during the examination.
Reference list
Items are written from, and defensible against, the published sources below. Where a program's rules change between editions, the examination follows the rule in force on the first day of the testing window, and a bulletin is issued when a change affects a scored item.
VA Community Care
- 38 U.S.C. § 1703 and 38 CFR §§ 17.4000–17.4040 — the Veterans Community Care Program
- VA Office of Integrated Veteran Care, community care provider guidance (va.gov/communitycare) — referrals, Standardized Episodes of Care, urgent and emergency care, claims and timely filing
- VA Standardized Episode of Care (SEOC) definitions as currently published
- VA Form 10-10172, Community Care Provider Request for Service
- Community Care Network provider manuals published by the third-party administrators for their regions
- Veterans Care Agreement provider terms and VA community care claims guidance for non-CCN care
TRICARE
- 32 CFR Part 199 — Civilian Health and Medical Program of the Uniformed Services (TRICARE)
- TRICARE Operations Manual, TRICARE Policy Manual and TRICARE Reimbursement Manual (manuals.health.mil)
- TRICARE beneficiary and provider guidance on referrals, pre-authorization, the point-of-service option and claims (tricare.mil)
- Provider handbooks of the current East and West regional contractors
CHAMPVA
- 38 CFR §§ 17.270–17.278 — CHAMPVA
- CHAMPVA Program Guide and provider information published by the VA Office of Integrated Veteran Care
- VA Form 10-7959c, CHAMPVA Other Health Insurance Certification
Cross-program and documentation
- 45 CFR Parts 160 and 164 — HIPAA privacy, security and breach notification rules
- Medicare Claims Processing Manual (CMS Pub. 100-04) and Medicare Secondary Payer Manual (Pub. 100-05), for the comparisons tested in Domain 4
- X12 claim adjustment reason codes and remittance advice remark codes as maintained by the code-list committees
Version history
| Version | Published | Effective | Change |
|---|---|---|---|
| 1.0 | September 20, 2026 | 2027 Window 1 | First published outline: six domains, weights, item counts, task statements and reference list. |
The outline is reviewed each September. A new version, if any, is published at least 90 days before it becomes effective, and no version applies retroactively to a candidate already holding an authorization-to-test.
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