CHAMPVA claim submission and appeal submission address

CHANGE OF ADDRESS
It is very important that you notify us if your address or phone number changes by contacting
us at: Mail Claims
Claims can be mailed to CHAMPVA at:

Department of Veterans Affairs
Chief Business Office Purchased Care

CHAMPVA
PO Box 469063
Denver CO 80246-9063

Claim form usage: This form is to be completed by the patient, sponsor, or guardian and is mandatory for all beneficiary claims. This claim form is NOT to be used for provider submitted claims.

Other health insurance (OHI): If OHI exists, attach OHI’s Explanation of Benefits (EOB) to the provider’s itemized billing statement(s).Dates of service and provider charges on EOB must match billing statements.

Timely filing requirement: Claims must be received no later than one year after the date of service or, in the case of inpatient care, within one year of the discharge date.

Itemized billing statements: An itemized statement must be attached and contain:

• patient name, date of birth, and CHAMPVA Identification Card (ID-Card) Member Number (same as patient’s Social Security number);
• provider name, degree, tax identification number (TIN), address and telephone number; and
• service dates, itemized charges and appropriate procedure/diagnosis codes for each service (i.e. CPT-4, HCPCS, and ICD-9-CM  codes), including narrative descriptions. Pharmacy claims are to include name, quantity, strength, and NDC of each drug.

Eligibility for CHAMPVA benefits can be impacted
by changes to your marriage status, eligibility for
Medicare or TRICARE, and by the student status
of children ages 18 to 23. Such changes must be
reported to us immediately.

Call us at
1-800-733-8387
or write us at:

CHAMPVA Eligibility
PO Box 469028
Denver CO 80246-9028

Interactive voice response (IVR)
system
Phone 

Toll Free: 1-800-733-8387
Hours of Availability: 24 Hours a Day,
Seven Days a Week

Talk to a customer service
representative
• Phone 

Toll Free: 1-800-733-8387, Monday
through Friday (excluding holidays)
• Hours of operation: 8:05 a.m. to 7:30 p.m.
Eastern Time

When CHAMPVA Is Secondary Insurance

To obtain reimbursement in cases where CHAMPVA is your secondary insurance, you can ask the provider to file the claim and Explanation of Benefits (EOB) from the primary insurer electronically with CHAMPVA as the secondary insurer. If the provider is not able or willing to do that, you will need to submit the itemized bill, CHAMPVA claim form and the EOB from the primary insurer to the Health Administration Center.

CHAMPVA ALLOWABLE AMOUNT

The allowable amount is the most we will pay for a covered medical service or supply. We determine the allowable amount before we calculate your cost share, the deductible or the other health insurance (OHI) payment. The CHAMPVA allowable amount is generally the same as TRICARE’s or Medicare’s allowable amount.

WHEN CHAMPVA PAYS INCORRECTLY

In the processing of millions of claims each year, there may be an inadvertent overpayment to you or your provider, depending on who submitted the claim. This might happen when we are not aware that you have other health insurance that should have paid before the bill was submitted to us, when a provider bills us twice for the same service or if we mistakenly pay for services for you or a family member during a period of ineligibility. No matter whose fault the incorrect payment was, we are required to take action to get the money back from whomever received the erroneous payment. That’s called recoupment, and it is done to help ensure that your tax dollars are spent properly, according to the law.

If you were overpaid, you will receive a letter requesting repayment and explaining your rights under the law. You should respond to the request within 30 days. If you can’t afford to pay the money all at once, you may be able to make monthly payments. You will be asked for financial information if you request a waiver of the overpayment. Depending on the outcome of the review of that information, the debt might be reduced or waived. If you do not respond to our notification, action to collect the amount owed to the VA will begin.

CHAMPVA AS PRIMARY PAYER

If you qualify for one of the four types of health insurance listed below, we will pay first (as the primary insurer). Those plans are: Medicaid

In those instances where Medicaid may have made payment for medical services and supplies first, we will reimburse the appropriate Medicaid agency for the amount we would have paid in the absence of Medicaid benefits, or the amount paid by Medicaid, whichever is less. State Victims of Crime Compensation Program We always pay first if you are eligible under a State Victims of Crime Compensation Program. Indian Health Services (IHS) We always pay first if you are eligible under Indian Health Services.

CHAMPVA Supplemental Health Insurance 

There are a number of companies that offer CHAMPVA supplemental policies. After we make a payment for health care services, your remaining out-of-pocket expenses, such as deductibles and copayments, often are payable by the supplemental insurance policy. If you have a policy that was specifically obtained for the purpose of supplementing CHAMPVA, we will compute the allowable amount, pay the claim, and then you can submit the balance due on the claim to your supplemental insurer.

We do not endorse one policy over another, and you should carefully consider your family’s needs for the additional coverage. Information on supplemental insurance is available on the HAC Web site www.va.gov/hac. Further information about supplemental health plans can also be obtained from Federal Publishing www.federalpublishing.com. Federal Publishing is not affiliated with the government, and we do not endorse their products or services.

CHAMPVA AS A SECONDARY OR TERTIARY PAYER

In all other cases, CHAMPVA is a secondary or tertiary payer: we pay after your OHI and, if you have more than one OHI (such as Medicare and Medicare supplemental plan), we pay after both plans. Having OHI complements the CHAMPVA program; it does not prevent anyone from using it. You may have another health plan through your employer, your spouse’s employer, or other government program such as Medicare. In most cases when you have OHI and CHAMPVA, there is no cost to you at all. When there is a cost to you, it is most often because you have exhausted your other health insurance benefits so the OHI is no longer making payment for a service or benefit period. In that case, when the medical service or supply is a covered benefit under CHAMPVA, we would pay up to our allowable amount.

You or the provider must file the claim with the other insurance plan before submitting it to us for payment. Upon receiving the EOB from the other insurer, you or the provider may file a CHAMPVA claim for any remaining balance. In addition to the EOB from the other health insurance, claims (billings) must include the provider’s itemized billing statement.

CHAMPVA AND HEALTH MAINTENANCE ORGANIZATION (HMO) OR PREFERRED PROVIDER ORGANIZATION (PPO) PLANS

If you have an HMO or PPO plan, we will pay your out-of-pocket expenses (your copayments under the HMO/PPO) for CHAMPVA covered services up to our allowable amount.

We will not pay for medical services that were available through your HMO/PPO plan if you choose to obtain care outside the plan without authorization from the HMO/PPO (for example, you choose to go to a doctor that is not part of your plan) or you do not follow the rules and procedures of your HMO/PPO to obtain the care. Additionally, if you have Medicare and choose to obtain care from a provider who does not accept Medicare patients, we will not pay for the care. You must follow your primary insurer’s guidelines, to include obtaining care from their network or participating providers.

1. CHAMPVA Claim Form, VA Form 10-7959a (available by phone or on the Web)

2. An itemized billing statement on a CMS 1500 or UB-04 with the same information listed in the Provider Submitted Claims section.

3. When you have other health insurance (OHI), an explanation of benefits (EOB) from the other health insurer.


Medical Services for Dependents and Survivors Of Veterans

The VA’s health care program for dependents and survivors of veterans is called the VA Civilian Health and Medical Program (“CHAMPVA”). CHAMPVA is a cost-sharing program in which the VA shares the cost of certain covered medical services with dependents or survivors. CHAMPVA provides medical care and is usually subject to the same limitations as found in the military’s TRICARE health care plan.

In the past, survivors lost eligibility for CHAMPVA when they turned age 65 and became eligible for Medicare Part A. Currently, those age 65 and older who are enrolled in Medicare Parts A and B may be eligible for  CHAMPVA as a secondary payer to Medicare.

Now, surviving spouses who remarry on or after turning age 57 and apply for benefits on or after December 16, 2003 are eligible for serviceconnected death benefits (DIC), VA home loan benefits, and other VA benefits, such as medical care (CHAMPVA). The remarriage need not end in order for these spouses to be eligible. They may remain remarried and still be entitled to benefits based on their earlier marriage to the veteran. This means that a spouse who remarried in 2002 (but after he or she turned 57) would be eligible for DIC if the application was filed after December 16, 2003. Still, the surviving spouse is not eligible for non-service-connected death pension.

Women eligible for survivor benefits (payments to dependents who have lost family members due to injuries or illnesses incurred during military service) and CHAMPVA (a health insurance program for dependents) can also be assisted by women benefits coordinators.

If your claim is denied, you can appeal it. Again obtaining your benefits can require a lot of persistence.

TRICARE and CHAMPVA (Civilian Health and Medical Program of Veterans Administration)

TRICARE and CHAMPVA are similar programs administered by the Department of Defense, except that the Veterans Administration determines the eligibility of persons seeking to establish entitlement to CHAMPVA coverage. TRICARE provides benefits for health care services furnished by civilian providers, physicians, and suppliers to retired members of the Uniformed Services and to spouses and children of active duty, retired, and deceased members. The term “Uniformed Services” includes the Army, Navy, Air Force, Marine Corps, Coast Guard, and the Commissioned Corps of the U.S. Public Health Service and of the National Oceanic and Atmospheric Administration. CHAMPVA provides similar benefits for spouses and children of veterans who are entitled to VA permanent and total disability benefits and to widows and children of bveterans who died of service-connected disabilities.

The governmental entity exclusion does not preclude Medicare payment for items or services furnished to a beneficiary who is also eligible for TRICARE/CHAMPVA benefit payments for the same services. Medicare is the primary payer for such items and services, and TRICARE/CHAMPVA is a supplementary payer.

Effect of Medicare Eligibility on TRICARE/CHAMPVA Entitlement

TRICARE/CHAMPVA beneficiaries, other than dependents of active duty members, lose their entitlement to TRICARE/CHAMPVA if they qualify for Medicare Part A on any basis and do not enroll in Medicare Part B

Individuals who are eligible for Medicare Part B benefits only, do not lose their entitlement to TRICARE/CHAMPVA benefits. If a Medicare beneficiary, who has lost entitlement to CHAMPVA upon becoming entitled to Part A of Medicare, thereafter exhausts any Part A benefits, the individual can again be entitled to CHAMPVA. Once the individual re-attains CHAMPVA benefits, the individual will not lose them by virtue of later again becoming eligible for Medicare Part A benefits. There is no similar provision for TRICARE which enables an individual to re-attain TRICARE eligibility after exhausting Medicare Part A benefits. A/B MACs (A) and (B) will direct questions concerning this provision to the CHAMPVA Center.

Medicare-TRICARE/CHAMPVA Relationship

If a TRICARE/CHAMPVA beneficiary also has Medicare coverage, TRICARE/ CHAMPVA reduces its liability in all cases by the amount payable by Medicare, i.e., Medicare is the primary payer and TRICARE/CHAMPVA supplements Medicare by paying the Medicare deductible and coinsurance amounts and portions of the bill not covered by Medicare. Thus, dually entitled individuals may be reimbursed up to 100 percent of expenses for items and services covered by both programs.

TRICARE/CHAMPVA has established policies and procedures which provide for (a) the identification of claimants who have coverage under both TRICARE/CHAMPVA and Medicare and (b) the detection of duplicate payments under both programs. If TRICARE/CHAMPVA inadvertently pays amounts which duplicate Medicare payments for the same items or services, TRICARE/CHAMPVA will take steps to recover the incorrect TRICARE/CHAMPVA payments.

CHAMPVA AND ACCIDENTAL INJURIES

If you are involved in an accident (such as an auto accident), you or your medical provider is required to file a medical claim with your (or the other person’s) insurance before submitting it to us. This is called third-party liability (TPL) and means that someone else is legally responsible for your medical care. When we receive the EOB from the insurance company, you may file a CHAMPVA claim for any remaining balance.

Filing a claim

The easiest way to file a claim for reimbursement is to have your provider do it for you. Providers know what is required and, in most cases, will file electronically, which means faster processing and payment.

If you file the claim yourself, here is what you need to do:
• Obtain a CHAMPVA Claim Form (VA Form 10-7959a) by calling us at 1-800-733-8387.

You can also obtain the form from our website at: http://www.va.gov/communitycare/pubs/ forms.asp

• It is very important that your name is listed onthe form exactly as it is on your CHAMPVA Identification Card. And be sure to date and sign the form. We CANNOT process your claim without your signature.

Include the following information with the claim form (your health care provider may be able to quickly print out this information for you):

• The full name and tax identification number of your provider
• The address where payment should be sent, and the address where the services were provided
• The provider’s professional status (doctor, nurse, etc)
• Specific date of the service
• Appropriate medical code for each service (see this chapter for details)

If you have other health insurance (OHI), file your claim with them first and send us the explanation of benefits (EOB) from that insurer.

For pharmacy claims, ask the pharmacy to file the claim for you. If you file, we need a completed and signed CHAMPVA Claim Form, the name, address and phone number of the pharmacy, the name of the prescribing physician, the name, strength and quantity of each drug, the 11-digit National Drug Code (NDC) for each drug, the charge for each drug and the date the prescription was filled. If you have other health insurance, make sure your co-payment amount is included on your receipt.

Send claims to:
CHAMPVA Claims
PO Box 469064
Denver CO 80246-9064

You will need to send in three items:

1. CHAMPVA Claim Form (VA Form 10-7959a). These forms are available by phone or on the Web.

2. An itemized billing statement from your  provider on a CMS-1500 (doctor/professional) or UB-04 (hospital/institutional) claim form containing the same information listed in the “Provider Submitted Claims” section on the next page. Ask your provider to itemize the bill on the appropriate form. (Copies of these forms are reproduced for illustration purposes only on the next few pages).

3. When you have other health insurance (OHI), an explanation of benefits (EOB) from the other health insurer

Tips for when you file claims

• Your name must be listed on the claim form exactly as it is on the CHAMPVA Identification Card.
• Your CHAMPVA Member Number (your Social Security number) must be on the claim.
• Keep copies of all receipts, invoices and other documents.
• Separate claim forms are required for each CHAMPVA beneficiary in your household.
• After billing your other health insurance and receiving their EOB, you can file with CHAMPVA for any remaining balance.
• If you do NOT use a CHAMPVA Claim Form (VA Form 10-7959a), payment will be made directly to the health care provider instead of to you.

EXPLANATION OF BENEFITS (EOB)

After a claim has been filed for your health care service, you will receive an Explanation of Benefits (EOB) from us in the mail. The EOB (see illustration on the following page) lists the details of the services you received and the amount you may be billed by your provider. If you paid for the service and submitted a claim for reimbursement, the EOB will tell you how we calculated your cost share.The EOB contains the following information:

• amount billed by the provider
• amount allowed by CHAMPVA
• amount not covered
• annual catastrophic cap accrual
• beneficiary and family deductible accrual
• CHAMPVA payment(s)
• date(s) of service
• provider name
• remarks
• amount paid by other health insurance