Claim Filing Information for CHAMPVA Beneficiaries
General Claim Filing Instructions
- Your name must be listed on the claim form exactly as it is on the CHAMPVA Authorization Card.
- Your Social Security number (SSN) must be on the claim. DO NOT USE the qualifying Veteran’s SSN.
- If you have other health insurance (OHI), include a copy of the OHI explanation of benefits.
- Keep copies of all receipts, invoices, etc.
- Separate CHAMPVA Claim Forms, VA Form 10-7959a, are required for each patient/beneficiary, even if they are members of the same family.
- If you fail to complete the VA Form 10-7959a, your health care provider will be paid directly.
- For inpatient hospitalizations, payment will be made to the hospital, whether or not you submit the billing.
Claims Submitted to CHAMPVA must include the following:
- CHAMPVA Claim Form, VA Form 10-7959a, (beneficiaries only)
- Itemized billing statement(s) are required and should be submitted on a standardized paper form (HCFA-1500, CMS-1500, UB-92, or UB-04). The following information must be provided on the forms:
- Full name, address, and Tax Identification number (TIN) of the provider
- Address where payment is to be sent
- Address where services were provided
- Provider professional status (doctor, nurse, physician assistant, etc.)
- Specific date of each service provided. Date ranges are acceptable only when they match the number of services/units of services
- Itemized charges for each service
- Appropriate medical code (ICD-9, CPT, HCPCS) for each service
- If you have other health insurance, a copy of their explanation of benefits (EOB) detailing what they paid. Please note: our mailroom equipment will only scan one side of the page. If important information is on the back of a page (processing remark codes), please photocopy the back page to include with submission.
The following information is required for pharmacy claims:
- An invoice/billing statement that includes:
- Name, address, and phone number of the pharmacy
- Name of prescribing physician
- Name, strength, and quantity for each drug
- Eleven-digit National Drug Code (NDC) for each drug (Please note that the “NDC” number is not the same as the “RX” number).
- Charge for each drug
- Co-payment for each drug
- Date prescription was filled
Where to Mail Claims
Chief Business Office Purchased Care
PO Box 469064
Denver, CO 80246-9064
How to Get Additional Claim Forms
You can request additional CHAMPVA Claim Forms, VA Form 10-7959a, at any time (including evenings and weekends) by calling us at 1-800-733-8387 and selecting the claim form option from our Interactive Voice Response (IVR) system. You can also order forms via the Inquiry Routing & Information System (IRIS). IRIS is a tool that allows us to communicate in a secure format.
Additional Claim Filing Information