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
Is Kaiser Permanente Your Primary Insurance?
Kaiser does not provide beneficiaries the necessary information needed to submit claims for reimbursement to CHAMPVA. To process a claim for a Kaiser Permanente bill, which does not include a medical diagnosis or procedure code, CHAMPVA can use code V70 for the diagnosis and code 99499 for the procedure.
So that the Purchased Care can process claims using this method, please provide a copy of your Kaiser Permanente card showing the amount of your co-payments with your claims. Although CHAMPVA is providing this method of processing claims for beneficiaries insured by Kaiser, we urge you to request a bill from Kaiser that includes the following information:
- Tax Identification number
- Address of the Kaiser provider
- Date of service
- Medical code or description for the diagnosis and the procedure
- Patient’s responsibility or patient co-payment
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