United States Department of Veterans Affairs

How to File a Claim

Mail claims for payment to

Spina Bifida Healthcare Benefits
PO Box 469065
Denver CO 80246-9065

We recommend that you keep a copy of all claim documents submitted.

Forms

Providers should use a standard billing form (UB-04, CMS 1500) to provide the required information as indicated below. Beneficiaries who are filing claims for reimbursement of out-of-pocket expenses must include the Chief Business Office Purchased Care supplied form, Claim for Miscellaneous Expenses (10-7959e).

Required Documentation

All claims must contain:

Patient Identification

  • full name (as it appears on identification card)
  • social security number (SSN)
  • address
  • date of birth

Provider Identification

  • full name and address of hospital or physician
  • individual provider’s professional status (M.D., Ph.D., R.N., etc.)
  • Medicare provider number (inpatient institutions only)
  • physical location where services were rendered
  • provider tax identification number (TIN) – indicate whether employer identification number (EIN) or social security number (SSN)
  • remittance address

Inpatient Treatment Information

(Universal Billing form – UB-04 Provider Only)

  • all procedures performed (ICD codes and descriptions) 16
  • principal diagnosis (ICD code and description) established, to be chiefly responsible for causing the patient’s hospitalization
  • all secondary diagnosis (ICD codes and descriptions)
  • dates and services (specific and inclusive)
  • dates for all absences from a hospital or other approved institution during the period which inpatient benefits are being claimed
  • discharge status of the patient
  • summary level itemization of billed charges (by revenue codes)

Treatment Information and Ancillary Outpatient Services

(Standard billing forms – UB-04 or CMS 1500 – Provider Only)

  • diagnosis (ICD codes and descriptions)
  • individual billed charges for each procedure, service, or supply for each date of service
  • procedure codes (CPT-4, HCPCS, ADA) and descriptions for each procedure, service, or supply for each date of service
  • specific dates of service

Prescription Drugs and Medicines

(Standard billing forms when submitted by provider/or Claim for Miscellaneous Expenses available from the Chief Business Office Purchased Care when submitted by the beneficiary)

  • pharmacy receipt to include:
    • date dispensed
    • drug name
    • National Drug Code (NDC)
    • name and address of pharmacy
    • strength and quantity
  • on each receipt, write the associated diagnosis legibly

Travel

(Claim for Miscellaneous Expenses available from the Chief Business Office Purchased Care – Beneficiary Only)

  • billing statements
  • claims for POV mileage to include:
    • certification of medical appointment
    • date of service
    • place of service
    • signature of provider
  • other (out-of-pocket) expenses - such as expenses for over- 17 the-counter medicines and supplies (standard billing form - Claim for Miscellaneous Expenses available from the Chief Business Office Purchased Care)
  • receipts for all travel expenses (except mileage) for personally owned vehicles (POV)

Filing Deadlines

Claims must be filed with the Health Administration Center no later than:

  • one year after the date of service; or
  • in the case of inpatient care, one year after the date of discharge; or
  • in the case of a VA Regional Office award for retroactive eligibility, 180 days following beneficiary notification of the award

Note: If you pay for care and subsequently file a claim for reimbursement, our payment will be limited to the VA allowed amount. For this reason, you should have your providers bill the Chief Business Office Purchased Care directly.

Other Health Insurance (OHI)

While VA assumes full responsibility for the cost of services related to the treatment of spina bifida and associated conditions, other health insurers to include Medicare and Medicaid may assume payment responsibility for services unrelated to the VA-covered conditions.

Explanation of Benefits (EOB)

When we finish processing a claim, we will mail you an EOB – even if the claim was filed by the provider. The EOB is a summarization of the action taken on the claim and contains the following information:

  • amount billed
  • beneficiary name
  • dates of service or supplies provided
  • description of services and/or supplies provided
  • reasons for denial (if applicable)
  • to whom payment, if any, was made
  • VA-allowed amount