Community Care

We encourage beneficiaries to have their provider(s) file claims directly with CHAMPVA. Providers are more likely to submit all the information necessary for CHAMPVA to process claims.

• Medical Claims
• Pharmacy Claims
• Claims from Kaiser Permanente
• Where to Mail Claims
• Additional Claim Forms
• Resources

Change Healthcare (CHC) Cybersecurity Breach

For those VA community providers serving beneficiaries of CHAMPVA, Spina Bifida Healthcare Benefits Program, Camp Lejeune Family Member Program, and Children of Women Vietnam Veterans Health Care Benefits Program, please follow the guidelines at the link below.

Change Healthcare (CHC) Cybersecurity Breach–Information for Family Member Care Claims

Required Documentation for Claims Submitted to CHAMPVA

Medical Claims Documentation

CHAMPVA Claim Form, VA Form 10-7959a | Forma S10-7959a en Español
If you fail to complete VA Form 10-7959a, CHAMPVA Claim Form, your health care provider will be paid directly.

• Your name must be listed on the claim form exactly as it is on your CHAMPVA Identification Card.
• Separate signed and dated claim forms are required for each patient/ beneficiary, even if they are members of the same family.
• Itemized bill(s)* from your provider with the following information:
  • Your Social Security number (SSN) must be on the claim. (DO NOT use the SSN of the qualifying Veteran.)
  • Full name, address, and tax identification number (TIN) of the provider
  • Provider professional status (doctor, nurse, physician assistant, etc.)
  • Address where payment is to be sent
  • Address where services were provided
  • Specific date of each service provided
  • Itemized charges for each service
  • Appropriate diagnosis and procedure codes (DX, 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 such as processing remark codes, please photocopy the back page and include it with the submission.

Pharmacy Claims Documentation

CHAMPVA Claim Form, VA Form 10-7959a | Forma S10-7959a en Español
If you fail to complete VA Form 10-7959a, CHAMPVA Claim Form, your health care provider will be paid directly.

• Your name must be listed on the claim form exactly as it is on your CHAMPVA Identification Card.
• Separate signed and dated claim forms are required for each patient/ beneficiary, even if they are members of the same family.
• An itemized bill/statement from your pharmacy is required. The itemized pharmacy bill/statement must include:
  • 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: The “NDC” number is not the same as the “RX” number.)
  • Charge for each drug
  • Copayment for each drug
  • Date prescription was filled

If Kaiser Permanente is 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.

For CHAMPVA to process claims using this method, please provide the following documentation with your claim:

• A copy of your Kaiser Permanente card showing the amount of your copayments with your claims.
• A bill from Kaiser that includes the following information:
  • Tax Identification Number (TIN)
  • Address of the Kaiser provider
  • Date of service
  • Medical code or description for the diagnosis and the procedure
  • Patient’s responsibility or patient copayment

IMPORTANT: Please retain a copy of all documents submitted to CHAMPVA.

Where to Mail Claims

How to Get Additional Claim Forms

Download a CHAMPVA Claim Form, VA Form 10-7959a from the VA Forms website.