Locating a Provider
Beneficiaries enrolled in a Veteran family member program–CHAMPVA, Spina Bifida Health Care Benefits Program, and the Children of Women Vietnam Veterans Health Care Benefits Program–administered by the Veterans Health Administration (VHA) Office of Integrated Veteran Care (IVC) have the flexibility to choose their own provider, as the program does not have a provider network.
The Medicare and TRICARE websites may be helpful in helpful in locating a provider.
Providers Who Accept “Assignment” for VA Family Member Programs
When you locate a medical provider, confirm if they will participate in the VA family member health care program you belong to. Providers most often refer to participation as "accepting assignment." Approved health care providers include Medicare, Medicaid, and TRICARE providers as well as those licensed or certified by a state to provide care and services. When a state does not offer licensure or certification, the provider must be certified by an appropriate national or professional association that sets standards for the specific medical provider.
Providers who accept assignment will bill the respective family member program directly for covered services, items, and supplies. Doctors or other providers who accept assignment must accept the VHA IVC allowable amount as payment-in-full and cannot collect additional amounts from you beyond your cost share and deductible.
IMPORTANT NOTE: All hospitals that participate in Medicare, and hospital-based health care professionals who are employed by, or contracted to, such hospitals are required by law to accept the VHA IVC allowable amount for inpatient hospital services.
Providers Who Do Not Accept “Assignment” for VA Family Member Programs
If your provider does not accept assignment, you can still see that provider, but your provider may require you to pay the entire charge at the time of service which may be more than the VHA IVC allowable amount. Once paid, submit the itemized bill from the provider along with the appropriate VA form.
To obtain reimbursement in cases where a VA family member health care program is your only health benefit plan, you will have to submit the itemized bill from the provider along with the appropriate VA form. VHA IVC will mail out your share of the allowable amount once the claim is approved and processed. What this means to you is that when the medical provider does not accept assignment, your cost will include not only your deductible amount but also your share of our determined allowable amount, and any charges over our allowable amount.
When a VA Family Member Program is Secondary to Your Primary Insurance
To obtain reimbursement in cases where a VA family member health care program is acting as a secondary health care benefit plan, you can ask the provider to file the claim and explanation of benefits (EOB) from the primary insurer electronically or by mail to VHA IVC. If the provider is not able or willing to do so, you will need to submit the itemized bill, appropriate VA form, and the EOB from the primary insurer to VHA IVC.
Medicare Exclusion List
The Department of Health and Human Services, Office of Inspector General (HHS OIG) maintains and publishes a monthly list of individual medical providers that are not allowed to provide medical services and supplies to federal health care program participants. Medical providers on this list have been convicted in state or federal court of certain felonies, criminal offenses, or have had other offenses toward federal agencies related to the delivery of health care. Mandatory exclusions include, but are not limited to, convictions related to patient abuse or neglect, felony convictions related to health care fraud, and controlled substances.
Excluded individual medical providers and medical institutions cannot, by law, receive payments for health care services or supplies from any federal health care program. That exclusion includes programs funded by the Department of Veterans Affairs such as CHAMPVA, the Spina Bifida Health Care Program, and the Children of Women Vietnam Veterans Health Care Program.