Locating a Provider
The family member programs administered by the Veterans Health Administration Office of Community Care (CHAMPVA, Spina Bifida Health Care Benefits Program, and the Children of Women Vietnam Veterans Health Care Benefits Program) do not have networks of medical providers. However, you may find both the Medicare and the TRICARE websites helpful in locating a provider.
Providers that Accept “Assignment” for VA Family Member Programs
When you locate a medical provider, confirm that they will participate in the VA family member health care program you belong to. Providers most often refer to participation as "accepting assignment." Providers that accept assignment will bill us directly for covered services, items and supplies. Doctors or other providers who accept assignment must accept the VHA Office of Community Care (OCC) 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 OCC allowable amount for inpatient hospital services.
Providers that Do Not Accept “Assignment” for VA Family Member Programs
If your provider does not accept assignment, you can still see that provider, but be aware that you will likely have to pay the entire charge at the time of service. Additionally, you may be charged more than the OCC allowable amount. To obtain reimbursement in cases where a VA family member health care program is your only insurance, you will have to submit the itemized bill from the provider along with the appropriate VA form. When the claim is processed, we will send you the OCC share of the allowable amount.
What this means to you is that when the medical provider does not accept assignment, your cost will include not only your share of our determined allowable amount, but also any charges over our allowable amount.
When a VA Family Member Program is Secondary Insurance
To obtain reimbursement in cases where a VA family member health care program is your secondary insurance, you can ask the provider to file the claim and explanation of benefits (EOB) from the primary insurer electronically or by mail to OCC. If the provider is not able or willing to do that, you will need to submit the itemized bill, appropriate VA form and the EOB from the primary insurer to OCC.
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.
Visit HHS OIG Exclusions Program for more information.