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VHA Office of Community Care

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How to File a Claim for the VA Spina Bifida Health Care Benefits Program

The information below has been provided to ensure that your claim is processed quickly and correctly. Please review the required documentation before submitting your claims. We recommend you keep a copy of all claim documents submitted.

Beneficiaries who are filing claims for reimbursement of out-of-pocket expenses must include the Veterans Health Administration Office of Community Care (OCC) supplied form, VA Form 10-7959e, Claim for Miscellaneous Expenses, along with their other required documentation.

Claims Mailing Address

VHA Office of Community Care
Spina Bifida Health Care Benefits Program
PO Box 469065
Denver, CO 80246-9065

Required Documentation for All Claims

Beneficiary/Patient Information:
  • Full name (as it appears on the Spina Bifida Health Care Benefits Program Member 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.)
  • Physical location where services were rendered
  • Povider tax identification number (TIN)
  • Remittance address
Inpatient Treatment Information
  • Medicare provider number (inpatient claims)
  • All procedures performed (ICD codes and descriptions)
  • Principal diagnosis (ICD code and description)
  • All secondary diagnoses (ICD codes and descriptions)
  • Dates and services (specific and inclusive)
  • Dates for all absences from a hospital or other approved institution during the period for 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
  • 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

Required Documentation for Pharmacy Claims

Providers must use standard billing forms when submitting prescription drug and medication claims. A Claim for Miscellaneous Expenses form (see link above) must be included with prescription drug and medication claims submitted by the beneficiary.

Pharmacy receipt must include:
  • Date dispensed
  • Drug name
  • National Drug Code (NDC)
  • Name and address of pharmacy
  • Strength and quantity

Required Documentation for Travel Claims

  • Billing statements
  • Claims for personally owned vehicle (POV) mileage, to include:
    • Certification of medical appointment
    • Date of service
    • Place of service
  • Signature of provider
  • Receipts for all travel expenses (except mileage) for personally owned vehicles (POV)
  • Other (out-of-pocket) expenses, such as expenses for over-the-counter medicines and supplies, require submission of standard billing form (provider) or Claim for Miscellaneous Expenses (beneficiary)

Filing Deadlines

Claims must be filed with the VHA Office of Community Care 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 provider bill OCC 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 summary of the action taken on the claim and contains the following information:

  • Amount billed
  • Beneficiary name
  • Dates of service
  • Description of services and/or supplies provided
  • Reasons for denial (if applicable)
  • To whom payment, if any, was made
  • VA-allowed amount

Denied Claims

Please review the information on denied claims for a list of the top 10 reasons claims are rejected/denied along with additional text that further explains the rejection codes and indicates what a beneficiary/provider needs to do to get the claim processed correctly.