File a Claim for the Spina Bifida Health Care Benefits Program

The information below is provided to ensure 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.

Required Documentation for:

All Claims Pharmacy Claims Travel Claims

Beneficiaries who are filing reimbursement claims for out-of-pocket expenses must include VA Form 10-7959e, Claim for Miscellaneous Expenses, along with other required documentation listed below.

VA Form 10-7959e, Claim for Miscellaneous Expenses

Claims Mailing Addresses:

BENEFICIARIES ONLY:
For pharmacy or self-file medical reimbursement

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

PROVIDERS ONLY:
Provide claims address to your medical provider

VHA Office of Integrated Veteran Care
ATTN: SB Claims
PO Box 30750, Tampa FL 33630-3750

Required Documentation for All Claims

Beneficiary/Patient Information:

Full name (as it appears on the SBHCBP
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
Provider tax identification number (TIN)
Remittance address

Inpatient Treatment Information

Medicare provider number (inpatient claims)
Principal diagnosis (ICD code and description)
All secondary diagnoses (ICD codes and descriptions)
All procedures performed (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
Administrative and/or Operation Report, and medical documentation to support treatment
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 must be included with prescription drug and medication claims submitted by the beneficiary.

Pharmacy receipt must include:

Date dispensed
Drug name
Strength and quantity

National Drug Code (NDC)
Name and address of pharmacy

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Required Documentation for Travel Claims

Billing statements
Signature of provider
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)
Receipts for all travel expenses (except mileage) for personally owned vehicles (POV)
Claims for personally owned vehicle (POV) mileage, to include:
- Certification of medical appointment
- Date of service
- Place of service

Other Health Insurance (OHI)

VA assumes full responsibility for the cost of services for Spina Bifida beneficiaries. We cover 100% of the VA-allowed amount, and are the exclusive payer to Medicare, Medicaid and any other health insurance.

Filing Deadlines

Claims must be filed with the VHA Office of Community Care no later than:

One year from the date of service
In the case of inpatient care, one year from the date of discharge

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 VHA OCC directly.

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.

Rejected Claims–Explanation of Codes

Community Care