Attention A T users. To access the menus on this page please perform the following steps. 1. Please switch auto forms mode to off. 2. Hit enter to expand a main menu option (Health, Benefits, etc). 3. To enter and activate the submenu links, hit the down arrow. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links.

Community Care

Menu
Menu

Quick Links

Veterans Crisis Line Badge
My healthevet badge
EBenefits Badge
 

How to 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 ClaimsPharmacy ClaimsTravel 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 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)
  • 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 form 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
  • 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