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VHA Office of Community Care

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How to File a Claim–Instructions for Providers

Paper Claims | Electronic Claims | Where to Mail Claims | Pharmacy Claims
Claims Payment Information | Claims Filing Requirements for CHAMPVA
 

For the PC3/Choice programs administered by VA contractors (Health Net and TriWest), claims are submitted to and paid by the contactors. You can find specific instructions and contact information on the Health Net Claims Submission for Providers and in the TriWest Claims and Reimbursement Quick Reference Guide. For programs that file claims directly with VA, instructions and helpful information are listed below.

Paper Claims

We accept paper claims, but the turnaround time to payment is, on average, an additional 20 days. Claims submitted by the provider must include an itemized billing statement. This can be submitted on a CMS-1500 form or UB-04 form. The following information must be provided:

  • Full name, address, NPI and tax ID number of the provider
  • Address where payment is to be sent
  • Address where services were provided
  • Provider professional status (doctor, nurse, physician assistant, etc.)
  • Specific date of each service provided. Date ranges are acceptable only when they match the number/units of services
  • Itemized charges for each service
  • Appropriate code (ICD-10, CPT, HCPCS) for each service

If other health insurance was billed, provide a copy of their explanation of benefits (EOB) detailing what they paid. Please include a copy of the reverse side of the EOB if the definition/explanation of their codes is listed on the back.

Medical records or notes must be submitted with the bill in some cases, such as skilled nursing, home health, physical therapy, specialized testing and some surgical procedures.

For more information about how to file paper claims, read our Helpful Claim Filing Hints for Providers.

More information on the use of National Provider Identifiers (NPI) can be found at CMS NPI of the Centers for Medicare & Medicaid Services website.

Where to Mail Claims

Claims contact information for specific VHA Office of Community Care programs can be found on Contact Us.

Electronic Claims

The Veterans Health Administration Office of Community Care (OCC) began accepting HIPAA-compliant electronic 837 Institutional, Professional and Dental claims on October 16, 2003. Using this service, doctors, dentists, hospitals and other medical service providers can cut claims processing time by weeks. You must submit electronic claims through our clearinghouse, Change Healthcare (formerly Emdeon Inc.).

For more information on filing electronic claims, visit Electronic Claims Information.

Pharmacy Claims

When submitting pharmacy claims on paper, an invoice/billing statement that includes the following information is required for us to process the claim:

  • Name, address, and phone number of the pharmacy
  • Name of prescribing physician
  • Name, strength, quantity for each drug
  • National Drug Code (NDC) for each drug
  • Charge for each drug
  • Date prescription was filled

Electronic pharmacy claims should be submitted through OptumRx (formerly Catamaran). The claims should be submitted using the following information:

BIN: 610593  |  PCN: VA  |  GROUP: HAC 

Pharmacy Contact Information

OptumRx (formerly Catamaran) Contacts

OptumRX beneficiary
help desk:
1-888-546-5502
If a beneficiary, or authorized representative, needs assistance from OptumRx, please call this number. This is also the number to contact to order a pharmacy card..
OptumRx pharmacy
help desk:
1-888-546-5503
Pharmacists who have questions or need assistance from OptumRx should use this number.
OptumRx website: https://vahac.rxportal.sxc.com/rxclaim/VAH/index.html
 

Claim Filing Requirements for CHAMPVA

By law, CHAMPVA is always the secondary payer except to Medicaid, Indian Health Services, State Victims of Crime Compensation, and supplemental CHAMPVA policies. If the patient has Other Health Insurance (OHI) coverage, the OHI should be billed first. A claim can then be sent to CHAMPVA, with the Explanation of Benefits (EOB) from the other insurer.

CHAMPVA Pre-authorization Requirement

The only pre-authorization requirements for CHAMPVA are for:

  • Organ and bone marrow transplants
  • Dental care
  • DME worth more than $2000, and
  • Most mental health or substance abuse services

Additionally, some payments are made based on specific clinical guidelines. Two common examples are breast reduction and weight reduction surgical procedures. Please be sure to check the CHAMPVA Guide for a complete listing of pre-authorization services and supplies.

CHAMPVA Claims and Eligibility Status

You can check the eligibility status of a CHAMPVA beneficiary or the status of a claim payment 24 hours-a-day through our Interactive Voice Recognition (IVR) system. To access this feature, call 1-800-733-8387 and respond to the voice prompts. Please have the beneficiary's Social Security number and your tax ID number available when calling.

Visit CHAMPVA–Information for Providers for more information about the CHAMPVA program.

Claims Payment Information

For information on claims payment, or if you would like details about payment via Electronic Funds Transfer, please visit Claims Payment Information.

View the Rejected Claims page for a list of the top 10 reasons claims are rejected/denied along with additional explanations of the rejection codes and what a beneficiary/provider needs to do to get the claim processed correctly.

Provider Resources

Our Provider Resources contain more information and tools regarding how to conduct business with the VHA Office of Community Care and the programs it administers.