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How to File a Claim–Instructions for Providers

 

For the Patient-Centered Community Care (PC3) network and Veterans Choice Program administered by VA contractors (Health Net and TriWest), claims are submitted to and paid by the contractors. You can find specific instructions and contact information on the Health Net Claims Submission for Providers website 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.

Health Net Claims Submission for Providers

TriWest Claims and Reimbursement Quick Reference Guide

icon stethoscope and dollar sign on claim form

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, National Provider Identifier (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.

Where to Mail Paper Claims

For community care provided to a Veteran, refer to the claim filing instructions that were included in the authorization document you received to provide the care.

For other Veterans Health Administration (VHA) Office of Community Care (OCC) programs, see the Contact Us page which includes contact information and mailing addresses for:

  • Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
  • Children of Women Vietnam Veterans Health Care Benefits Program (CWVV)
  • Foreign Medical Program (FMP)
  • Indian Health Services/Tribal Health Reimbursement Agreements Program
  • Spina Bifida Health Care Benefits Program
  • State Home Per Diem Program
Contact Information and Mailing Addresses

Electronic Claims

The VHA 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.).

Electronic Claims InformationPaper to Electronic Claims Transition

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, and 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

 

OptumRx Pharmacy Contacts

OptumRX beneficiary help desk:
888-546-5502
If a beneficiary or authorized representative needs assistance from OptumRx, please call this number. This is also the number to call to order a pharmacy card.

OptumRx pharmacy help desk:
888-546-5503
This number is for pharmacists who have questions or need assistance from OptumRx.

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 Preauthorization Requirement

The only preauthorization 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 check the CHAMPVA Guide for a complete listing of preauthorization 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. Please have the beneficiary's Social Security number and your tax ID number available when calling.

Interactive Voice Recognition System: 800-733-8387

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