Electronic Claims–Information for Providers
You are a valued provider for the Veterans Health Administration Office of Community Care (VHA OCC) and the programs we service at Station 741 in Denver, Colorado. We want to be sure we are sending you accurate and timely reimbursements for the services you provide to our beneficiaries. It is important that we have your most current and accurate information to make this possible.
National Provider Identifier (NPI)
The VHA OCC requires the use of the NPI on all inbound medical, dental and pharmacy transactions. If you are a HIPAA-covered health care provider who electronically bills for services to VA programs, or submits other electronic transactions through our clearinghouse, you need an NPI. NPIs that should be sent include, but are not limited to, rendering, referring, and prescribing NPIs.
More information on the use of NPIs can be found on the CMS NPI page.
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.).Paper to Electronic Claims Transition
Electronic Pharmacy Claims
The National Council for Prescription Drug Programs' Telecommunications Standards utilizes Version D.0, along with Medicaid Subrogation, Version 3.0, as of January 1, 2012. For information regarding changes to electronic pharmacy claim standards, please visit D.0 Resources on the Centers for Medicare & Medicaid Services website.
Also, visit our Pharmacy Benefits page for detailed information on family member pharmacy benefits for programs administered by OCC: CHAMPVA, Spina Bifida, and the Children of Women Vietnam Veterans programs.CMS D.0 Resources OCC Pharmacy Benefits
The VHA Office of Community Care accepts HIPAA-compliant 837 EDI health care claims through our clearinghouse, Change Healthcare (formerly Emdeon Inc.).
For all compliant EDI claims sent to us through Change Healthcare, we can provide an 835/Electronic Remittance Advice (ERA). An 835/ERA is not provided for paper claims submitted to OCC. At this time, we will continue to send a paper explanation of benefits (EOB) for all paper and EDI claims processed.
Providers must complete an enrollment form at Change Healthcare to receive OCC 835s. You should enroll to receive both regular network ERAs as well as ERAs created from claims that are received from Medicare crossover through the Coordination of Benefits Contractor. The form can be found on the Change Healthcare Enrollment Services website.
If you are interested in submitting claims through Change Healthcare, or if you need to change or cancel your enrollment, please contact Change Healthcare directly or visit their website.
If you are not connected to Change Healthcare, contact your EDI clearinghouse and have our payer IDs added to their software system.
EDI Claims for Community Medical Care
To register and/or submit an EDI claim for community medical care to your local VA health care facility, please use the following payer IDs:
• 12115 for medical claims/ERA
• 12116 for dental claims/ERA
• VAFEE for eligibility inquiry
VA now requires an authorization number for preapproved services to be submitted on all EDI and paper claim submissions. This additional claim data will allow for increased claim adjudication automation which will enable faster claims processing. Please begin adjusting processes/systems now as noncompliance after June 2019 will result in claim rejection.
(NOTE: This requirement does not pertain to VA family member programs, CHAMPVA and the Spina Bifida Healthcare Benefits Program.)
For EDI 837, please use the following information:
- Referral Number: Loop = 2300 | Segment = REF*9F | Position = REF02
- Prior Authorization: Loop = 2300 | Segment = REF*G1 | Position = REF02
EDI Claims for Family Member Programs
You must submit non-pharmacy claims and other EDI transactions through Change Healthcare for family member care programs administered by OCC: CHAMPVA, Spina Bifida and Children of Women Vietnam Veterans. Please remember that for all family member care programs administered by OCC, our beneficiary/your patient is always the subscriber. To ensure an accurate response to your claim or inquiry, please submit the patient's first and last name as it appears on the OCC program identification card, their member ID (SSN) and their date of birth for all transactions.
The OCC Change Healthcare (formerly Emdeon Inc.) payer ID number for family member care claims is:
- 84146 for medical claims/ERA
- 84147 for dental claims/ERA
Real-time Communications for Family Member Programs
For family member care programs, the VHA Office of Community Care provides real-time information through Change Healthcare for eligibility, benefits and claim verification. Our real-time payer ID at Change Healthcare is VAHAC.
- Health Care Claims Status (277–Health Care Claim Status Response)
- Health Care Services Review (278–Response to an EDI Health Care Services Request for Review)
- Eligibility Status (271–Health Care Eligibility Benefit Response)
We can respond with an acknowledgment that tells the requester if the patient is unknown or has active coverage for our programs. For patients with active coverage, our response would include:
- The dates of the most recent coverage
- Response to Service Type Code “30” or Explicit Service Type Inquiries
- Patient Responsibility for Individual and Family including deducible amounts, co-insurance amounts, and catastrophic cap amounts
Claims Payment Information
Provider Payment Information
Information on claims payment including details about payment via Electronic Funds Transfer.
How to File a Claim–Instructions for Providers
Details about the information and documentation needed when filing paper claims, including helpful claim-filing hints. You will also find information for CHAMPVA claims filing and authorization requirements.
A list of the top 10 reasons claims are rejected/denied along with additional explanations for the rejection codes and what needs to be done to get the claim processed correctly.