Community Care

If you do not agree with a VA decision related to care you provided under a family member care program, you may request further review. This page explains the decision review and appeal options available to providers and how to submit a request.

Programs covered on this page

This page applies to providers seeking decision reviews or appeals related to the following programs:

• Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
• Foreign Medical Program
• Spina Bifida Health Care Benefits Program
• Children of Women Vietnam Veterans Health Care Benefits Program
• Camp Lejeune Family Member Health Care Benefits Program

VA Form 20-0998, Your Right to Seek Review Our Decision, explains your decision review rights and outlines the available review options.

VA Form 20-0998, Your Right to Seek Review of Our Decision

Requests that Do Not Require a Decision Review or Appeal

You do not need to request a decision review or appeal to:

• Submit missing documentation
• Provide Other Health Insurance (OHI) Explanation of Benefits (EOB)
• Submit proof of payment

Learn how to file a family member care claim as a provider.

Decision Review and Appeal Options of Medical Claims and Eligibility

There are multiple options available to providers who do not agree with a payment decision. You may pursue only one review option at a time.

You may not request a higher-level review of a Higher-Level Review Decision, or request a higher-level review of a Board Decision.

Supplemental Claim

If you disagree with the payment decision or eligibility determination and have new and relevant evidence to submit or want to request a review of your claim based on a change in law, a supplemental claim may be an option for you with both of the following:

• New evidence is information that hasn’t been considered before.
• Relevant evidence is information that proves or disproves something in your claim.

Unless your supplemental claim is based on a change in law, you will need to submit supporting evidence that is new and relevant for your request to be complete.

VA Form 20-0995, Decision Review Request: Supplemental Claim

Higher-Level Review

If you disagree with a VA payment decision or eligibility determination, you can request a new review of VA’s decision by a higher-level reviewer. The reviewer will determine whether an error or a difference of interpretation changes the claims processing decision. New evidence will not be considered with a Higher-Level Review.

VA Form 20-0996, Decision Review Request: Higher-Level Review

Appeal to the Board of Veterans’ Appeals

When you choose this option, you’re appealing to a Veterans Law Judge at the Board of Veterans’ Appeals. For more information, please visit the VA Board Appeals webpage.

Board Appeals | Veterans Affairs (va.gov)

Decision Review or Board Appeal Submission

Use the information below to submit your appeal or decision review.

Clinical Appeals of Preauthorizations

Clinical appeals apply to preauthorization determinations for services that have not yet occurred. The process below explains how to submit a clinical appeal.

If you disagree with a VA determination regarding preauthorization of covered services or supplies, submit your clinical appeal in writing and include:

• An explanation of why you believe the decision is in error
• Any new and relevant information not previously considered

If you disagree with the outcome of the first-level review, you may submit a written request for a second-level clinical review. Submit all first-level and second-level clinical appeals in writing to:

VFMP Appeals
P.O. Box 600
Spring City, PA 19475

NOTE: Retroactive preauthorization requests for services that have already occurred follow the process in the Decision Review and Appeal section above.