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File a Claim for Family Member Care

There are four different VA family member health care programs, each with slightly different claim filing requirements and processes, and one pharmacy benefits program. VA family member programs include:

  • Civilian Health and Medical Program of Veterans Affairs (CHAMPVA)
  • Camp LeJeune Family Member Program (CLFMP)
  • Children of Women Vietnam Veterans (CWVV) Health Benefits Program
  • Spina Bifida Health Care Benefits Program (SBHCBP)
  • Pharmacy benefits for CHAMPVA, CWVV and SBHCBP

Claims Submissions

To submit a CHAMPVA, CLFMP, CWVV or SBHCP claim, you must use a standard billing form to provide the required information–UB-04 Uniform Bill (CMS 1450) or Centers for Medicare and Medicaid Services-Health Insurance Claim Form (CMS 1500). Electronic pharmacy claims should be submitted through OptumRx. Review the program information below for details on how to file a claim with us for reimbursement.

Uniform Bill-04 (UB-04)CMS-1500 (CMS 1500)

IMPORTANT: While we accept paper claims, processing time is 20 days longer on average. Please file your claim electronically for prompt processing and payment.

Civilian Health and Medical Program of Veterans Affairs (CHAMPVA)

Eligibility and Claims Status

You can check on the eligibility status of a CHAMPVA beneficiary or the status of a claim 24/7 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

CHAMPVA Preauthorization

Preauthorization is required for the following services:

  • Organ and bone marrow transplants
  • Dental care
  • Durable Medical Equipment (DME) worth more than $2000
  • Most mental health or substance abuse services

Please check the CHAMPVA Guide for a complete listing of preauthorization services and supplies.

CHAMPVA Guide

Claim Filing Requirements

  • 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.
  • The Explanation of Benefits (EOB) from the OHI should be submitted to CHAMPVA with the claim for reimbursement. By law, CHAMPVA is always the last payer.

Electronic Claims
To file electronically, send a HIPAA-compliant 837 electronic data interchange (EDI) health care claim through our clearinghouse, Change Healthcare.

To ensure accuracy, please include the following information when submitting CHAMPVA claims:

  • VA beneficiary (your patient) is always the subscriber
  • Patient’s first and last name as it appears on the VA program identification card
  • Member ID (Social Security Number)
  • Patient’s date of birth
  • Payer ID numbers:
    • 84146 for medical claims/ERA
    • 84147 for dental claims/ERA

Paper Claims
We encourage you to submit claims electronically for CHAMPVA. We do accept paper claims, but the processing time is 20 days longer on average.

Send paper claims to:

VHA Office of Community Care
ATTN: CHAMPVA Claims
PO Box 30750
Tampa, FL 33630-3750

Payment Limitations

Some payments are made based on specific clinical guidelines. Two common examples are breast reduction and weight reduction surgical procedures. For more information, visit CHAMPVA–Information for Providers.

CHAMPVA–Information for Providers

CHAMPVA Contacts

Customer Call Center: 800-733-8387
Monday–Friday 8:05 a.m. to 7:30 p.m. Eastern Time (ET)

Veterans Health Administration
ATTN: CHAMPVA
P.O. Bo 469063
Denver, CO 80246-9063

Camp LeJeune Family Member Program (CLFMP)

CLFMP covers treatment costs for one or more of the 15 conditions listed in the Honoring America’s Veterans and Caring for Camp LeJeune Families Act of 2012. We also reimburse qualified family members as the last payer of medical claims for these 15 conditions. For information, review the CLFMP–Information for Providers fact sheet.

Fact Sheet: CLFMP–Information for Providers

Claim Filing Requirements

Electronic Claims
CLFMP accepts electronically submitted 837 claim transactions including 837 Institutional, 837 Professional, and 837 Dental transactions. Transactions are accepted from providers for medical services and supplies provided in the United States, a U.S. Commonwealth, or U.S. territories.

You must submit electronic claims through VA’s clearinghouse, SSI Claimsnet. Registration can be completed online. For questions about the electronic claims process, contact SSI Claimsnet.

Payer ID numbers are:

  • CLFM1 for medical claims
  • 276 / 270 for medical claims status and eligibility status

CLFMP Contacts

CLFMP Customer Service:
866-372-1144

Fax: 512-460-5536

VHA Customer Service:
877-222-8387

SSI Claimsnet Customer Service: 800-356-0092

SSI Claimsnet Provider Registration

CLFMP Resources

CLFMP website

Apply for benefits online

Paper Claims
We encourage you to submit claims electronically for CLFMP. We do accept paper claims, but the processing time is 20 days longer on average.

Send paper claims to:

U.S. Department of Veterans Affairs
Financial Services Center
P.O. Box 149200
Austin, TX 78714-9200

PLEASE NOTE: If the family member has Other Health Insurance (OHI), the OHI must be billed first. The explanation of benefits from the OHI should be submitted to CLFMP with the claim for reimbursement. By law, CLFMP is always the last payer.

Children of Women Vietnam Veterans Health Benefits Program (CWVV)

For CWVV claims, the determined allowable amount for payment is considered payment-in-full. A provider may not bill the beneficiary for the difference between the billed amount and the VA-determined allowed amount.

Claim Filing Requirements

Electronic Claims
VA accepts HIPAA-compliant 837 EDI CWVV health care claims through our clearinghouse, Change Healthcare. To ensure accuracy, please include the following information when submitting CWVV claims:

  • Our beneficiary (your patient) is always the subscriber
  • Patient’s first and last name as it appears on the VA program identification card
  • Member ID (Social Security Number)
  • Patient’s date of birth
  • Payer ID numbers are:
    • 84146 for medical claims/ERA
    • 84147 for dental claims/ERA Paper

Paper Claims
VA encourages providers to submit claims electronically for CWVV. However, we do accept paper claims. Send paper claims to:

VHA Office of Community Care
ATTN: CWVV Health Care Benefits Program
P.O. Box 469065
Denver, CO 80246-9065

CWVV Contact

Customer Service:
888-820-1756
8:05 a.m.–6:45 p.m., Monday–Friday
Eastern Time (ET)

Spina Bifida Health Care Benefits Program (SBHCBP)

You must be properly licensed in your state and must not be on the Medicare exclusion list to participate in this program. Additionally, you must accept the VA-determined allowable amount for care.

To ensure that a claim is processed quickly and accurately, please review the How to File a Claim for the Spina Bifida Health Care Benefits Program webpage. For more information on the Spina Bifida Health Care Benefits Program, including claims and payments, please visit Spina Bifida Health Care Benefits–Information for Providers.

How to File a Claim for the SBHCBPSpina Bifida Health Care Benefits–Information for Providers

Claim Filing Requirements

Electronic Claims
VA accepts HIPAA-compliant 837 EDI Spina Bifida health care claims through our clearinghouse, Change Healthcare. To ensure accuracy, please include the following information when submitting Spina Bifida claims:

  • Our beneficiary (your patient) is always the subscriber
  • Patient’s first and last name as it appears on the OCC program identification card
  • Member ID (Social Security Number)
  • Patient’s date of birth
  • Payer ID numbers are:
    • 84146 for medical claims/ERA
    • 84147 for dental claims/ERA

Paper Claims
VA encourages providers to submit claims electronically for Spina Bifida. However, we do accept paper claims, but the processing time is 20 days longer on average.

Send paper claims to:

VHA Office of Community Care
ATTN: Spina Bifida Health Care Benefits Program
P.O. Box 469065
Denver, CO 80246-9065

Spina Bifida Health Care Benefits Enrollment Status

You can check on the eligibility status of a Spina Bifida beneficiary or the status of payment for a claim 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: 888-820-1756

SBHCBP Contacts

VHA Office of Community Care
Spina Bifida Health Care Benefits Program
P.O. Bo 469065
Denver, CO 80246-9065

Customer Call Center: 888-820-1756
Monday–Friday, 8:05 a.m. to 6:45 p.m.
Eastern Time (ET)

Pharmacy Benefits

Family members who receive care through the CHAMPVA program, the Children of Women Vietnam Veterans program, or the Spina Bifida Health Care Benefits Program can access pharmacy benefits through the Meds by Mail program, or by visiting a pharmacy in the OptumRx network.

If you are currently participating in the OptumRx Premier Network, you are eligible to provide services to VA beneficiaries. If you are not currently participating, contact OptumRx Provider Helpdesk for contracting information.

Claim Filing Requirements

Electronic Claims
Electronic pharmacy claims should be submitted through OptumRx. The claims should be submitted using the following information:

OptumRX Contacts

OptumRx Pharmacy Helpdesk:
888-546-5503

OptumRx website

Resources

Pharmacy Benefits

BIN: 610593 | PCN: VA | GROUP: HAC

Please use the beneficiary’s Social Security Number (SSN) for the NCPDP Cardholder ID (302/C2). For security and privacy reasons, OptumRx will not provide a beneficiary’s SSN to anyone.

All compliant pharmacy claims will automatically be sent electronically to OptumRx. Please contact OptumRx if you have questions or need assistance submitting your claim.

Right to Request Reconsideration

You have the right to request reconsideration. A written statement explaining your disagreement must be received within one year from the date of notification. Please attach any pertinent documentation to support your claim and include a copy of the notification with your request.

VHA Office of Community Care
ATTN: Appeals
PO Box 460948
Denver, CO 80246

For immediate questions or concerns, contact the
VA Customer Call Center: 800-733-8387
Monday–Friday, 8:05 a.m.–7:30 p.m. Eastern Time

Clearinghouses

File claims electronically using an 837 claim and 835 supporting documentation submission. You are encouraged to use Change Healthcare or another clearinghouse of your choice.

Change Healthcare

Change Healthcare is the Claims Clearinghouse that CHAMPVA, the Spina Bifida Health Care Benefits Program and the Children of Women Vietnam Veterans (CWVV) Health Care Benefits Program use for providers to submit their claims electronically to VA for payment.

Electronic 837 claim and 835 supporting documentation submissions can be completed through Change Healthcare.

Enroll in Change Healthcare by visiting Change Healthcare Enrollment Services. If you need to change or cancel your enrollment, contact Change Healthcare.

EDI Referral/Authorization Annotation Information

Change Healthcare Contacts

888-545-6127

Change Healthcare website

Change Healthcare Enrollment Services

When submitting claims:

  • Include a National Provider Identifier (NPI) on all inbound medical, dental, and pharmacy transactions. NPIs that should be sent include rendering, referring, and prescribing NPIs. For more information about NPIs, please visit National Plan and Provider Enumeration System (NPPES) website.

    National Plan and Provider Enumeration System (NPPES)
  • 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 claim submissions. At this time, we continue to send a paper explanation of benefits (EOB) for all paper and EDI claims processed. Complete an enrollment form on the Change Healthcare Enrollment Services website to receive OCC 835s.

For family member care programs, VA 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:
    • 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