Attention A T users. To access the menus on this page please perform the following steps. 1. Please switch auto forms mode to off. 2. Hit enter to expand a main menu option (Health, Benefits, etc). 3. To enter and activate the submenu links, hit the down arrow. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links.

Community Care

Menu
Menu

Quick Links

Veterans Crisis Line Badge
My healthevet badge
EBenefits Badge
 

Rejected Claims–Explanation of Codes

icon medalVA classifies all processed claims as accepted, denied, or rejected.

  • VA accepts correctly billed claims for care that has been pre-authorized by VA and providers will receive prompt payment for that care.
  • VA denies claims when the care was not preauthorized, and the Veteran does not meet eligibility requirements for emergency care.
  • VA rejects claims that cannot be paid or denied due to billing errors or the need for additional information. You can resubmit a rejected claim once errors have been corrected or additional information is available and provided.

If you need additional information beyond what is supplied on the Preliminary Fee Remittance Advice Report (PFRAR) or available in the Customer Engagement Portal (CEP), please contact the designated customer service support for the unit that adjudicated your claim. That unit will be able to provide clear guidance on the steps you need to take for VA to reprocess your claims.

To learn more about reimbursment for providing care to Veterans and their family members, please visit Provider Payments.

Rejections During the Electronic Conversion Process

VA requires all paper claims to be converted to 837 electronic submissions. When VA receives a paper claim, it is reviewed for errors twice: once during electronic conversion and again during claims processing. During the conversion process, if a claim has been found non-compliant with standardized billing requirements, the claim will be rejected until the error is corrected. If an error is identified during this scan, the provider will receive a letter from VA with information about the error and reason for rejection.

Top 10 Rejection Reasons for Veteran Care

The following are the most common reasons HCFA and UB paper claims for Veteran care are rejected:

Top reasons for HCFA/CMS-1500 rejections
Top Reasons for HCFA/CMS-1500 Rejections
RankCodeReason/Detail

1

016

Missing/Incomplete/Invalid Insured ID
Requires a numeric character entry (SSN) with no alpha, punctuation, or special characters. Must be nine (9) numeric characters –no exceptions.

2

086

Missing Insurance Plan Name or Program Name

3

092

Missing/Invalid Admission Date for POS 21 Refer to Box 18

4

088

Invalid Service Facility Address. Must be a valid street address.

5

005

Missing NDC Units

6

002

Claim contains one or more missing/incomplete/invalid/inappropriate Place of Service codes

7

081

Invalid Rendering NPI

8

034

Claim contains ICD9 Principal Dx code
ICD 10 codes must be used for DOS after 09/30/2015.

9

105

Invalid Service line Provider Taxonomy code

10

004

Invalid/Incomplete CPT/HCPCS codes

Top reasons for UB/CMS-1450 rejections
Top Reasons for UB/CMS-1450 Rejections
RankCodeReason/Detail

1

016

Missing/Incomplete/Invalid Insured ID
Requires a numeric character entry (SSN) with no alpha, punctuation, or special characters. Must be nine (9) numeric characters –no exceptions.

2

125

The outpatient claim has a missing Admission Type code

3

097

Missing Admission Type when Admission Date is Present

4

108

Referring and Attending Physician NPI are equal

5

007

This claim contains a missing/incomplete/invalid Billing Provider Address

6

013

Claim contains missing or invalid Patient Status

7

034

Claim contains ICD9 Principal Dx code
ICD 10 codes must be used for DOS after 09/30/2015.

8

031

Claim contains invalid or missing Patient Reason diagnosis code

9

021

Missing Patient Account Number

10

117

Invalid Type of Bill code

Top 10 Rejection Reasons for Family Member Care

The top 10 reasons claims for family member programs (like CHAMPVA) are rejected during claims processing are listed below, along with additional explanations of the denial codes and what providers need to do to get the claim corrected.

More information about filing accurate claims for CHAMPVA can be found on Helpful Hints: CHAMPVA Claim Filing for Providers.

If the denial code you’re looking for is not listed below, you can contact VA by using the Inquiry Routing & Information System (IRIS), a tool that allows secure email communications, or you can call our Customer Call Center at one of the numbers listed below.

Top 10 Reasons Family Member Program Claims are Rejected or Denied
Top 10 Reasons Family Member Program Claims are Rejected or Denied
RankCodeReason/Detail

1

65/159/177

Duplicate claim – Previously processed

Our payment system determined that this claim is an exact match of a claim that we previously processed. Our claim number for the duplicate claim should be shown in the comment at the bottom of our EOB. If you do not believe that this is correct, you will need to contact the Customer Call Center and speak to a customer service representative to resolve this issue.

IMPORTANT NOTE: Do not resubmit this claim without contacting us as it will only result in another denial.

2

78

EOB from other insurance required – VHA OCC secondary payer

We need to see the explanation of benefits (EOB) generated by the primary health plan before we can process this request. Our files indicate the patient is enrolled in a health insurance plan that, by law, must process this request prior to the VHA OCC program. Please resubmit this request with the EOB from the primary plan and include a copy of the VHA OCC EOB, or have the patient contact us to update their other health insurance (OHI) status. We can accept OHI updates through the Customer Call Center.

3

124

Claim not timely filed. (See applicable VHA OCC program guide.)

A beneficiary or health care provider must file claims for current treatment within 365 days from the date of service. Upon initial enrollment into the plan, we grant a 180‑day grace period for the enrollee to file any applicable claims that were more than 365 days old. Based on the date this claim arrived at our mail room, it did not meet these requirements. You may submit a written appeal if you were unable to file the claims due to exceptional circumstances. Send your written appeal to:

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

NOTE: Do not send your written appeal to the claims processing address as this will only delay your appeal.

4

278

Multiple primary insurance coverage. Please resubmit EOBs from each payer

A secondary review in our claims payment area determined that this claim or service is an exact match of a claim or service we previously processed. If this is an exact match of a previous claim, the matching VHA OCC claim number will be shown in the comments at the end of the explanation of benefits (EOB). If you do not believe this is correct, you will need to contact the Customer Call Center and speak to a customer service representative to resolve this issue.

IMPORTANT NOTE: Do not resubmit this claim without contacting us as it will only result in another denial.

5

148

Claim denied – Chiropractic services not covered

If you do not believe this is correct, you will need to contact the Customer Call Center and speak to a customer service representative to resolve this issue.

IMPORTANT NOTE: Do not resubmit this claim without contacting us as it will only result in another denial.

6

137

Beneficiary not eligible on date of service claimed

This claim is for a date of service or period of hospitalization that is not covered under the VHA OCC health benefits plan. Please consult the period of eligibility listed on the member card and check the date of service, or period of admission, in your records. If the bill was submitted with an incorrect date, please send a corrected bill. If the service or admission date is correct, then we cannot pay the claim since the patient was not covered by our plan at that time.

7

224

Must provide medical history/documentation to support treatment

Please resubmit the claim for reconsideration, and include a copy of the VHA OCC explanation of benefits (EOB) form. If you have questions, please contact the Customer Call Center.

8

218/220

Clarification of OHI information required. Certification sent to beneficiary.

We do not have an Other Health Insurance (OHI) Certification on file for the patient/beneficiary. We cannot process any claims until we know if the individual is covered by another health plan. Even if the individual has no OHI coverage, we still need them to attest to this fact. Please submit a CHAMPVA OHI Certificate, VA Form 10-7959c, or call the Customer Service Center and a customer service representative can help complete the certification over the phone.

CHAMPVA OHI Certificate, VA Form 10-7959c

9

27

Not a covered service and/or benefit for diagnosis listed

Some services/procedures are only covered for specific conditions as outlined in the applicable VHA OCC policy manual. Services which do meet these conditions will be denied. You can access all VHA OCC policy manuals from our Publications page. There is a search function within each policy manual to help you to quickly locate the section of our policy that covers this request.

VHA OCC Publications

10

391

ICD diagnostic code(s) missing/unreadable/ invalid. Resubmit with EOB form

A diagnosis is required to determine if the service denied on this claim is covered under the applicable VHA OCC health benefits program. We were unable to pay this claim due to a missing/unreadable/or invalid ICD code. Please check the accuracy and readability of the claim and resubmit it with a copy of the VHA OCC Explanation of Benefits form for reconsideration.

Contact Us

Inquiry Routing & Information System (IRIS)

Claims and Adjudication Team Contacts

Customer Call Centers

CHAMPVA: 800-733-8387
8:05 a.m. – 6:45 p.m., Eastern Standard Time

Spina Bifida/Children of Women Vietnam Veterans programs: 888-820-1756
8:00 a.m. – 7:00 p.m., Eastern Standard Time

Mailing Addresses for Family Member Claims:

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

VHA Office of Community Care
ATTN: Resubmissions
PO Box 469063
Denver, CO 80246