CHAMPVA Claim Types and Filing a Claim

Filing a claim for CHAMPVA payments is usually smooth and painless.  Often the enrolled beneficiary does not even need to do the filing; the provider takes care of it.  However there are instances where you may have to do it yourself, such as when you had to pay upfront and are seeking reimbursement for the CHAMPVA share of its allowable amount.

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You can think of different types of CHAMPVA claims.  If you are a beneficiary, however, you normally don’t need to worry about this.  Exceptions are when your provider or a pharmacy you buy from won’t bill, or when you go to a provider abroad where, of course, CHAMPVA does not serve directly.

Beneficiary Claims

Normally, the patient or beneficiary who uses CHAMPVA does not need file a claim.  Instead, this is left to the provider.  If you do have to file the claim yourself, use VA Form 10-7959a: CHAMPVA Claim Form, which is for beneficiary use only.

When filing a CHAMPVA claim, the beneficiary, or his or her guardian or sponsor, must include details such as the provider’s name, address and tax info; procedure and diagnosis codes, dates of service and itemized charges; information about the beneficiary, etc.  If you have other health insurance that pays before CHAMPVA, you must also attach the appropriate Explanation of Benefits.

Under normal circumstances, you have up to one year to file a claim for any given service.

You can get a fillable Form 10-7959a online at the VA Health Administration Center website.

Provider Claims

Most providers should have no difficulty figuring out how to file a CHAMPVA claim.  It’s important to note that direct claim-filing means the provider agrees to accept CHAMPVA’s determined allowable amount as full payment for its charges.  The allowed amount is what CHAMPVA will pay plus what it decides the beneficiary must pay (unless beneficiary has other insurance that may impact, such as a CHAMPVA supplement).

A provider must include a standard itemized billing statement with medical does; details about the provider such as name and address; the EOB from other insurance; and medical records for some types of services which require this, such as physical therapy or skilled nursing services.

Do not use the VA Form 10-7959a as do beneficiaries.  See also CHAMPVA claims for providers.

Pharmacy Claims

If a beneficiary gets his or her prescription drugs via the SXC Health Solutions Network of pharmacies, the pharmacy will file the CHMPVA claim electronically– no need for you to fill out anything.  Any other retail pharmacy won’t do this, and you must do so on your own.

Foreign Claims

CHAMPVA will accept claims filed for overseas medical services.  Usually you will have to pay upfront in such cases, and then obtain repayment from the VA afterward.  The same restrictions and rules apply as for domestic claims.  However, the VA is more permissive as far as documentation goes when it comes to foreign claims.  Even without the standard itemized billing forms used in the United States, your claim(s) may still be processed if you submit other documents that provide the required information.

 

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This website, CHAMPVAbenefits.com, is NOT affiliated with the Department of Veterans Affairs or any part of the U.S. government. Please DO NOT send us information about yourself such as your SSN, name, address, etc. for help with CHAMPVA. Further, we cannot guarantee that the information here is accurate and up-to-date. To ensure you have the latest information, please visit the official CHAMPVA home page at http://www.va.gov/hac/forbeneficiaries/champva/champva.asp. Your use of this site means you agree to and understand this disclaimer. Thank you!

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