CHAMPVA EOB Sample

Whenever CHAMPVA processes a claim for a beneficiary, he or she will receive an explanation of the process known as an Explanation of Benefits or EOB.  Understanding your EOB is important, so you know what payments are being made to whom and what you may owe.

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Below is a sample CHAMPVA EOB.

SCAN0002

This form includes information such as:

  • CHAMPVA claims address where to send appeals, etc.
  • Patient name
  • Member ID number written as “Patient SSN” (not shown for security)
  • Individual, family deductible and catastrophic cap accruals
  • Provider name
  • Dates of service
  • Standard codes to identify service
  • Remark codes to explain claim decision
  • Amount billed by the provider
  • Amount allowed by CHAMPVA
  • Amount not covered by CHAMPVA
  • Payment issued by HAC (VA Health Administration Center, which administers CHAMPVA)
  • Payment by OHI (other health insurance)
  • Member’s cost share (OHI may impact)
  • Form number and version date
  • Information about your appeal rights, etc.

If you have a CHAMPVA supplement, you or your provider must attach the CHAMPVA EOB to your claims.  Without it, the supplement won’t be able to determine its liability.

When appealing a decision, you should also attach the EOB along with your correspondence.

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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…. The pharmacy network for CHAMPVA now is Catamaran (formerly SXC)…. 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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