How to Appeal a Denied CHAMPVA Claim

Sometimes a CHAMPVA claim doesn’t turn out as desired.  If you file a claim and it gets denied, you may be able to ask for reconsideration.  Be aware that not all denied claims can be appealed, however.  Those that can must be appealed within a limited time frame.

Advertisement

End of Advertisement


Denied Claims That Can Be Appealed

CHAMPVA will review only appeals that pertain to the following:

  • Decisions on your CHAMPVA eligibility
  • Requests for preauthorization (e.g. for Durable Medical Equipment, dental care, etc.)
  • Covered benefits and services
  • Mental health (second level only; first level are made by VA”s mental health contractor)

Note that if you disagree with the disability status given you by the VA, do not submit your appeal to CHAMPVA.  Instead, send it to your local VARO (see further down this page).

Denied Claims That Cannot Be Appealed

CHAMPVA will not consider appeals about any of the following:

  • Your annual deductible, whether family or individual
  • CHAMPVA’s determined allowable amount based on its payment system or methodology
  • Excluded or non-covered benefits
  • Providers who have been excluded/sanctioned due to fraud, abuse, lack of proper credentials, etc. (Exception is if you are the provider or their authorized representative, and then the appeal should go to the Office of the Inspector General or the Department of Health and Human Services.)
  • Claims that are passed the deadline for appeals (one year from date of denial for first-level appeals, 90 days for second-level appeals)

Also, if you appeal a claim but don’t give a reason why, CHAMPVA will return your appeal to you with nothing done with the claim.

Who Can Submit an Appeal

The CHAMPVA Policy Manual states that these can file an appeal:

  • The beneficiary
  • The beneficiary’s legal guardian
  • The beneficiary’s representative
  • A provider

How to Appeal a Denied CHAMPVA Claim

To file an appeal:

  1. Submit the appeal within one year from the date you received your letter of denial (if it’s for eligibility), or one year from the date of the EOB (Explanation of Benefits) if it’s a denial of benefit or service coverage.
  2. Write a cover letter explaining why you disagree with the decision.
  3. Attach the relevant letter of denial or EOB.
  4. Attach evidence that can support your appeal and which was not considered before.
  5. Send the appeal to the CHAMPVA office.

The current CHAMPVA mailing address for appeals is:

VA Health Administration Center
CHAMPVA ATTN: Appeals
PO Box 460948
Denver CO 80246-0948

Note: To get the latest address information, contact CHAMPVA or call their toll-free number at 1-800-733-8387.

What Happens After You Appeal

If your claim can be appealed at all, CHAMPVA will review your case and send you its decision in writing.  If you still disagree, you can ask for another review within 90 days of the first one.

Should CHAMPVA deny your claim on the second review, it is final.  Known as second level reviews, these cannot be appealed.

Claims with Missing or Incorrect Information

CHAMPVA claims that are missing or have incorrect data need no formal review.  Instead, the VA will reprocess them once you have sent the corrected or missing information.  Examples are:

  • Claims with missing codes (e.g. National Drug Codes for medicine, type of service codes)
  • Claims that are missing required evidence such as a certificate of diagnosis, medical necessity certificate, reports, etc.
  • Claims that require an Explanation of Benefits (EOB) from another health insurer that pays prior to CHAMPVA (e.g. Medicare or a private health insurance plan)
  • Miscellaneous billing errors or omissions

If you file such a claim as above and CHAMPVA tells you that there is missing information or paperwork, don’t panic. It doesn’t necessarily mean the claim will be denied.  Submit the corrected and missing documents as instructed.  Then the VA can make a decision on your claim.

Appealing a VA Disability Rating

If you get denied CHAMPVA benefits because you lack the required VA disability status, do not file an appeal with CHAMPVA or the VA Health Administration Center.

Instead, appeals regarding your VA rating should go to your VA Regional Office or VARO.  It is the VARO servicing your area that determines your disability status, not CHAMPVA.

Advertisement

End of Advertisement


email

Comments are closed.