CHAMPVA Information for Providers

Not all providers are familiar with the CHAMPVA health coverage.  Many mistake it for TRICARE or expect it to follow the same procedures as TRICARE.  It’s important to realize that the two are not the same.  CHAMPVA has its own rules and requirements.

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What is CHAMPVA?  Are CHAMPVA and TRICARE the same?

CHAMPVA or Civilian Health and Medical Program of the Veterans Affairs is a health coverage program for beneficiaries of certain disabled veterans.  It is administered by the VA Health Administration Center and has nothing to do with TRICARE, which is a regionally managed program under the Department of Defense.  One cannot be eligible for both programs; if a person becomes eligible for TRICARE, they cannot also have CHAMPVA. However CHAMPVA coverage is similar to TRICARE Standard.

How do I become a CHAMPVA provider?  Do I need to sign a contract?

No, the VA does not have contract agreements with providers, nor does it keep a directory of these providers.

However make sure you are:

  1. Licensed to practice in your health care field in your state
  2. Not in the Medicare exclusion list

How much does CHAMPVA pay?

CHAMPVA pays 75% of its allowable amount under normal circumstances, or up to 100% of the allowable if the beneficiary has met the catastrophic cap for the year.

CHAMPVA usually pays the same as TRICARE and Medicare.

Does CHAMPVA have a patient cost share?

Yes, usually 25% of the allowable rate unless he or she has other health insurance.

Does CHAMPVA need prior authorization?

Yes, for some services and supplies such as Durable Medical Equipment (DME) if the rental or purchase price exceeds $2,000, hospice services and dental services.  For information, please see CHAMPVA preauthorization.

Will I have to accept the CHAMPVA allowable amount?

Yes, you will. The only exception is if a patient/beneficiary is informed prior to receiving service that you don’t accept CHAMPVA and that they could be responsible for paying the entire bill, and they agree to be treated anyway.

What if the patient has other health insurance?

In most cases, the other health insurance must be billed first, such as if it’s Medicare or a private health coverage plan. Exceptions are Medicaid, State Victims of Crime Compensation Programs, Indian Health Services and a CHAMPVA supplemental insurance.  You then submit the OHI’s Explanation of Benefits (EOB) along with your claim to CHAMPVA.

If the patient has Medicare besides CHAMPVA, Medicare will automatically forward claims to the VA if the VA has the patient’s Medicare health insurance claim number.

If the patient has a CHAMPVA supplement, either you or the patient must file a claim there after CHAMPVA processes a claim.The VA has no agreement with CHAMPVA supplement insurers to forward claims to them.

How do I verify CHAMPVA eligibility?

Every CHAMPVA beneficiary receives an authorization card with his or her name and coverage period printed on the card. If you wish to check eligibility and coverage by phone, you may contact the VA Health Administration Center. 

When inquiring about the beneficiary’s account, use that person’s Social Security Number.  Do not use the veteran sponsor’s or anyone else’s SSN, even if it is a child.

How do I file a CHAMPVA claim?

For faster processing, you can electronically file 837 claim transactions (institutional, dental and professional).  Claims are accepted anywhere within the United States, the U.S. Commonwealth and any of its territories.

To submit an electronic claim, send to Emdeon™ for Payer ID 84146 (medical) or 84147 (dental).

To check the status of an electronic claim through Emdeon™, use 276 and 270 HIPAA transactions.

To submit a paper claim, send to:

VA Health Administration Center
CHAMPV A Claims
PO Box 469064
Denver CO 80246-9064

How long will it take CHAMPVA to process a claim?

Turnaround time for claims is about 30 days.  Electronic filing is faster; paper claims take about another 3 weeks longer.

Need more information?  Contact CHAMPVA.

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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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