Denied Claims
Do you need help to reprocess a denied claim? The HAC has recently created a new service to provided additional guidance on how to respond to a claim denial, based on our 10 most frequent used denial codes. If you have the Explanation of benefits (EOB) form available, you can use the denial code on the form to get detailed instruction about how to respond to the claim denial. We also offer an e-mail address to submit questions on our less common claims denial codes.
Click here to go to the denied claims page.
Overview
The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a comprehensive health care program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries. The program is administered by Health Administration Center and our offices are located in Denver, Colorado.
Due to the similarity between CHAMPVA and the Department of Defense (DoD) TRICARE program (sometimes referred to by its old name, CHAMPUS) the two are often mistaken for each other. CHAMPVA is a Department of Veterans Affairs program whereas TRICARE is a regionally managed health care program for active duty and retired members of the uniformed services, their families, and survivors. In some cases a veterans may look to be eligible for both/either program on paper. However, if you are a military retiree, or the spouse of a veteran who was killed in action, you are and will always be a TRICARE beneficiary, you can´t choose between the two.
To be eligible for CHAMPVA, you cannot be eligible for TRICARE/CHAMPUS and you must be in one of these categories:
the spouse or child of a veteran who has been rated permanently and totally disabled for a service-connected disability by a VA regional office, or
the surviving spouse or child of a veteran who died from a VA-rated service connected disability, or
the surviving spouse or child of a veteran who was at the time death rated permanently and totally disabled from a service connected disability, or
the surviving spouse or child of a military member who died in the line of duty, not due to misconduct (in most of these cases, these family members are eligible for TRICARE, not CHAMPVA).
An eligible CHAMPVA sponsor may be entitled to receive medical care through the VA health care system based on his or her own veteran status. Additionally, as the result of a recent policy change, if the eligible CHAMPVA sponsor is the spouse of another eligible CHAMPVA sponsor, both may now be eligible for CHAMPVA benefits. In each instance where the eligible spouse requires medical attention, he or she may choose the VA health care system or coverage under CHAMPVA for his/her health care needs. If you have been previously denied CHAMPVA benefits and you believe you would now be qualified, please submit an application following the guidelines as listed on the “How to apply” section.
In general our CHAMPVA program covers most health care services and supplies that are medically and psychologically necessary. Upon confirmation of eligibility, you will receive program material that specifically addresses covered and noncovered services and supplies in the form of a CHAMPVA handbook.
General Exclusions
Like all health programs there are certain services and supplies that are not covered by our program, some of these are:
Services and supplies obtained as part of a grant, study, or research program.
Services and supplies not provided in accordance with accepted professional medical standards or related to experimental/investigational or unproven procedures or treatment regimens.
Care for which you are not obligated to pay, such as services obtained at a health fair.
Care provided outside the scope of the provider's license or certification.
Services or supplies above the appropriate level required to provide the necessary medical care.
Services by providers suspended or sanctioned by any federal agency.
Services provided by a member of your immediate family or person living in your household.
For a complete listing of noncovered services and supplies please consult the CHAMVPA handbook.
Medicare Impact
CHAMPVA is always the secondary payer to Medicare. If you are eligible for CHAMPVA, under age 65 and enrolled in both Medicare Parts A&B, SSA documentation of enrollment in both Parts A&B is required.
For your benefits to be extended past age 65, you must meet the following conditions:
if the beneficiary was 65 or older prior to June 5, 2001, and was otherwise eligible for CHAMPVA, and was entitled to Medicare Part A coverage, then the beneficiary will be eligible for CHAMPVA without having to have Medicare Part B coverage.
if you turned 65 on/or before June 5, 2001, and have Medicare Parts A and B, you must keep both Parts to be eligible.
if you turned 65 on or after June 5, 2001, you must be enrolled in Medicare Parts A and B to be eligible.
you are not required to enroll in Medicare Part D in order to become or remain CHAMPVA eligible.
If you are expecting and you need to establish CHAMPVA eligibility for your new child, the following must be accomplished before you can submit an application.
Obtain a Social Security Number for the newborn by applying to the nearest Social Security Administration office.
Establish dependency of the newborn to the veteran sponsor by contacting the local VA regional office.
Since the payment of claims for this child is contingent upon his/her eligibility status, as new parents you are encouraged to take the above action as early as possible.
Eligibility Definitions
Term
Definition
Beneficiary
A CHAMPVA-eligible spouse, widow(er), or child.
Child
Includes birth, adopted, stepchild, or helpless child as determined by a VA regional office (see the Rules that Impact CHAMPVA Eligibilty section of the CHAMVPA handbook).
Dependents
A child, spouse, or widow(er) of a qualifying sponsor.
Qualifying Sponsor
A veteran who is permanently and totally disabled from a service-connected condition, died as a result of a service-connected condition, was rated permanently and totally disabled from a service-connected condition at the time of death, or died on active duty and whose dependents are not otherwise entitled to DoD TRICARE benefits.
Service-connected
A VA regional office determination that a veteran's illness or injury is related to military service.
Spouse
The wife or husband of a qualifying sponsor.
Widow(er)
The surviving spouse of a qualifying sponsor.
NOTE: The eligibility of a child is not affected by the divorce or remarriage of the spouse except in the case of a stepchild. When a stepchild leaves the sponsor's household, the child is no longer eligible for CHAMPVA.
Remarriage: Eligibility for CHAMPVA ends at midnight on the date of your remarriage if you remarry prior to age 55. If you remarry on or after your 55 th birthday, The Veterans Benefit Act of 2002, Public Law 107-330, allows you to keep your CHAMPVA benefits.
Termination of Remarriage: If you are a widow(er) of a qualifying sponsor and you remarry and the remarriage is later terminated by death, divorce, or annulment you may reestablish CHAMPVA eligibility. The beginning date of your re-eligibility is the first day of the month after termination of the remarriage or December 1, 1999, whichever date is later. To reestablish CHAMPVA eligibility, copies of the marriage certificate and death, divorce, or annulment documents (as appropriate) must be provided.
How to Learn More About CHAMPVA Before Your Card Arrives
You can read more about CHAMPVA by visiting the
Fact Sheets posted on our web site or by visiting the CHAMPVA handbook also posted on our web site.
Communicating with CHAMPVA
When sending correspondence, applications or claims to the Health Administration Center, please do not staple, tape or bind the materials together in any manner as this will cause a delay in your correspondence or request being processed.
CHAMPVA is managed by the VA's Health Administration Center. You can call us at 800-733-8387, Monday through Friday from 8:05 AM to 7:30 PM ET. For general questions, contact us via the Inquiry Routing & Information System (IRIS). IRIS is a tool that allows us to communicate in a secure format and will be used instead of our traditional email links. For specific guidance when using IRIS for your inquiry click here. You can also fax us at 1-303-331-7804. PLEASE do NOT fax applications to this number. Online Chat is available Monday, Wednesday, and Friday from 10:00 AM to 6:30 PM ET. We also have an automated web service available 24 hours 7 days a week at www.mychampva.com
We do not maintain a provider listing. Most Medicare and TRICARE providers will also accept CHAMPVA (but be sure you ask the provider). If you are having difficulty finding a provider, we recommend you visit the Medicare website HTTP://WWW.MEDICARE.GOV and use the “Search Tools” at the bottom of that page to locate a Medicare provider. You may also visit the TRICARE website at (http://www.tricare.mil/STANDARDPROVIDER/) to locate a provider in your area. If you choose to see a provider who does not accept CHAMPVA, you will likely have to pay the entire bill and then submit a claim for reimbursement of our cost share. Remember that CHAMPVA cost shares are based on the CHAMPVA allowable amount.
If you have a general question, or need information on payment, or need to reprocess a denied claim, please send you request to:
VA Health Administration Center
CHAMPVA
PO Box 469063
Denver CO 80246-9063
For submitting new health care claims only, please use:
VA Health Administration Center
CHAMPVA Claims
PO Box 469064
Denver CO 80246-9064
Frequently Asked Questions
Before you ask us your question, chances are someone else has already asked it. Please check the Frequently Asked Questions (FAQ) first. Thank you.
CHAMPVA Handbook
The CHAMPVA Handbook contains important benefit information that is of interest to you. You are highly encouraged to carefully read the handbook prior to using CHAMPVA benefits.
You can view the online version here.
The Health Administration Center has received quite a few complaints from beneficiaries who have insurance with Kaiser Permanente; basically, that we have not honored submitted claims. This is due to the fact that Kaiser does not provide beneficiaries the necessary data they need to submit claims for reimbursement of their cost share from CHAMPVA. We recognize that this is, and has been an ongoing problem, however, we are please to announce that we have solved that problem. This is how it works (and please pardon us for sounding so technical): in order to process a claim for a Kaiser Permanente bill that is submitted to CHAMPVA which does not include a medical diagnosis or procedure code, CHAMPVA will default to using the code V70 "General Medical Examination" for the diagnosis, and code 99499 "Unlisted evaluation and Management service" for the procedure. So that the HAC can process these claims using the new method, please provide a copy of your Kaiser Permanente card showing the amount of your copayments with your claims to assist CHAMPVA in calculating reimbursement of your cost share. Although CHAMPVA is providing this method of processing claims for beneficiaries insured by Kaiser, we urge you to request that Kaiser provide a bill that includes the following information: Tax Identification number and address of the Kaiser provider; Date of Service; Medical Code or description for the Diagnosis and the procedure; Patients responsibility or Patient Copayment for services.
Chat live!
If you would like to chat live, online with a Customer Service Representative you can do so
between the hours of 10:00 a.m. to 6:30 p.m. Eastern Standard Time, Monday - Friday.
The HAC needs your help - if you change your address, it is vital that you let us know your new address.
You can do this by contacting us via the Inquiry Routing & Information System (IRIS). IRIS is a tool that allows us to communicate in a secure format and will be used instead of our traditional email links. For specific guidance when using IRIS for your inquiry click here.
You can mail the information to:
PO BOX 469063
Denver CO 80246-9063
You can call us at 800-733-8387. Please help us keep our records up to date!
Medicare Exclusion List
The Department of Health and Human Services, Office of Inspector General (HHS OIG) maintains and publishes a monthly list of individual medical providers that are not allowed to provide medical services and supplies to Federal health care program participants. Medical providers on this list have been convicted in State or Federal court of certain felonies, criminal offenses, or have had other offenses toward Federal Agencies related to the delivery of health care. Mandatory exclusions include, but are not limited to, convictions related to patient abuse or neglect, felony convictions related to health care fraud, and controlled substances.
Excluded individual medical providers and medical institutions cannot, by law, receive payments for health care services or supplies from any Federal health care program. That exclusion includes programs funded by the Department of Veterans Affairs such as CHAMPVA, Foreign Medical Program (FMP), Spina Bifida, and the Children of Women Vietnam Veterans Health Care Programs. To access the list, use either of the following link:
