How to File a Claim

• Chapter 3, Section 1.1

General Claim Filing Instructions

• Your name must be listed on the claim form exactly as it is on the CHAMPVA Authorization Card.
• Your Social Security number must be on the claim. DO NOT USE the qualifying veteran’s Social Security number.
• If you have other health insurance (OHI), include a copy of the OHI explanation of benefits.
• After billing your other health insurance, you can file with CHAMPVA for the remaining balance.
• Keep copies of all receipts, invoices, etc.
• Separate claim forms are required for each patient/beneficiary.
• If you fail to complete the VA Form 10-7959a, payment will be made directly to the health care provider instead of to you.
• For inpatient hospitalizations, payment will always be made to the hospital whether or not you submit the billing.

Claims Submitted by the Beneficiary/Provider must include the following:

• CHAMPVA Claim Form, VA Form 10-7959a, (beneficiaries only)
• Itemized billing statement(s) are required. These can be submitted on a standardized paper form (HCFA-1500, CMS-1500, UB-92, or UB-04). The following information must be provided on the forms:
• Full name, address, and tax identification number of the provider
• Address where payment is to be sent
• Address where services were provided
• Provider professional status (doctor, nurse, physician assistant, etc.)
• Specific date of each service provided. Date ranges are acceptable only when they match the number of services/units of services
• Itemized charges for each service
• Appropriate medical code (ICD-9, CPT, HCPCS) for each service
• If other health insurance was billed, a copy of their explanation of benefits detailing what they paid is required. Sometimes the definition or explanation of codes is on the reverse side of their explanation of benefits form. Please include a copy of that information as well.

Pharmacy Claims

Most pharmacies submit claims to CHAMPVA electronically. The following information is required for pharmacy claims regardless of whether submitted electronically or on paper and regardless of whether submitted by the pharmacy or by you.

• An invoice/billing statement that includes:
• Name, address, and phone number of the pharmacy
• Name of prescribing physician
• Name, strength, and quantity for each drug
• Eleven (11) digit National Drug Code for each drug
• Charge for each drug
• Co-payment for each drug
• Date prescription was filled
• If the billing is submitted by you, also provide the sales receipt (cash register receipt) with the date and dollar amount that corresponds to the date and dollar amount on the pharmacy invoice/billing statement.

Where to Mail Claims

Mail claims to:

VA Health Administration Center
CHAMPVA
PO Box 469064
Denver CO 80246-9064

How to Get Additional Claim Forms

Additional claim forms can be requested at any time (including evenings and weekends) by calling us at 1-800-733-8387 and selecting the claim form option from our voice-mail menu. You can also 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.