File a Claim for Family Member Care
The process for submitting claims for health care and services provided for a Veteran’s family members and dependents (beneficiaries) is different depending on the specific family member care program.VA accepts both electronic and paper claims for family member care. VA encourages filing electronically for prompt processing and payment.
Electronic Claims
VA accepts HIPAA-compliant 837 EDI health care claims through our clearinghouse, Change Healthcare. Providers must submit non-pharmacy claims and other EDI transactions through Change Healthcare for the following family member care programs: Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), Children of Women Vietnam Veterans (CWVV) Health Care Benefits Program, and the Spina Bifida Health Care Benefits Program.
VA requires the use of the National Provider Identifier (NPI) on all inbound medical, dental, and pharmacy transactions. NPIs that should be sent include, but are not limited to, rendering, referring, and prescribing NPIs.
For more information, please visit National Plan and Provider Enumeration System (NPPES) website.
For all compliant EDI claims sent to us through Change Healthcare, we can provide an 835/Electronic Remittance Advice (ERA). An 835/ERA is not provided for paper claims submitted to VA. At this time, VA continues to send a paper explanation of benefits (EOB) for all paper and EDI claims processed.
Providers must complete an enrollment form at Change Healthcare to receive OCC 835s from VA. The form can be found on the Change Healthcare Enrollment Services website.
To enroll in Change Healthcare, visit Change Healthcare Enrollment Services. To submit claims through Change Healthcare, or if you need to change or cancel your enrollment, contact Change Healthcare.
- CHAMPVA
- Camp Lejeune Family Member Program
- Children of Women Vietnam Veterans
- Spina Bifida Health Care Benefits Program
- Pharmacy Benefits
- Real-time Communications
CHAMPVA Claims
CHAMPVA is a health care benefits program in which VA shares the cost of certain health care services and supplies with eligible beneficiaries. VA processes CHAMPVA applications, determines eligibility, authorizes benefits, and processes medical claims.
Providers must accept the CHAMPVA allowable rate and cannot bill for the difference between the billed charge and the VA-determined allowable amount.
Claim Filing Requirements for CHAMPVA
By law, CHAMPVA is always the secondary payer except to Medicaid, Indian Health Services, State Victims of Crime Compensation, and supplemental CHAMPVA policies. If the patient has Other Health Insurance (OHI) coverage, the OHI should be billed first. A claim can then be sent to CHAMPVA, with the Explanation of Benefits (EOB) from the other insurer.
CHAMPVA Preauthorization Requirement
The only preauthorization requirements for CHAMPVA are for:
- Organ and bone marrow transplants
- Dental care
- Durable Medical Equipment (DME) worth more than $2000
- Most mental health or substance abuse services
Some payments are made based on specific clinical guidelines. Two common examples are breast reduction and weight reduction surgical procedures. Please check the CHAMPVA Guide for a complete listing of preauthorization services and supplies. For more information on CHAMPVA, visit CHAMPVA–Information for Providers.
CHAMPVA Guide CHAMPVA–Information for ProvidersElectronic Claims
VA accepts HIPAA-compliant 837 EDI CHAMPVA health care claims through our clearinghouse, Change Healthcare. To ensure accuracy, please include the following information when submitting CHAMPVA claims:
- VA beneficiary (your patient) is always the subscriber
- Patient’s first and last name as it appears on the VA program identification card
- Member ID (Social Security Number)
- Patient’s date of birth
- Payer ID numbers are:
- 84146 for medical claims/ERA
- 84147 for dental claims/ERA
Paper Claims
VA encourages providers to submit claims electronically for CHAMPVA. However, we do accept paper claims. Send paper claims to:
VHA Office of Community Care
ATTN: CHAMPVA Claims
P.O. Box 469064
Denver, CO 80246-9064
CHAMPVA Claims and Eligibility Status
You can check on the eligibility status of a CHAMPVA beneficiary or the status of a claim 24/7 through our Interactive Voice Recognition (IVR) system. Please have the beneficiary's Social Security Number and your tax ID number available when calling.
Interactive Voice Recognition System: 800-733-8387
Contacts
Customer Call Center: 800-733-8387
Monday–Friday 8:05 a.m. to 7:30 p.m. Eastern Standard Time (EST)
VHA Office of Community Care
ATTN: CHAMPVA
P.O. Bo 469063
Denver, CO 80246-9063
Resources
Camp LeJeune Family Member Program Claims
The Camp LeJeune Family Member Program (CLFMP) is for family members of Veterans that lived or served at U.S. Marine Corps Base Camp LeJeune, North Carolina between August 1, 1953 and December 31, 1987 and were potentially exposed to drinking water contaminated with industrial solvents, benzene, and other chemicals.
CLFMP covers treatment costs for one or more of the 15 conditions listed in the Honoring America’s Veterans and Caring for Camp LeJeune Families Act of 2012. VA also reimburses qualified family members as the last payer of medical claims for these 15 conditions.
For information, review the CLFMP–Information for Providers fact sheet.
Electronic Claims
CLFMP accepts electronically submitted 837 claim transactions including 837 Institutional, 837 Professional, and 837 Dental transactions. Transactions are accepted from providers for medical services and supplies provided in the United States, a U.S. Commonwealth, or U.S. territories.
Providers must submit electronic claims through VA’s clearinghouse, SSI Claimsnet. Registration can be completed online. For questions about the electronic claims process, contact SSI Claimsnet.
VA’s Payer ID numbers are:
- CLFM1 for medical claims
- 276 / 270 for medical claims status and eligibility status
SSI Claimsnet Contacts
Customer Service: 800-356-0092
CLFMP Contact
Customer Service Helpdesk:
866-372-1144
Fax: 512-460-5536
Paper Claims
VA encourages providers to submit claims electronically for CLFMP. We do accept paper claims, but the processing time is 20 days longer on average. Send paper claims to:
U.S. Department of Veterans Affairs
Financial Services Center
P.O. Box 149200
Austin, TX 78714-9200
PLEASE NOTE: If the family member has Other Health Insurance (OHI), the OHI must be billed first. The explanation of benefits from the OHI should be submitted to CLFMP with the claim for reimbursement. By law, CLFMP is always the last payer.
Children of Women Vietnam Veterans Health Benefits Program Claims
The Children of Women Vietnam Veterans (CWVV) Health Care Benefits Program provides health care benefits to women Vietnam Veterans’ birth children who the Veterans Benefits Administration has determined to have a covered birth defect. CWVV is not a comprehensive health care plan and only covers those services necessary for the treatment of a covered birth defect and associated medical conditions.
For CWVV claims, the determined allowable amount for payment is considered payment-in-full. A provider may not bill the beneficiary for the difference between the billed amount and the VA-determined allowed amount.
Electronic Claims
VA accepts HIPAA-compliant 837 EDI CWVV health care claims through our clearinghouse, Change Healthcare. To ensure accuracy, please include the following information when submitting CWVV claims:
- Our beneficiary (your patient) is always the subscriber
- Patient’s first and last name as it appears on the VA program identification card
- Member ID (Social Security Number)
- Patient’s date of birth
- Payer ID numbers are:
- 84146 for medical claims/ERA
- 84147 for dental claims/ERA Paper
Paper Claims
VA encourages providers to submit claims electronically for CWVV. However, we do accept paper claims. Send paper claims to:
VHA Office of Community Care
ATTN: CWVV Health Care Benefits Program
P.O. Box 469065
Denver, CO 80246-9065
Contacts
Customer Service: 888-820-1756
Monday–Friday 8:05 a.m. to 6:45 p.m.
Eastern Standard Time (EST)
VHA Office of Community Care
ATTN: CWVV Health Care Benefits Program
P.O. Bo 469065
Denver, CO 80246-9065
Resources
- Provider billing forms:
Spina Bifida Health Care Benefits Program Claims
The Spina Bifida Health Care Benefits Program is administered by VA for Vietnam and certain Korean Veterans’ birth children who have been diagnosed with spina bifida (except spina bifida occulta). Comprehensive health care considered medically necessary and appropriate is covered under the Spina Bifida program.
Providers must be properly licensed in their state and must not be on the Medicare exclusion list to participate in this program. Additionally, providers must accept the VA-determined allowable amount for care.
To ensure that a claim is processed quickly and accurately, please review How to File a Claim for the Spina Bifida Health Care Benefits Program.
For more information on the Spina Bifida Health Care Benefits Program, including claims and payments, please visit Spina Bifida Health Care Benefits–Information for Providers.
Electronic Claims
VA accepts HIPAA-compliant 837 EDI Spina Bifida health care claims through our clearinghouse, Change Healthcare. To ensure accuracy, please include the following information when submitting Spina Bifida claims:
- Our beneficiary (your patient) is always the subscriber
- Patient’s first and last name as it appears on the OCC program identification card
- Member ID (Social Security Number)
- Patient’s date of birth
- Payer ID numbers are:
- 84146 for medical claims/ERA
- 84147 for dental claims/ERA
Paper Claims
VA encourages providers to submit claims electronically for Spina Bifida. However, we do accept paper claims, but the processing time is 20 days longer on average. Send paper claims to:
VHA Office of Community Care
ATTN: Spina Bifida Health Care Benefits Program
P.O. Box 469065
Denver, CO 80246-9065
Spina Bifida Health Care Benefits Enrollment Status
You can check on the eligibility status of a Spina Bifida beneficiary or the status of payment for a claim 24 hours a day through our Interactive Voice Recognition (IVR) system. Please have the beneficiary's Social Security Number and your tax ID number available when calling.
Interactive Voice Recognition System: 888-820-1756
Contacts
VHA Office of Community Care
Spina Bifida Health Care Benefits Program
P.O. Bo 469065
Denver, CO 80246-9065
Customer Call Center: 888-820-1756
Monday–Friday, 8:05 a.m. to 6:45 p.m.
Eastern Standard Time (EST)
Pharmacy Benefits
Family members who receive care through the CHAMPVA program, the Children of Women Vietnam Veterans program, or the Spina Bifida Health Care Benefits program can access pharmacy benefits through the Meds by Mail program, or by visiting a pharmacy in the OptumRx network.
Providers who are currently participating in the OptumRx Premier Network are eligible to provide services to VA beneficiaries. If you are not currently participating, contact OptumRx’s Provider Helpdesk for contracting information.
Electronic Claims
Electronic pharmacy claims should be submitted through OptumRx. The claims should be submitted using the following information:
BIN: 610593 | PCN: VA | GROUP: HAC
Please use the beneficiary’s Social Security Number (SSN) for the NCPDP Cardholder ID (302/C2). For security and privacy reasons, OptumRx will not provide a beneficiary’s SSN to anyone.
Where to Send It
All compliant pharmacy claims will automatically be sent electronically to OptumRx. Please contact OptumRx if you have questions or need assistance submitting your claim.
For more information on pharmacy benefits for family member programs, please visit Pharmacy Benefits.
Right to Request Reconsideration
Providers have the right to request reconsideration. A written statement explaining your disagreement must be received within one year from the date of notification. Please attach any pertinent documentation to support your claim and include a copy of the notification with your request.
VHA Office of Community Care
ATTN: Appeals
PO Box 460948
Denver, CO 80246
For immediate questions or concerns, contact the
VA Customer Call Center: 800-733-8387
Monday–Friday, 8:05 a.m.–7:30 p.m. Eastern Standard Time (EST)
Real-time Communications for Family Member Care Programs
For family member care programs, VA provides real-time information through Change Healthcare for eligibility, benefits, and claim verification. Our real-time payer ID at Change Healthcare is VAHAC.
- Health Care Claims Status (277–Health Care Claim Status Response)
- Health Care Services Review (278–Response to an EDI Health Care Services Request for Review)
- Eligibility Status (271–Health Care Eligibility Benefit Response)
We can respond with an acknowledgment that tells the requester if the patient is unknown or has active coverage for our programs. For patients with active coverage, our response would include:- The dates of the most recent coverage
- Response to Service Type Code “30” or Explicit Service Type Inquiries
- Patient Responsibility for Individual and Family including deducible amounts, co-insurance amounts, and catastrophic cap amounts
