Locating a Provider
Beneficiaries enrolled in a Veteran family member program – CHAMPVA, Spina Bifida Health Care Benefits Program, and the Children of Women Vietnam Veterans Health Care Benefits Program – administered by the Veterans Health Administration (VHA) Office of Integrated Veteran Care (IVC) have the flexibility to choose their own provider, as the program does not have a provider network.
The Medicare and TRICARE websites may be helpful in locating a provider.
Medicare website TRICARE website
On this page
- Provider Participation
- Filing for Reimbursement
- Information about Benefits
- Medicare Exclusion List
- Contacts
Provider Participation
Providers Who Accept “Assignment” for VA Family Member Programs
When you locate a medical provider, confirm if they will participate in the VA family member health care program you belong to. Providers most often refer to participation as "accepting assignment." Approved health care providers include Medicare, Medicaid, and TRICARE providers as well as those licensed or certified by a state to provide care and services. When a state does not offer licensure or certification, the provider must be certified by an appropriate national or professional association that sets standards for the specific medical provider.
Providers who accept assignment must accept the VHA IVC allowable amount as payment-in-full and cannot collect additional amounts from you beyond your cost share and deductible.
IMPORTANT NOTE: All hospitals that participate in Medicare, and hospital-based health care professionals who are employed by, or contracted to, such hospitals are required by law to accept the VHA IVC allowable amount for inpatient hospital services.
Providers Who Do Not Accept “Assignment” for VA Family Member Programs
If your provider does not accept assignment, you can still see that provider, but your provider may require you to pay the entire charge at the time of service which may be more than the VHA IVC allowable amount. For care that is not covered by a VA family member health care program, you will be responsible for the full bill. Once paid, you may submit the itemized bill from the provider along with the appropriate VA claim form.
Filing for Reimbursement
To obtain reimbursement in cases where a VA family member health care program is your only health benefit plan, you will have to submit the itemized bill from the provider along with the appropriate VA form. VHA IVC will mail out your share of the allowable amount once the claim is approved and processed. This means, when the medical provider does not accept assignment, your cost will include your annual deductible, your cost share and any provider-billed amount that exceeds the VHA IVC allowable amount.
When a Veteran Family Member Program is Secondary to Your Primary Insurance
To obtain reimbursement in cases where a VA family member health care program is acting as a secondary health care benefit plan, you can ask the provider to file the claim and explanation of benefits (EOB) from the primary insurer electronically or by mail to VHA IVC. If the provider is not able or willing to do so, you will need to submit the itemized bill, appropriate VA form, and the EOB from the primary insurer to VHA IVC.
Please check the program benefits information below for details.
Information about Benefits
Information about CHAMPVA
Providers may elect to participate in CHAMPVA. Under CHAMPVA, you are responsible for paying your beneficiary cost share and any charges for noncovered services. Under Title 38 CFR, Section 17.272(b) (2) and (3), providers must accept the CHAMPVA allowable rate and cannot require you to pay the difference between their billed charge and the VA-determined allowable amount. If your provider accepts assignment, request that they submit your claims directly to CHAMPVA.
If your provider does not accept CHAMPVA assignment, you can still see that provider; however, you will likely have to pay the entire billed charges at the time of service and submit a claim for reimbursement. When a provider does not accept CHAMPVA assignment, your cost may include not only your share of the CHAMPVA-determined allowable amount, but also any charges over the allowable amount.
To obtain reimbursement, you must submit the itemized bill from the provider along with a CHAMPVA Claim Form, VA Form 10-7959a. When CHAMPVA processes the claim for payment, you will be reimbursed the allowable amount for covered services.
To help us process claims in a timely manner, have your provider submit claims with your name exactly as it is shown on your CHAMPVA Identification Card. If different names are used, it will cause a delay in the handling of claims. The rejection of claims could cause you to receive claims for payment directly from your provider.
CHAMPVA also offers a voluntary program called the CHAMPVA In-House Treatment Initiative (CITI) that allows beneficiaries to be treated at participating Veterans Affairs medical centers (VAMCs).
CHAMPVA Resources
Information about Spina Bifida and CWVV Health Care Benefits Programs
Providers may elect to participate in these health care benefits programs. Under Title 38 CFR, Section 17.903(c), providers must accept the VA payment and cannot require you to pay the difference between their billed charge and the VA-determined allowable amount.
For more information, visit the Spina Bifida Health Care Benefits Program (SBHCBP) webpage or contact the Spina Bifida Care Coordination Team.
Information about Pharmacy Benefits
IVC Veteran Family Member Programs offer a medication by mail option, Meds by Mail (MbM), where prescribed medications are mailed directly to your home. As long as you are eligible as a Veteran Family Member Program beneficiary, and do not have other health insurance that includes pharmacy services, you can use Meds by Mail for your nonurgent maintenance medications. There is no enrollment. Simply have your provider submit your prescriptions electronically for you.
Enrollment in an IVC Veteran Family Member Program also makes you eligible to use our network of more than 66,000 OptumRx local pharmacies. To obtain a temporary pharmacy identification card and information on pharmacies that are part of the OptumRx network, visit the OptumRx website or call OptumRx Beneficiary Services.
OptumRx Beneficiary Services: 888-546-5502
Please consult the program guide for the program you are enrolled in before using pharmacy benefits. The impact of OHI and out-of-pocket expenses varies from program to program.
If you are being seen under the CHAMPVA In-House Treatment Initiative (CITI), you should check with the VA medical center (VAMC) providing your care about whether their pharmacy participates in CITI. Patients who participate in CITI can choose whether they want to use their VAMC or MbM to receive prescribed medications for free. For more information, visit the Pharmacy Benefits webpage.
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, the Spina Bifida Health Care Program, and the Children of Women Vietnam Veterans Health Care Program.
Contacts
General Information: 800-733-8387
Monday-Friday 8:05 a.m. to 7:30 p.m. ET
Contact us online through Ask VA: Ask.VA.gov
Mailing Address:
CHAMPVA PO Box 469063
Denver, CO 80246-9063
