CHAMPVA–Information for Providers
The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a comprehensive health care program for the spouse or widow(er) and children of an eligible Veteran. Through CHAMPVA, VA shares the cost of certain health care services and supplies with eligible beneficiaries. CHAMPVA may also provide benefits to the Primary Family Caregiver through the Caregiver Support Program. For more information, check out the CHAMPVA and the Caregiver programs.
Starting January 1, 2025, prescriptions for Ozempic and Mounjaro will require a Type 2 diabetes diagnosis code to be covered under CHAMPVA pharmacy benefits. If other diagnosis codes are used, CHAMPVA will reject the prescription until there is documentation that the patient has a diagnosis for Type 2 diabetes.
Using Ozempic and Mounjaro for obesity (weight loss) is not covered per CHAMPVA policy. For questions, please contact CHAMPVA (800-733-8387) or OptumRx Pharmacy (888-546-5503).
The VHA Office of Integrated Veteran Care (IVC) processes CHAMPVA applications, determines eligibility, authorizes benefits, and processes medical claims. Providers are encouraged to file claims directly with CHAMPVA. For information on filing claims, visit the Filing a CHAMPVA Claim page.
IMPORTANT NOTE: Community care providers, including under CHAMPVA, must enroll for Electronic Funds Transfer (EFT) and payments will be deposited directly into a bank account.
Frequently Asked Questions
Is preauthorization required for services?
Certain types of care/services require advance approval, commonly known as preauthorization. This approval, or preauthorization, is extremely important, and the failure to obtain it may result in denial of the claim. Preauthorization is required for:
- Adjunctive Dental (procedures that are directly related to covered medical conditions)
- Mental health/substance abuse services
- Organ and bone marrow transplants
Is there a contract or agreement that I must sign to accept/participate in CHAMPVA?
No. CHAMPVA does not have contract providers. You must be properly licensed in your state to receive payment from CHAMPVA, and cannot be on the Medicare exclusion list.
Do I have to accept the CHAMPVA allowable rate?
Yes, under 38 CFR section 272(b) (3) and (4), providers who agree to accept the beneficiary must accept the CHAMPVA allowable charges and cannot balance bill the beneficiary. The sole exception is when the beneficiary is notified prior to any services being rendered that you do not accept CHAMPVA and the beneficiary must pay the entire billed amount up front and file the claim to CHAMPVA.
How do I get a claim paid?
The most efficient way to file a claim for CHAMPVA is electronically. The VHA Office of Integrated Veteran Care accepts electronically submitted 837 claim transactions. These include the 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 the territories.
You must submit electronic claims through the VA clearinghouse. Our Payer ID number is 84146 for medical claims and 84147 for dental claims. You can also check medical claim status and eligibility status electronically through the VA clearinghouse using the 276 and 270 HIPAA transactions.
CHAMPVA receives Medicare Crossover Parts A & B and DMERC claims for our beneficiaries. If your patient is a Medicare beneficiary your claim will be forwarded electronically to CHAMPVA if we have the Medicare Health Insurance Claim number (HICN) on file. Please review your electronic remittance advice from Medicare to determine if your claim has been forwarded to us. Claims can be mailed to the address listed in the contacts below.
Visit Filing a CHAMPVA Claim for more information on filing CHAMPVA claims.
Contacts
VA Customer Call Center: 800-733-8387
8:05 a.m. to 7:30 p.m. ET, Monday-Friday
VHA Office of Integrated Veteran Care
ATTN: CHAMPVA
PO Box 469063, Denver CO 80246-9063
