Community Care

Eligibility and Claims 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

CHAMPVA Preauthorization

Preauthorization is required for the following services:

CHAMPVA Guide
More information about CHAMPVA including a list of preauthorization services and supplies.

Claim Filing Requirements

• 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.
• The Explanation of Benefits (EOB) from the OHI should be submitted to CHAMPVA with the claim for reimbursement. By law, CHAMPVA is always the last payer.

Payment Limitations

Some payments are made based on specific clinical guidelines. Two common examples are breast reduction and weight reduction surgical procedures. For more information, visit CHAMPVA–Information for Providers.

CHAMPVA–Information for Providers

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.

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.

Claim Filing Requirements

Electronic Claims
VA accepts HIPAA-compliant 837 EDI CWVV health care claims through the VA clearinghouse or another clearinghouse of your choice. To ensure accuracy, please include the following information when submitting CWVV claims:

You must be properly licensed in your state and must not be on the Medicare exclusion list to participate in this program. Additionally, you must accept the VA-determined allowable amount for care.

To ensure that a claim is processed quickly and accurately, please review the How to File a Claim for the Spina Bifida Health Care Benefits Program webpage. 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.

Claim Filing Requirements

Electronic Claims
VA accepts HIPAA-compliant 837 EDI Spina Bifida health care claims through the VA clearinghouse or another clearinghouse of your choice. To ensure accuracy, please include the following information when submitting Spina Bifida claims:

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

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.

All compliant pharmacy claims will automatically be sent electronically to OptumRx. Please contact OptumRx if you have questions or need assistance submitting your claim.

Right to Request Reconsideration

You 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. For immediate questions or concerns, contact the VA Customer Call Center.

File claims electronically using an 837 claim and 835 supporting documentation submission. You are encouraged to use the VA clearinghouse or another clearinghouse of your choice.

VA Clearinghouse

VA uses a clearinghouse for providers to submit CHAMPVA, Spina Bifida Health Care Benefits Program, and Children of Women Vietnam Veterans (CWVV) Health Care Benefits Program claims electronically to VA for payment. Electronic 837 claim and 835 supporting documentation submissions can be completed through the VA clearinghouse.

Electronic Data Interchange (EDI) Referral/Authorization Annotation Information

When submitting claims:

• Include a National Provider Identifier (NPI) on all inbound medical, dental, and pharmacy transactions. NPIs that should be sent include rendering, referring, and prescribing NPIs. For more information about NPIs, please visit National Plan and Provider Enumeration System (NPPES) website.
  

  National Plan and Provider Enumeration System (NPPES)

• For all compliant EDI claims sent to us through the VA clearinghouse, we can provide an 835/Electronic Remittance Advice (ERA). An 835/ERA is not provided for paper claim submissions. At this time, we continue to send a paper explanation of benefits (EOB) for all paper and EDI claims processed.

For family member care programs, VA provides real-time information through the VA clearinghouse 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:
  • 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