Rejected Claims–Explanation of Codes
VA classifies all processed claims as accepted, denied, or rejected.
- VA accepts correctly billed claims for care that has been pre-authorized by VA and providers will receive prompt payment for that care.
- VA denies claims when the care was not preauthorized, and the Veteran does not meet eligibility requirements for emergency care.
- VA rejects claims that cannot be paid or denied due to billing errors or the need for additional information. You can resubmit a rejected claim once errors have been corrected or additional information is available and provided.
ATTENTION CHAMPVA: Remark codes CARC 299 and RARC N24 may be resolved by enrolling in EFT.
Visit the VA Financial Services Center (FSC) Customer Engagement Portal below for more information and complete the Payment Account Setup webform to enroll. Review the Vendor File Request Webform User Guide below for step-by-step instructions or call the FSC Customer Support Help Desk for assistance.
If you need additional information beyond what is supplied on the Preliminary Fee Remittance Advice Report (PFRAR) or available in the Customer Engagement Portal (CEP), please contact the designated customer service support for the unit that adjudicated your claim. That unit will be able to provide clear guidance on the steps you need to take for VA to reprocess your claims.
VA FSC Customer Engagement Portal
Reconciliation tool for providers and vendors to verify the status of claims and run payment reports.
Webform User Guide
Step by Step instructions for users adding themselves to the VA financial system.
FSC Customer Support Help Desk:
877-353-9791
Monday – Friday, 7:15 a.m. – 4:15 a.m. CT
Provider Payments
Learn more about reimbursement for providing care to Veterans and their family members.
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Rejections During the Electronic Conversion Process
VA requires all paper claims to be converted to 837 electronic submissions. When VA receives a paper claim, it is reviewed for errors twice: once during electronic conversion and again during claims processing. During the conversion process, if a claim has been found non-compliant with standardized billing requirements, the claim will be rejected until the error is corrected. If an error is identified during this scan, the provider will receive a letter from VA with information about the error and reason for rejection.
Top 10 Claim Rejection Reasons for Veteran Care
The following are the most common reasons HCFA/CMS-1500 and UB/CMS-1450 paper claims for Veteran care are rejected:
Rank | Code | Reason/Detail |
---|---|---|
1 | 016 | Missing/Incomplete/Invalid Insured ID Requires the 17 alpha-numeric internal control number (ICN) [format: 10 digits + "V" + 6 digits] or 9-digit social security number (SSN) with no special characters. |
2 | 086 | Missing Insurance Plan Name or Program Name |
3 | 092 | Missing/Invalid Admission Date for POS 21 Refer to Box 18 |
4 | 088 | Invalid Service Facility Address. Must be a valid street address. |
5 | 005 | Missing NDC Units |
6 | 002 | Claim contains one or more missing/incomplete/invalid/inappropriate "Place of Service" codes. |
7 | 081 | Invalid Rendering NPI |
8 | 034 | Claim contains ICD9 Principal Dx code ICD 10 codes must be used for DOS after 09/30/2015. |
9 | 105 | Invalid Service line Provider Taxonomy code |
10 | 004 | Invalid/Incomplete CPT/HCPCS codes |
Rank | Code | Reason/Detail |
---|---|---|
1 | 016 | Missing/Incomplete/Invalid Insured ID Requires the 17 alpha-numeric internal control number (ICN) [format: 10 digits + "V" + 6 digits] or 9-digit social security number (SSN) with no special characters. |
2 | 125 | The outpatient claim has a missing "Admission Type" code |
3 | 097 | Missing Admission Type when Admission Date is Present |
4 | 108 | Referring and Attending Physician NPI are equal |
5 | 007 | This claim contains a missing/incomplete/invalid Billing Provider Address |
6 | 013 | Claim contains missing or invalid Patient Status |
7 | 034 | Claim contains ICD9 Principal Dx code ICD 10 codes must be used for DOS after 09/30/2015. |
8 | 031 | Claim contains invalid or missing "Patient Reason" diagnosis code |
9 | 021 | Missing Patient Account Number |
10 | 117 | Invalid "Type of Bill" code |
Top 10 Rejection Reasons for Family Member Care
The top 10 reasons claims for family member programs (like CHAMPVA) are rejected during claims processing are listed below, along with explanations of the denial codes and what providers need to do to get the claim corrected.
Helpful Hints: CHAMPVA Claim Filing for Providers
Information about filing accurate claims for CHAMPVA.
If the denial code you’re looking for is not listed below, you can contact VA by using the Inquiry Routing & Information System (IRIS), a tool that allows secure email communications, or you can call our Customer Call Center at one of the sites or centers listed below.
Rank | Code | Reason/Detail |
---|---|---|
1 | 65/159/177 |
Duplicate claim – Previously processed Our payment system determined that this claim is an exact match of a claim that we previously processed. Our claim number for the duplicate claim should be shown in the comment at the bottom of our explanation of benefits (EOB). If you do not believe that this is correct, you will need to contact the Customer Call Center and speak to a customer service representative to resolve this issue. IMPORTANT NOTE: Do not resubmit this claim without contacting us as it will only result in another denial. |
2 | 78 |
EOB from other insurance required – VHA IVC secondary payer We need to see the explanation of benefits (EOB) generated by the primary health plan before we can process this request. Our files indicate the patient is enrolled in a health insurance plan that, by law, must process this request prior to the VHA IVC program. Please resubmit this request with the EOB from the primary plan and include a copy of the VHA IVC EOB, or have the patient contact us to update their other health insurance (OHI) status. We can accept OHI updates through the Customer Call Center. |
3 | 124 |
Claim not timely filed. (See applicable VHA IVC program guide.) A beneficiary or health care provider must file claims for current treatment within 365 days from the date of service. Upon initial enrollment into the plan, we grant a 180‑day grace period for the enrollee to file any applicable claims that were more than 365 days old. Based on the date this claim arrived at our mail room, it did not meet these requirements. You may submit a written appeal if you were unable to file the claims due to exceptional circumstances. Send your written appeal to: VHA Office of Integrated Veteran Care NOTE: Do not send your written appeal to the claims processing address as this will only delay your appeal. |
4 | 278 |
Multiple primary insurance coverage. Please resubmit EOBs from each payer. A secondary review in our claims payment area determined that this claim or service is an exact match of a claim or service we previously processed. If this is an exact match of a previous claim, the matching VHA IVC claim number will be shown in the comments at the end of the explanation of benefits (EOB). If you do not believe this is correct, you will need to contact the Customer Call Center and speak to a customer service representative to resolve this issue. IMPORTANT NOTE: Do not resubmit this claim without contacting us as it will only result in another denial. |
5 | 148 |
Claim denied – Chiropractic services not covered. If you do not believe this is correct, you will need to contact the Customer Call Center and speak to a customer service representative to resolve this issue. IMPORTANT NOTE: Do not resubmit this claim without contacting us as it will only result in another denial. |
6 | 137 |
Beneficiary not eligible on date of service claimed. This claim is for a date of service or period of hospitalization that is not covered under the VHA IVC health benefits plan. Please consult the period of eligibility listed on the member card and check the date of service, or period of admission, in your records. If the bill was submitted with an incorrect date, please send a corrected bill. If the service or admission date is correct, then we cannot pay the claim since the patient was not covered by our plan at that time. |
7 | 224 |
Must provide medical history/documentation to support treatment. Please resubmit the claim for reconsideration, and include a copy of the VHA IVC explanation of benefits (EOB) form. If you have questions, please contact the Customer Call Center. |
8 | 218/220 |
Clarification of OHI information required. Certification sent to beneficiary. We do not have an Other Health Insurance (OHI) Certification on file for the patient/beneficiary. We cannot process any claims until we know if the individual is covered by another health plan. Even if the individual has no OHI coverage, we still need them to attest to this fact. Please submit a CHAMPVA OHI Certificate, VA Form 10-7959c, or call the Customer Service Center and a customer service representative can help complete the certification over the phone. |
9 | 27 |
Not a covered service and/or benefit for diagnosis listed. Some services/procedures are only covered for specific conditions as outlined in the applicable VHA IVC policy manual. Services which do meet these conditions will be denied. You can access all VHA IVC policy manuals from our Publications page. There is a search function within each policy manual to help you to quickly locate the section of our policy that covers this request. |
10 | 391 |
ICD diagnostic code(s) missing/unreadable/invalid. Resubmit with EOB form. A diagnosis is required to determine if the service denied on this claim is covered under the applicable VHA IVC health benefits program. We were unable to pay this claim due to a missing/unreadable/or invalid ICD code. Please check the accuracy and readability of the claim and resubmit it with a copy of the VHA IVC Explanation of Benefits form for reconsideration. |
Contact Us
Customer Call Centers
CHAMPVA: 800-733-8387
Monday – Friday, 8:05 a.m. – 6:45 p.m., ET
Spina Bifida/Children of Women Vietnam Veterans programs: 888-820-1756
Monday – Friday, 8:00 a.m. – 7:00 p.m., ET
Mailing Addresses for Family Member Claims:
VHA Office of Integrated Veteran Care
ATTN: Appeals
PO Box 460948, Denver CO 80246
VHA Office of Integrated Veteran Care
ATTN: Resubmissions
PO Box 469063, Denver CO 80246