CHAMPVA Cards and Billing: How to Read the Card and File the Claim

CHAMPVA (the Civilian Health and Medical Program of the Department of Veterans Affairs) is a health benefit for the spouse, surviving spouse and dependent children of a veteran who is permanently and totally disabled from a service-connected condition, or who died from one. The veteran is the sponsor; the family members are the beneficiaries, and they can be treated by any licensed provider who accepts Medicare rates, with the claim paid by the VA from Denver. It is not TRICARE, and it is not VA care; a CHAMPVA patient is a civilian with federal coverage.

Many billers see a CHAMPVA card only a few times a year and apply the TRICARE rules by mistake. The two programs look alike but work differently.

Reading the card

The CHAMPVA identification card is a plain card from the VA Office of Integrated Veteran Care (the former Office of Community Care). It is not a smart card and it does not prove current eligibility, which is why the first step is always a check.

On the card	What it is	Where it goes on the claim
Beneficiary name	the patient, not the veteran	box 2
Member number	the beneficiary’s own identifier (historically the sponsor’s SSN; newer cards use a VA-assigned number)	box 1a, insured’s ID
Sponsor name and status	the veteran whose disability or death created the eligibility	box 4 and box 11, with “CHAMPVA” as the plan
Effective date	when coverage began; ends at remarriage before age 55 for a spouse, or at 18 (23 if a student) for a child	eligibility check
Claims address	For providers: VHA Office of Integrated Veteran Care, CHAMPVA Claims, PO Box 30750, Tampa FL 33630-3750. (The Denver PO Box 469064 printed in older guides is for beneficiaries filing their own reimbursement claims.)	where the paper claim goes
Customer service number	800-733-8387	eligibility and claim status

CHAMPVA, TRICARE and VA care are three different things

	CHAMPVA	TRICARE	VA community care
Who is covered	family of a permanently disabled or deceased veteran	active duty, retirees and their families	the veteran, when the VA authorizes care outside its own facilities
Run by	Department of Veterans Affairs, centrally in Denver	Department of Defense, through regional contractors	the VA, through authorizations and a third-party administrator
Network	none; any Medicare-accepting provider	contracted networks by region	referral and authorization required for each episode
Pays	CHAMPVA allowable, tied to the Medicare fee schedule	TRICARE allowable	VA fee schedule, per the authorization
Patient cost share	25 percent of the allowable after a 50.00 annual deductible per person (100.00 per family), with an annual cap of 3,000	varies by plan	none to the veteran

A veteran’s spouse cannot be covered by both CHAMPVA and TRICARE; if the veteran qualifies for TRICARE (for example as a military retiree), the family uses TRICARE.

Filing the claim

1. Verify eligibility first. Call 800-733-8387 or use the VA’s provider portal. The card alone does not prove current coverage, and a child who turned 18 last month may no longer be covered.
2. Bill every other insurance before CHAMPVA. CHAMPVA is secondary to Medicare, Medicare Advantage, employer plans and individual plans. A beneficiary over 65 must be enrolled in Medicare Part B to keep CHAMPVA. Attach the primary payer’s EOB to the CHAMPVA claim.
3. Use the standard forms. CMS-1500 for professional services, UB-04 for facility. Electronic claims are accepted through clearinghouses using the CHAMPVA payer ID; your clearinghouse will have it on its payer list.
4. Code normally. CPT, HCPCS, ICD-10 and modifiers as for any other payer. There are no CHAMPVA-specific codes.
5. File within one year. Claims must be filed within one year of the date of service (for inpatient care, one year from discharge).
6. Expect Medicare rates. CHAMPVA’s allowable is based on the Medicare fee schedule, and a provider who accepts a CHAMPVA patient accepts the allowable as payment in full apart from the cost share. You may not balance-bill.

A worked example

A CHAMPVA beneficiary, age 58 with no other insurance, has a weekly radiation treatment management visit (CPT 77427). The allowable is 190.00 (illustrative). She met her 50.00 deductible in January.

	Amount
Allowable	190.00
Deductible applied	0.00 (already met)
Patient cost share, 25 percent	47.50
CHAMPVA pays	142.50
Provider may bill the patient	47.50 and nothing more

If the same patient were 68 with Medicare Part B, Medicare would pay first (80 percent of its allowable), the claim would cross over or be filed to CHAMPVA with the Medicare remittance attached, and CHAMPVA would generally pay the remaining 20 percent, leaving the patient with nothing to pay. This is the main reason to confirm the patient’s Medicare status at check-in.

What to do

• Put CHAMPVA in your payer list as a secondary payer by default, with Medicare rates and the Tampa provider claims address, so the front desk does not set it up as a TRICARE plan.
• Collect the EOB from the primary before the CHAMPVA claim goes out; without it the claim is returned.
• Track the one-year limit like any other timely filing rule. Iridium Suite’s claim scrubber can hold a payer-specific timely filing rule for CHAMPVA so the claim is flagged before the deadline.
• Denials to recognize: eligibility (verify and rebill, or bill the patient if coverage had ended), other health insurance not reported (attach the primary EOB), and timely filing.

Related terms

• Secondary claims: three ways to file
• Medicare crossover claims
• Timely filing limits by payer
• Coordination of benefits
• TRICARE billing basics

Further reading: VA: CHAMPVA benefits; VA: Filing a CHAMPVA claim, with current claims addresses; VA: Information for providers.