CHAMPVA
Overview
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.
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.
Note about GLP-1 medication coverage
- CHAMPVA does not cover GLP-1 medications prescribed for weight loss.
- Coverage is limited based on diagnosis:
- For type 2 diabetes, CHAMPVA covers Mounjaro, Ozempic, Rybelsus, Trulicity, and Victoza
- For moderate to severe obstructive sleep apnea, verified by a sleep study within the past 12 months, CHAMPVA covers Zepbound
- For metabolic-associated steatohepatitis (MASH) or prevention of major adverse cardiovascular events (MACE), CHAMPVA covers Wegovy
- Prior authorization is required for Wegovy and Zepbound. Submit requests to OptumRx at 844-403-1029.
CHAMPVA beneficiary eligibility and preauthorization
Providers can verify CHAMPVA beneficiary eligibility electronically or by phone.
- Electronic verification
Check eligibility status 24/7 through your electronic data interchange (EDI) system. After connecting with VA’s clearinghouse, Change Healthcare (Optum), or another clearinghouse of your choice, submit an eligibility and benefit inquiry (270) transaction.- VA’s real-time payer ID is VAHAC.
- VA’s real-time payer ID is VAHAC.
- Phone verification
Call 888-820-1756 to verify eligibility. Available 24 hours a day, 7 days a week. Have the beneficiary’s Social Security Number and your tax ID number available when calling.
Preauthorization is required for dental care, organ and bone marrow transplants, and most mental health or substance abuse services. To request preauthorization, call the VA Customer Call Center.
VA Customer Call Center: 800-733-8387
Monday-Friday, 8:05 a.m. to 7:30 p.m. ET
CHAMPVA claims
This information is for CHAMPVA providers only. There are two ways to file a claim: electronically or by mail. Submit claims electronically for faster processing times.
- Electronic claims
Submit a HIPAA-compliant 837 electronic data interchange (EDI) health care claim through the VA clearinghouse, PNT Data.- Medical Payer ID: 84146
- Dental Payer ID: 84147
- Paper claims
VHA Office of Integrated Veteran Care
CHAMPVA Claims
PO Box 30750 Tampa, FL 33630-3750
For questions about submitting electronic claims through the VA clearinghouse, contact PNT Data Customer Support.
PNT Data Customer Support: 860-257-2030
Monday–Friday, 8 a.m.–8 p.m. ET
Email: Support@pntdata.com
Resubmitting claims
Include the CHAMPVA EOB when resubmitting a claim. Do not resubmit claims with only a claim number, as this may delay processing.
Check CHAMPVA claim status
Check medical claim status electronically through the VA clearinghouse using 276/277 HIPAA claim status transactions.
Tips to help avoid delays or denials
We have compiled the following information to help ensure your CHAMPVA claim is processed correctly the first time it is submitted.
- Include the complete nine-digit EIN/TIN (Employer Identification Number/Taxpayer Identification Number). Extra digits or letters may delay processing or cause incorrect payment.
- Include both the billing address and the physical address where services were provided (do not use a PO Box as a physical address)
- Ensure the patient’s legal name (no nicknames), address, Social Security Number (SSN), and date of birth are correct
- Ensure all attachments include patient information that matches the claim
- Submit EOBs from all primary and secondary insurance plans, if applicable
- Ensure all billed services appear on submitted EOBs, even if not covered
- Submit only adjudicated EOBs showing payment or denial
- Submit professional and facility fees on separate claim forms. Submitting both on the same form may result in incorrect processing.
- Use the correct anesthesia code when billing anesthesia services. Do not use the surgical equivalent.
- Include all required surgery codes and corresponding charges when billing for ambulatory surgery services. Missing codes may delay processing.
- Bill each service and each date of service as a separate line item to ensure accurate reimbursement and avoid underpayment
- Billing each service separately is especially important for Evaluation and Management (E/M) codes (99201–99288, 99304–99318, 99354–99499)
- Align your claim form so all data prints in the correct fields
- Use a legible font and avoid light print
- Do not use highlighters
- Do not staple, clip, tear, or tape documents
- Ensure handwritten claims are legible
Pharmacy benefits for CHAMPVA
Pharmacies participating in the OptumRx Network may fill prescriptions for CHAMPVA beneficiaries. If you are not currently a participant, contact the OptumRx Pharmacy Help Desk for contracting information.
Prescriptions filled at pharmacies outside the OptumRx network must be paid in full by the patient. The patient may then submit a claim to the VHA Office of Integrated Veteran Care for reimbursement.
Pharmacy claims routing information
- BIN: 610593
PCN: VA
Group: HAC - Use the beneficiary’s Social Security Number (SSN) as 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 are automatically transmitted electronically to OptumRx. Contact the OptumRx Help Desk if you have questions or need assistance submitting a claim.
Pharmacy benefits contact
OptumRx Pharmacy Help Desk: 888-546-5503
For pharmacists who have questions or need assistance from OptumRx.
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CHAMPVA contact
VA Customer Call Center: 800-733-8387
Monday-Friday, 8:05 a.m. to 7:30 p.m. ET