Decision reviews and appeals for family member care
If you are a community provider and don’t agree with a VA decision related to care you provided under a family member care program, you may request further review. This page explains the decision review and appeal options available and how to submit a request.
This information applies to providers seeking decision reviews or appeals related to the following programs:
- Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
- Foreign Medical Program
- Spina Bifida Health Care Benefits Program
- Children of Women Vietnam Veterans Health Care Benefits Program
- Camp Lejeune Family Member Health Care Benefits Program
Requests that do not require a decision review
You do not need to request a decision review or appeal to:
- Submit missing documentation
- Provide Other Health Insurance (OHI) Explanation of Benefits (EOB)
- Submit proof of payment
Decision review and appeal options
There are multiple options available to providers who do not agree with a payment decision. You may pursue only one review option at a time. VA Form 20-0998 explains your decision review rights and outlines the available review options.
If you disagree with the payment decision or eligibility determination and have new and relevant evidence to submit or want to request a review of your claim based on a change in law, a supplemental claim may be an option for you with both of the following:
- New evidence is information that hasn’t been considered before.
- Relevant evidence is information that proves or disproves something in your claim.
Unless your supplemental claim is based on a change in law, you will need to submit supporting evidence that is new and relevant for your request to be complete. Supplemental claims may be submitted anytime.
VFMP Appeals
PO Box 600
Spring City PA 19475
If you disagree with a VA payment decision, you can request a new review of your claim by a higher-level reviewer. The reviewer will determine whether an error or a difference of opinion changes the claims processing decision. You can’t submit new evidence with a Higher-Level Review. Requests for Higher-Level Review must be submitted within 1 year of the decision.
VFMP Appeals
PO Box 600
Spring City PA 19475
When you choose this option, you’re appealing to a Veterans Law Judge at the Board of Veterans’ Appeals. For more information, visit the VA Board Appeals webpage.
Clinical appeals of preauthorizations
Clinical appeals apply to preauthorization determinations for services that have not yet occurred. The process below explains how to submit a clinical appeal.
If you disagree with a VA determination regarding preauthorization of covered services or supplies, submit your clinical appeal in writing and include:
- An explanation of why you believe the decision is in error
- Any new and relevant information not previously considered
If you disagree with the outcome of the first-level review, you may submit a written request for a second-level clinical review. Submit all first-level and second-level clinical appeals in writing to:
VFMP Appeals
P.O. Box 600
Spring City PA 19475
NOTE: Retroactive preauthorization requests for services that have already occurred follow the process in the Decision Review and Appeal section above.
Request assistance
As a community provider, you may contact us to discuss CHAMPVA or family member care claims processing questions and review options.
VA Customer Support: 800-733-8387
Related pages
Family member care
- CHAMPVA
- Spina Bifida Healthcare Benefits Program
- Children of Women Vietnam Veterans
- Camp Lejeune Family Member Program
- Decision reviews and appeals–Family member care
- Family member claim denial codes