Overview

The Spina Bifida Health Care Benefits Program provides health care benefits to the birth children of Vietnam and certain Korean Veterans who have been diagnosed with spina bifida (except spina bifida occulta). The program covers medically necessary and appropriate health care services related to spina bifida.

To participate, providers must be properly licensed in their state and must not be on the Medicare exclusion list. Additionally, providers must accept the VA-determined allowable amount for care.

Spina bifida beneficiary eligibility and preauthorization

To be eligible for the Spina Bifida Health Care Benefits Program, a child must first be eligible for a monetary award through the Veterans Benefits Administration (VBA).

Spina bifida eligibility verification

• 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.
    
    
• 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.

Spina bifida preauthorization

Preauthorization is required for the following:

• Attendant services
• Dental services
• Durable medical equipment costing more than $2,000
• Homemaker services (must be health-related services)
• Outpatient mental health services in excess of 23 visits per calendar year
• Substance abuse treatment
• Training of family members, guardians and members of the child’s household
• Transplantation services
• Travel (other than mileage for local travel and when one way trip is more than 50 miles) in private automobiles at the General Services Administration (GSA) rate
  
  

Fax or email preauthorization requests to:

Spina bifida claims

Include the following information when submitting spina bifida claims:

• Standard billing form: UB-04 Uniform Bill (CMS 1450) or Centers for Medicare and Medicaid Services-Health Insurance Claim Form (CMS 1500)
• Patient’s first and last name as it appears on the VA program identification card. The patient is always the subscriber
• Member ID (Social Security Number)
• Patient’s date of birth

How to file a spina bifida claim

There are two ways to file a spina bifida 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, Optum Insight.
  • Medical Payer ID: 84146
  • Dental Payer ID: 84147

• Paper claims

For questions about submitting electronic claims through the VA clearinghouse, contact Optum Insight Customer Support.

Check claim status

Check medical claim status electronically through the VA clearinghouse using 276/277 HIPAA claim status transactions.

Pharmacy benefits for spina bifida

Providers participating in the OptumRx Network may deliver services to VA beneficiaries. If you are not currently a participant, contact the OptumRx Pharmacy Helpdesk 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