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FS01-16 For Outpatient Providers and Office Managers. Fact Sheet 01-16 For Outpatient Providers and Office Managers - va

FS01-16 For Outpatient Providers and Office Managers. Fact Sheet 01-16 For Outpatient Providers and Office Managers - va 2025

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CHAMPVA is a health benefits program managed by the Department of Veterans Affairs that shares healthcare costs with eligible beneficiaries. It differs from TRICARE, as individuals eligible for TRICARE cannot receive CHAMPVA benefits. Preauthorization is required for certain services, and dental care is generally not covered unless related to a medical condition. Providers must accept CHAMPVA's allowable rates and can submit claims electronically or via paper. CHAMPVA typically pays 95% of claims within 30 days and serves as a secondary payer to other health insurance.

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What is not covered under Champva?

For example, CHAMPVA does not cover dental, chiropractic services, routine eye exams or corrective lenses. It is possible that Medicaid recipients could have less of a financial burden if covered by Medicaid than under CHAMPVA program.

How do providers submit claims to Champva?

To submit a CHAMPVA, CLFMP, CWVV or SBHCP claim, you must use a standard billing form to provide the required informationUB-04 Uniform Bill (CMS 1450) or Centers for Medicare and Medicaid Services-Health Insurance Claim Form (CMS 1500). Electronic pharmacy claims should be submitted through OptumRx.

Does Champva require a referral to a specialist?

CHAMPVA is a fee-for-service plan under which the VA provides coverage through civilian doctors for certain veterans family members. CHAMPVA patients may find their own doctors. Visits with other doctors, including specialists, do not require pre-approval in most cases.

Do providers have to accept Champva?

Do I have to accept the CHAMPVA allowable rate? Yes, under 38 CFR section 272(b) (3) and (4), providers who agree to accept the beneficiary must accept the CHAMPVA allowable charges and cannot balance bill the beneficiary.

Does Champva contract with providers?

No. CHAMPVA does not have contract providers.

How to find a provider that accepts Champva?

Theres no specific network of CHAMPVA providers. When you find a new provider, ask if they accept assignment from CHAMPVA. This means they agree to accept CHAMPVA insurance and to charge only the allowable amount. If you go to a provider who doesnt accept CHAMPVA, we may still cover some of the cost.

Does Champva cover outpatients?

CHAMPVA will cover some or all of your Medicare Part B deductible for outpatient care.

What are the disadvantages of Champva?

There are a few drawbacks when it comes to CHAMPVA such as: Eligibility qualifications may be confusing, including the notion that if an individual is eligible for TRICARE, they are not eligible for CHAMPVA. It can take many months for CHAMPVA applications to be processed and put into effect.

FS01-16 For Outpatient Providers and Office Managers. Fact Sheet 01-16 For Outpatient Providers and Office Managers - va 2025

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