What is CHAMPVA?
CHAMPVA is a health benefits program in which the Department of Veterans Affairs (VA)
shares the cost of certain health care services and supplies with eligible beneficiaries
(see Eligibility Fact Sheet 01-03 for criteria for CHAMPVA coverage). CHAMPVA is
managed by the VA’s Health Administration Center (HAC) in Denver, Colorado. We
process CHAMPVA applications, determine eligibility, authorize benefits, and process
medical claims.
How does CHAMPVA relate to TRICARE?
Both are federal programs, however, an individual who is eligible for TRICARE is not
eligible for CHAMPVA. Although similar, TRICARE (formerly CHAMPUS – which is
administered by the Department of Defense) should not be confused with CHAMPVA.
TRICARE provides coverage to the families of active duty service members, families of
service members who died while on active duty, and retirees and their families, whether or not the veteran is disabled.
Is preauthorization required for services?
Certain types of carelservices require advance approval commonly known as
preauthorization. This approval or preauthorization is extremely important and the
failure to obtain it may result in denial of the claim. Preauthorization is required for:
–Dental care
–Durable medical equipment with a purchase price or total rental price of $300 or
more
–Hospice services
–Mental healthlsubstance abuse services (see Mental Health and Substance Use
–Disorder Benefits Fact Sheet 01 -01 )
–Transplants
Do I need approvals for referrals to specialists or for diagnostic tests?
No, as long as they are medically necessary.
Are case management and utilization reviews performed?
Yes, clinical claims reviews are performed for a variety of medical services including physical, occupational and speech therapy, home health, skilled nursing, rehabilitation, and utilization of controlled substances. Simply submit the medical documentation along with your claim. Utilization reviews are also performed for services requiring preauthorization.
Is there a contract or agreement that I must sign to acceptlparticipate in
CHAMPVA?
No. CHAMPVA does not have contract providers. You must be properly licensed in your
state to receive payment from CHAMPVA and cannot be on the Medicare exclusion list.
Do I have to accept the CHAMPVA allowable rate?
Yes, under 38 CFR section 17.272(b) (3) and (4), providers must accept the CHAMPVA
allowable rate and cannot balance bill the beneficiary.
