Table of Contents
VA Form 10-7959A Printable, Fillable in PDF – This form is to be completed by the patient, sponsor, or guardian and is mandatory for all beneficiary claims. This claim form is NOT to be used for provider submitted claims.
Other Health Insurance (OHI)
If OHI exists, attach OHI’s Explanation of Benefits (EOB) to the provider’s itemized billing statement(s). Dates of service and provider charges on EOB must match billing statements.
Timely Filing Requirement
Claims must be received no later than one year after the date of service or, in the case of inpatient care, within one year of the discharge date.
Itemized Billing Statements
An itemized statement must be attached and contain:
- Patient name, date of birth, and CHAMPVA Identification Card (ID-Card) Member Number (same as patient’s Social Security number);
- Provider name, degree, tax identification number (TIN), address and telephone number; and
- Service dates, itemized charges and appropriate procedure/diagnosis codes for each service (i.e. CPT-4, HCPCS, and ICD-9-CM codes), including narrative descriptions. Pharmacy claims are to include name, quantity, strength, and NDC of each drug.