[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283912-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283912-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","champva-claim-form-expiration-and-instructions","CHAMPVA Claim Form - Expiration and Instructions","","CHAMPVA Claim Form for the Department of Veterans Affairs, including submission instructions, eligibility and reporting notices, and required patient and claimant information. The form specifies documentation needed for claims such as itemized billing statements, dates of service, provider identifiers, diagnosis/procedure codes, and pharmacy details when applicable. It also covers Other Health Insurance reporting, timely filing rules, and OHI-related reconciliation with an Explanation of Benefits.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/champva-claim-form-expiration-and-instructions/283912/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/champva-claim-form-expiration-and-instructions/283912.png","ImageObject",442,249,{"name":42,"@type":43},"River Wang","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-29","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",8,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who must complete and submit this CHAMPVA claim form?","Question",{"text":63,"@type":64},"The patient, sponsor, or guardian must complete the form and return it with requested information to the address shown. Provider-submitted claims are not to use this form.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What is required when the beneficiary has Other Health Insurance (OHI)?",{"text":68,"@type":64},"OHI coverage must be reported by checking the appropriate option and providing coverage details. An Explanation of Benefits (EOB) from the other insurer must be attached to the provider’s itemized billing statement(s).",{"name":70,"@type":61,"acceptedAnswer":71},"What are the timely filing requirements for CHAMPVA claims?",{"text":72,"@type":64},"Claims must be received no later than one year after the date of service. For inpatient care, claims must be received within one year of the discharge date.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283912,1790125958,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":22},1099514067438,"https://ap-avatar.wpscdn.com/avatar/100002539ee87300030?x-image-process=image/resize,m_fixed,w_180,h_180&k=1780474512215547542","Expiration Date:12/31/2027  \n\n| Department of Veterans Affairs   |  |  |  |  |  |  | CHAMPVA CLAIM FORM   |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| VHA Office of Integrated Veteran Care CHAMPVA Claims PO Box500,Spring City,PA 19475|Customer Service Center:1-800-733-8387   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| ATTENTION:Refer to the following information for instructions and assistance completing this form in its entirety(print or type only).Return  \u003Cbr>the form and any additional,requested information to the address shown above.  \u003Cbr>Claim form usage:This form is to be completed by the patient,sponsor or guardian and is mandatory for all beneficiary claims.This claim form is NOT  \u003Cbr>to be used for provider submitted claims.  \u003Cbr>Other Health Insurance (OHI):By law,other coverage must be reported.Except for CHAMPVA supplemental policies,CHAMPVA is always the  \u003Cbr>secondary payer.If OHl exists,attach an Explanation of Benefits(EOB)from the other health insurance to the provider's itemized billing statement(s).  \u003Cbr>Dates of service and provider charges on the EOB must match billing statements.  \u003Cbr>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  \u003Cbr>the discharge date.  \u003Cbr>Itemized billing statements:An itemized statement must be attached and contain:  \u003Cbr>·patient name,date of birth,and CHAMPVA ldentification Card Member Number (same as patient's Social Security number);  \u003Cbr>·provider name,NPI,tax identification number (TIN),address and telephone number;and  \u003Cbr>·service dates,temized charges and appropriate procedure/diagnosis codes for each service (ie.,CPT-4,HCPCS,and ICD-9-CM codes),  \u003Cbr>including narrative descriptions.  \u003Cbr>Pharmacy claims must include name,quantity,strength,and National Drug Code(NDC)of each drug.   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Last Name (requiredfield)   |  |  |  | SECTIONI-PATIENT INFORM  \u003Cbr>First Name (required field)   |  |  |  |  | ATION   |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  | MI   | CHAMPVA Member Number(required field)   |  |  |  |  |  |\n| □Check if new address   | Street Address   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| City   |  |  |  |  |  |  |  |  |  |  |  | State   |  | Zip Code (99999-9999)   |  |\n| Date of Birth (MM/DD/YYYY)   | Phone Number (include area code)((999)999-9999)   |  |  |  |  |  |  |  | Email Address   |  |  |  |  |  |  |\n| SECTIONIⅡ-OTHER HEALTH INSURANCE(OHI)INFORMATION  \u003Cbr>If more space is needed,please continue in the same format on a separate sheet.   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Is patient covered by OHI,to include coverage through a family member?(Supplemental or secondary insurance excluded)  \u003Cbr>□Yes (check type and provide coverage information below)      No(proceed to Section II)  \u003Cbr>□Employer sponsored (group)□Private (non group)   □Medicare (Part Aor B)  □Other (Specify):   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Name of Other Health Insurance (OHI)   |  |  |  |  |  |  |  | Name of Other Health Insurance(OHI)   |  |  |  |  |  |  |  |\n| Policy Number   |  |  |  |  |  |  |  | Policy Number   |  |  |  |  |  |  |  |\n| OHI Effective Date(MM/DD/YYYY)   |  | OHI Termination Date (MMDD/YYYY)   |  |  |  |  |  | OHI Effective Date (MM/DD/YYYY)   |  |  |  |  | OHI Termination Date(MMDD/YYYY)   |  |  |\n| Phone Number (include area code)((999)999-9999)   |  |  |  |  |  |  |  | Phone Number (include area code)((999)999-9999)   |  |  |  |  |  |  |  |\n| Was treatment for a work-related injury/condition?□Yes □No   |  |  |  |  |  |  |  | Was treatment for an injury or accident outside of work?□Yes □No   |  |  |  |  |  |  |  |\n| SECTIONⅢ-SPON   |  |  |  |  |  |  |  | SOR INFORMATION   |  |  |  |  |  |  |  |\n| Last Name   |  |  |  |  |  |  |  | MI  \u003Cbr>First Name   |  |  |  |  |  |  |  |\n| SECTION VI-CLAIMANT CERTIFI","cbCaicVC9XWfcjAn","https://ap.wps.com/l/cbCaicVC9XWfcjAn","pdf",821696,"English","# Claim submission instructions\n## Other Health Insurance (OHI) reporting\n## Patient information and member certification\n## Claimant certification, notices, and privacy act","[{\"question\":\"Who must complete and submit this CHAMPVA claim form?\",\"answer\":\"The patient, sponsor, or guardian must complete the form and return it with requested information to the address shown. Provider-submitted claims are not to use this form.\"},{\"question\":\"What is required when the beneficiary has Other Health Insurance (OHI)?\",\"answer\":\"OHI coverage must be reported by checking the appropriate option and providing coverage details. An Explanation of Benefits (EOB) from the other insurer must be attached to the provider’s itemized billing statement(s).\"},{\"question\":\"What are the timely filing requirements for CHAMPVA claims?\",\"answer\":\"Claims must be received no later than one year after the date of service. For inpatient care, claims must be received within one year of the discharge date.\"}]","CHAMPVA Claim Form - Expiration and Instructions | PDF",1789622389]