Vha Form 10-7959a - Champva Claim Form

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OMB Number: 2900-0219
Est. Burden: 10 minutes
CHAMPVA Claim Form
VA Health Administration Center
CHAMPVA
PO Box 469064
Denver CO 80246-9064
1-800-733-8387
Attention: After reviewing the following information, complete the form in its entirety (print or type only) and return with the
required documentation.
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 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.
Section I - Patient Information
Last Name (this is a mandatory field)
First Name (this is a mandatory field)
MI
CHAMPVA Member Number (this is a mandatory field)
Street Address
Date of Birth (mm/dd/yyyy)
Check if new
City
State
ZIP Code
Telephone Number (include area code)
Section II - Other Health Insurance (OHI) Information
By law, other coverage must be reported. Except for CHAMPVA supplemental policies, CHAMPVA is always the secondary payer.
If more space is needed, please continue in the same format on a separate sheet.
• Was treatment for a work-related injury or
Name of Other Health Insurance (OHI)
condition?
Yes
No
• Was treatment for an injury or accident
outside of work?
Yes
No
OHI Policy Number
OHI Telephone Number (include area code)
• Is patient covered by other primary health
insurance to include coverage through a
family member (supplemental or
secondary insurance excluded)?
Name of Other Health Insurance (OHI)
Yes (check type below and provide
coverage information on the right)
employer sponsored (group)
private (non group)
OHI Policy Number
OHI Telephone Number (include area code)
Medicare (Part A or B)
other
(specify)
no (proceed to Section III)
Section III - Sponsor Information
Last Name
First Name
MI
CHAMPVA Member Number (this is a mandatory field)
Section IV - Claimant Certification
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting or making false, fictitious, or fraudulent statements or claims.
I certify that the above information and attachments are correct
Signature (type if electronic)
Date
4
and represent actual services, dates, and fees charged. (Sign and
date on right.) If certification is signed by a person other than the
patient, complete the information the signature and date.
MI
Relationship to Patient
Last Name
First Name
Street Address
City
State
ZIP Code
Telephone Number (include area code)
VA FORM
10-7959a
MAY 2010

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