CHAMPVA Claim Form (Beneficiary Claim)

Your information as the CHAMPVA beneficiary (the covered dependent, not the veteran). Include your CHAMPVA eligibility number from your CHAMPVA card or authorization letter. If you don't have it, use the veteran sponsor's VA File Number.

(your name, SSN, CHAMPVA eligibility number)

Common mistakes

• ×Submitting under the veteran's information instead of the beneficiary who received care.

For each claim: provider name and address, date(s) of service, diagnosis code (ICD), procedure code (CPT) if available, and charges. If you have the itemized bill, attach it and reference it here.

e.g., Dr. Jane Smith, MD; 05/15/2026; Diagnosis: J06.9 (URI); Office visit: $185. Paid $185 out-of-pocket.

Common mistakes

• ×Not attaching the itemized bill - CHAMPVA cannot process without it.
• ×Submitting only a summary bill ("office visit $185") without itemized CPT codes.
• ×Forgetting to submit the other insurance EOB first - CHAMPVA is always secondary to other insurance.
• ×Claiming beyond the 1-year filing deadline - CHAMPVA will not reimburse claims older than 1 year.

Authority

• 38 CFR 17.270 - Spouse/child of veteran rated 100% P&T or who died of service-connected condition.

CHAMPVA is always the payer of last resort. If Medicare or private insurance covered part of the cost, attach their Explanation of Benefits (EOB). CHAMPVA will pay only the cost-sharing amount after other insurance. If you have no other insurance, note that clearly.

e.g., No other insurance. OR: Medicare paid $148; CHAMPVA should cover remaining cost-share.

Common mistakes

• ×Not submitting other insurance EOB - CHAMPVA will put your claim on hold until they receive it.
• ×Not knowing CHAMPVA cost-shares: 25% of allowable charges after the annual deductible.

Sign and date certifying the services were received and the charges are accurate. Mail to: VA HAC, P.O. Box 469069, Denver CO 80246.

(your signature/date)

Common mistakes

• ×Mailing to the local VAMC instead of CHAMPVA Center in Denver.