The Department of Veterans Affairs (VA) health care program is a cornerstone of support for those who have served in the military. For healthcare providers working with veterans, understanding the nuances of VA claim processing is crucial for ensuring timely and accurate payments. This article delves into the VA claims system, clarifying common rejection reasons and guiding providers on how to navigate the process effectively. While the VA health care system provides significant benefits to veterans, it’s important to understand if it aligns with the principles of universal care and how its claim processes function.
Navigating VA Claims: Accepted, Denied, and Rejected
The VA categorizes processed claims into three distinct statuses: accepted, denied, or rejected. This classification system is essential for providers to understand the outcome of their submissions and any necessary follow-up actions.
- Accepted Claims: These are correctly submitted claims for pre-authorized care. Providers can expect prompt payment for accepted claims, ensuring a smooth revenue cycle for the services rendered to veterans.
- Denied Claims: Claims are denied when pre-authorization for care was not obtained, or if the veteran does not meet the specific eligibility criteria for emergency care coverage under VA programs. Understanding these denial reasons is vital for providers to ensure adherence to VA guidelines and patient eligibility.
- Rejected Claims: Rejection signifies that a claim cannot be processed for payment or denial due to errors in billing or the need for further information. Crucially, rejected claims are not final. Providers have the opportunity to correct errors, provide the required information, and resubmit the claim for reconsideration and processing.
CHAMPVA and Electronic Funds Transfer (EFT)
For providers working with the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), remark codes CARC 299 and RARC N24 indicate potential resolution through enrollment in Electronic Funds Transfer (EFT). EFT enrollment streamlines payment processes, reduces administrative burden, and can help resolve issues associated with these specific remark codes.
The VA Financial Services Center (FSC) Customer Engagement Portal offers comprehensive resources and support for providers. Enrolling in EFT through the Payment Account Setup webform, accessible via the portal, is a recommended step. The Vendor Webform User Guide provides step-by-step instructions, and the FSC Customer Support Help Desk is available for direct assistance.
Seeking Further Claim Information
Beyond the Preliminary Fee Remittance Advice Report (PFRAR) and the Customer Engagement Portal (CEP), providers may require additional clarification on claim statuses. In such cases, contacting the designated customer service support unit that adjudicated the claim is recommended. These units are equipped to provide specific guidance and direct providers on the necessary steps for claim reprocessing.
Electronic Conversion and Claim Rejections
The VA mandates electronic submission for all claims, necessitating a conversion process for paper claims to the 837 electronic format. This conversion involves a dual error review: initially during electronic conversion and subsequently during the formal claims processing stage. Claims found to be non-compliant with standardized billing requirements during conversion are rejected. Providers are notified of these rejections via letters detailing the error and rejection reason, allowing for correction and resubmission.
Top 10 Claim Rejection Reasons for Veteran Care (HCFA/CMS-1500)
For HCFA/CMS-1500 paper claims, commonly used for physician and outpatient services, the top rejection reasons include:
| Rank | Code | Reason/Detail |
|---|---|---|
| 1 | 016 | Missing/Incomplete/Invalid Insured ID (Requires 17-digit ICN or 9-digit SSN) |
| 2 | 086 | Missing Insurance Plan Name or Program Name |
| 3 | 092 | Missing/Invalid Admission Date for POS 21 (Refer to Box 18) |
| 4 | 088 | Invalid Service Facility Address (Must be valid street address) |
| 5 | 005 | Missing NDC Units |
| 6 | 002 | Missing/Invalid “Place of Service” codes |
| 7 | 081 | Invalid Rendering NPI |
| 8 | 034 | Claim contains ICD9 Principal Dx code (ICD-10 required after 09/30/2015) |
| 9 | 105 | Invalid Service line Provider Taxonomy code |
| 10 | 004 | Invalid/Incomplete CPT/HCPCS codes |
These rejection reasons highlight the importance of meticulous attention to detail when completing claim forms, particularly regarding patient identification, dates, addresses, and coding accuracy.
Top 10 Claim Rejection Reasons for Veteran Care (UB/CMS-1450)
For UB/CMS-1450 paper claims, typically used for hospital and inpatient services, common rejection reasons include:
| Rank | Code | Reason/Detail |
|---|---|---|
| 1 | 016 | Missing/Incomplete/Invalid Insured ID (Requires 17-digit ICN or 9-digit SSN) |
| 2 | 125 | Missing “Admission Type” code (Outpatient claim) |
| 3 | 097 | Missing Admission Type when Admission Date is Present |
| 4 | 108 | Referring and Attending Physician NPI are equal |
| 5 | 007 | Missing/Invalid Billing Provider Address |
| 6 | 013 | Claim contains missing or invalid Patient Status |
| 7 | 034 | Claim contains ICD9 Principal Dx code (ICD-10 required after 09/30/2015) |
| 8 | 031 | Missing/Invalid “Patient Reason” diagnosis code |
| 9 | 021 | Missing Patient Account Number |
| 10 | 117 | Invalid “Type of Bill” code |
Similar to HCFA-1500 claims, UB-1450 rejections often stem from incomplete or inaccurate administrative and coding information. Providers should double-check admission details, provider information, patient status, and diagnostic codes.
Top 10 Rejection Reasons for Family Member Care (CHAMPVA)
Claims for family member programs like CHAMPVA have a distinct set of common rejection reasons, often related to coordination of benefits and eligibility:
| Rank | Code | Reason/Detail |
|---|---|---|
| 1 | 65/159/177 | Duplicate claim – Previously processed (Contact Customer Call Center, do not resubmit) |
| 2 | 78 | EOB from other insurance required – VHA IVC secondary payer (Resubmit with primary EOB) |
| 3 | 124 | Claim not timely filed (File within 365 days of service, appeal possible for exceptions) |
| 4 | 278 | Multiple primary insurance coverage (Resubmit EOBs from each payer) |
| 5 | 148 | Claim denied – Chiropractic services not covered (Contact Customer Call Center for review) |
| 6 | 137 | Beneficiary not eligible on date of service claimed (Verify eligibility period) |
| 7 | 224 | Must provide medical history/documentation to support treatment (Resubmit with documentation) |
| 8 | 218/220 | Clarification of OHI information required (Submit CHAMPVA OHI Certificate or call Customer Service) |
| 9 | 27 | Not a covered service/benefit for diagnosis listed (Review VHA IVC policy manuals) |
| 10 | 391 | ICD diagnostic code(s) missing/unreadable/invalid (Resubmit with corrected codes and EOB) |
These CHAMPVA rejection reasons emphasize the importance of understanding benefit coordination, timely filing deadlines, service coverage limitations, and accurate beneficiary eligibility verification. The need for Other Health Insurance (OHI) information is a recurring theme, highlighting the secondary payer role of CHAMPVA in many cases.
Is The Veterans Health Care Program Universal Care?
While the VA health care system offers substantial and often comprehensive medical benefits to enrolled veterans, it is not considered universal care in the same way that some national healthcare systems are. Universal healthcare typically implies healthcare access for all citizens or residents of a nation, regardless of factors like military service, employment history, or income level.
The VA system, in contrast, is specifically designed for veterans who meet certain eligibility criteria based on their military service. It is a targeted program, not a universal one. However, within its target population, the VA aims to provide a broad spectrum of healthcare services, striving for high quality and accessibility for enrolled veterans.
In the context of claim processing, the VA’s system, while not universally accessible, aims for comprehensive coverage for eligible veterans. The detailed claim review processes, categories of accepted, denied, and rejected claims, and the support systems for providers all contribute to ensuring that veterans receive the care they are entitled to, within the framework of this targeted program. Understanding the intricacies of VA claim processes is therefore essential for providers to effectively participate in this critical aspect of veterans’ healthcare.
Contact and Support Resources
For further assistance and clarification, the VA provides multiple contact points:
- Ask VA (AVA): An online portal for inquiries and secure communication.
Customer Call Centers
- CHAMPVA: 800-733-8387 (Monday – Friday, 8:05 a.m. – 6:45 p.m., ET)
- Spina Bifida/Children of Women Vietnam Veterans programs: 888-820-1756 (Monday – Friday, 8:00 a.m. – 7:00 p.m., ET)
Mailing Addresses for Family Member Claims:
- Appeals: VHA Office of Integrated Veteran Care Appeals, PO Box 600, Spring City PA 19475
- Resubmissions: VHA Office of Integrated Veteran Care Resubmissions, PO Box 500, Spring City PA 19475
By utilizing these resources and diligently addressing claim rejection reasons, healthcare providers can play a vital role in ensuring veterans receive the healthcare benefits they deserve through the VA system.
