The short answer
A provider who accepts CHAMPVA assignment agrees to take CHAMPVA's allowable amount as payment in full. They can bill you your deductible and cost share, but not the difference between their price and CHAMPVA's. A provider who doesn't accept assignment can ask you to pay upfront and bill you above the allowable amount. Ask before your visit.
What does accepting assignment mean?
It's an agreement about payment. Under 38 CFR 17.270 and 38 CFR 17.272(b), a provider who accepts assignment:
- bills CHAMPVA for your covered care,
- accepts CHAMPVA's allowable amount as payment in full, and
- can collect only your deductible and cost share from you.
The CHAMPVA Guidebook says it plainly: a provider that accepts assignment can't bill you for the difference between the allowable amount and what they normally charge.
The regulation also says a provider who tries to collect more can be excluded from federal health programs.
What if the provider doesn't accept assignment?
You can still see them. VA's CHAMPVA care page says you may have to:
- pay the provider yourself,
- file the claim yourself, and
- pay anything above CHAMPVA's allowable amount.
CHAMPVA reimburses you based on its allowable amount, not the full bill. And the extra above the allowable amount doesn't count toward your $3,000 yearly cap.
Example
A provider bills $300. CHAMPVA's allowable amount is $200. Your deductible is met.
| Accepts assignment | Doesn't accept assignment | |
|---|---|---|
| Your 25% cost share | $50 | $50 |
| The $100 above the allowable amount | Not yours to pay | Can be billed to you |
| You could owe | $50 | $150 |
What should you ask before the visit?
"Taking CHAMPVA" can mean different things. Ask specifically:
"Do you accept CHAMPVA assignment, and will you bill CHAMPVA directly under payer ID 84146?"
If you have other insurance, tell them which plan pays first. More here: How to find a provider that takes CHAMPVA.
Is there a hospital rule?
Yes. Under 38 CFR 17.272(b), a hospital that participates in Medicare has to accept CHAMPVA's allowable amount as payment in full for inpatient care. That's narrower than saying every Medicare provider has to take CHAMPVA. More here: When hospitals must accept CHAMPVA.
What do you do if an assigning provider overbills you?
- Compare the bill with your CHAMPVA explanation of benefits (EOB) for the same date. Look at the billed amount, the allowed amount, what CHAMPVA paid, and what the EOB says you owe.
- Confirm the provider accepted assignment for that service.
- Call the billing office. Give them the EOB and say something like:
"You billed CHAMPVA and accepted assignment for this visit. My EOB says I owe $50. The rest of this balance is the difference between your charge and CHAMPVA's allowable amount, which I'm not responsible for under 38 CFR 17.272(b). Can you adjust the account?"
- If they won't fix it, call CHAMPVA at 800-733-8387 with the EOB, the bill, and your notes.
- Don't ignore it. If a bill is heading to collections, tell the office in writing that you're disputing it.
Is it a billing problem or a claim problem?
If the provider is billing more than the EOB says you owe, that's a billing problem. Start with the office and CHAMPVA. If you think CHAMPVA itself got the claim wrong, that's a claim review. More here: CHAMPVA claim denials and delays.