VA Form 10-7959A: Line-by-Line CHAMPVA Claim Guide

Quick answer

VA Form 10-7959A is the CHAMPVA Claim Form used when an enrolled beneficiary needs to file a reimbursement claim. The current paper form is the March 2025 revision. VA also allows beneficiaries to file a claim online instead of sending the paper form.

This form is for beneficiary claims, not provider-submitted claims. In most cases, VA says the provider should file the CHAMPVA claim. Use Form 10-7959A when you need to file the beneficiary reimbursement claim yourself.

A complete paper claim normally includes:

• the completed Form 10-7959A;
• proof that you paid the provider;
• an itemized billing statement with the required patient, provider, service, diagnosis, and procedure information;
• the other insurer's Explanation of Benefits (EOB) when other health insurance applies; and
• the required pharmacy record instead of a medical itemized statement when the claim is for prescription medication.

VA also requires direct deposit before it can pay a beneficiary reimbursement claim.

Before you start the form

Download a fresh copy from VA rather than using an old saved version. The current VA form page identifies the paper revision as March 2025.

Gather the documents that belong with the claim before you start:

1. Proof of payment, such as a receipt or a billing statement marked paid.
2. An itemized bill or superbill from the provider.
3. The final EOB from other health insurance, if another health plan processed the care first.
4. Pharmacy documentation, if you are seeking reimbursement for a prescription.
5. Your CHAMPVA information and the sponsor's name.

If you have not yet received your CHAMPVA enrollment packet, VA's form page says not to use Form 10-7959A yet.

Section I — Patient Information

This section identifies the CHAMPVA beneficiary whose care is being claimed.

Last Name — required

Enter the patient's last name. The form marks this as a required field.

First Name — required

Enter the patient's first name. The form marks this as a required field.

MI

Enter the patient's middle initial if applicable.

CHAMPVA Member Number — required

Enter the patient's CHAMPVA Member Number. The current form identifies this as a required field and notes that the member number is the same as the patient's Social Security number.

Because this is sensitive personal information, treat the completed claim form as a sensitive document and send it only through the VA claim-submission route you intend to use.

Check if new address

Check this box when the patient address you are entering is a new address.

Street Address

Enter the patient's current street address.

City, State, and Zip Code

Enter the city, state, and ZIP code for that address.

Date of Birth

Enter the patient's date of birth in the MM/DD/YYYY format shown on the form.

Phone Number

Enter a current phone number, including the area code.

Email Address

Enter a current email address.

Section II — Other Health Insurance (OHI) Information

This section tells CHAMPVA whether another health plan may need to process the claim first.

Is the patient covered by OHI, including coverage through a family member?

Check Yes or No.

The form says CHAMPVA supplemental or secondary insurance is excluded from this question. If you check No, the form directs you to proceed to Section III.

If you check Yes, identify the type of coverage and complete the insurance information below.

Type of other health insurance

Check the applicable type:

• Employer sponsored (group)
• Private (non-group)
• Medicare (Part A or B)
• Other, with the type specified

First OHI plan

For the first plan, enter:

• Name of Other Health Insurance
• Policy Number
• OHI Effective Date
• OHI Termination Date, if coverage ended
• Phone Number

Second OHI plan

The form provides a second set of the same fields for another plan:

• Name of Other Health Insurance
• Policy Number
• OHI Effective Date
• OHI Termination Date, if applicable
• Phone Number

If more space is needed, the form says to continue in the same format on a separate sheet.

Was treatment for a work-related injury or condition?

Check Yes or No accurately.

Was treatment for an injury or accident outside of work?

Check Yes or No accurately.

These questions can matter because a workers' compensation plan, auto insurer, liability insurer, or another payer may be responsible for some medical costs.

What to attach when OHI applies

The current form instructs beneficiaries with OHI to attach the other insurer's EOB to the provider's itemized billing statement. The service dates and provider charges on the EOB should match the billing documents.

VA's current claim page adds that the EOB should show:

• the date of service;
• the provider's full name;
• the provider's 10-digit NPI if it is not on the itemized bill;
• the services the other insurer paid for; and
• the amount the other insurer paid.

For the paid services, VA says to include a CPT code, HCPCS code, or a description of the service or procedure.

For a deeper explanation of payer order, see How CHAMPVA Works With Other Health Insurance.

Section III — Sponsor Information

The current form asks only for the sponsor's:

• Last Name
• First Name
• Middle Initial

Enter the sponsor name associated with the beneficiary's CHAMPVA eligibility.

Section VI — Claimant Certification

The current March 2025 form jumps from Section III to Section VI. That is how the official form is printed; it does not mean pages or sections are missing from your copy.

The certification states that the information on the form and attachments is correct and represents the actual services, dates, and fees charged.

Signature

Sign the certification. The form specifically says the signature may be electronic or typed.

Date

Enter the date in MM/DD/YYYY format.

If someone other than the patient signs

If the certification is signed by someone other than the patient, complete the additional signer fields:

• Last Name
• First Name
• Middle Initial
• Relationship to Patient
• Street Address
• City
• State
• Zip Code
• Phone Number
• Email Address

The form says it may be completed by the patient, sponsor, or guardian.

The itemized bill: what VA currently requires

A regular balance-due statement is not enough. VA's current claim instructions say to submit an itemized billing statement, sometimes called a superbill.

The current VA claim page says the itemized statement should include:

• the patient's full name and date of birth;
• the provider's full name and medical title;
• the provider's Tax Identification Number (TIN/Tax ID);
• the office and building address where the service occurred;
• each charge and the date of service;
• the quantity of services;
• the diagnosis code using ICD-10; and
• either the applicable CPT or HCPCS procedure code.

The Form 10-7959A PDF itself also asks for the provider name, NPI, TIN, address and telephone number, service dates, itemized charges, diagnosis/procedure codes, and narrative descriptions.

Important coding note

The March 2025 PDF still prints an ICD-9-CM example in its itemized-bill instruction. VA's newer claim page, last updated July 15, 2026, instead says the itemized statement should contain DX/ICD-10 diagnosis codes along with CPT or HCPCS procedure codes.

Do not try to convert or invent billing codes yourself. Ask the provider for a current itemized billing statement or superbill containing the codes the provider actually used.

Proof of payment

VA's current claim instructions require proof that you paid the provider when you are filing for reimbursement.

Examples VA gives include:

• a receipt; or
• a billing statement marked paid.

Keep the proof of payment together with the itemized bill so VA can connect the amount you paid to the services claimed.

Prescription reimbursement claims

For a prescription-medication reimbursement claim, VA says to submit pharmacy documentation instead of the provider itemized statement.

The pharmacy document should include:

• pharmacy name, address, and phone number;
• medication name;
• dosage and strength;
• quantity;
• cost, including the copay amount;
• the 11-digit National Drug Code (NDC);
• the date the prescription was filled; and
• the name of the prescriber.

The paper form also specifically calls for the drug name, quantity, strength, and NDC.

Common errors that can delay a Form 10-7959A claim

Before you send the claim, check for these common problems:

• Using the beneficiary form for a provider-submitted claim. Form 10-7959A is not the provider claim form.
• Using an outdated saved form. Download the current form from VA when you are ready to file.
• Sending a regular bill instead of an itemized bill. Ask for a superbill or another itemized billing statement with the required details.
• Missing proof of payment. Include the receipt or paid statement for beneficiary reimbursement.
• Missing or inconsistent OHI documents. When OHI applies, include the EOB and make sure its service dates and provider charges correspond to the billing statement.
• Missing provider identifiers or codes. Check for the provider's required TIN, NPI where required, current diagnosis code, and CPT or HCPCS procedure code.
• Leaving the certification incomplete. Make sure the form is signed and dated, and complete the extra signer block when someone other than the patient signs.
• Leaving the OHI Yes/No question unanswered. Complete the question even when the patient has no OHI.
• Forgetting the back of a double-sided supporting document. VA says its claim-scanning process can scan only one side of each document, so include photocopies of the backs when needed.
• Waiting too long to file. For an ordinary claim, VA says the claim must be filed within one year of the date of service, or within one year after discharge for inpatient care. Special rules can apply to retroactive authorization or retroactive CHAMPVA eligibility.

Filing the completed paper claim

If you are filing by mail, VA currently directs beneficiary claims to:

VHA Office of Integrated Veteran Care
CHAMPVA Claims
PO Box 500
Spring City, PA 19475

You can also file a new beneficiary reimbursement claim online instead of mailing Form 10-7959A.

For a complete mailing workflow, see How to File a CHAMPVA Claim by Mail. For the electronic route, see How to File a CHAMPVA Claim Online.

What happens after filing

VA's current claim page says CHAMPVA claim processing takes about 90 days. VA will contact you if it needs additional information.

If VA asks for missing documents, the current claim page says you must respond within one year of the date on the EOB or request letter.

If you are unsure whether you or the provider should submit the claim in the first place, see Who Files a CHAMPVA Claim: Provider or Beneficiary?.

Final pre-submission checklist

Before submitting a beneficiary claim, confirm that:

• you are already enrolled in CHAMPVA;
• you are using the current Form 10-7959A if filing on paper;
• Section I is complete;
• the OHI question and any applicable OHI plan fields are complete;
• the sponsor name is entered;
• the certification is signed and dated;
• any non-patient signer information is complete;
• proof of payment is attached;
• the itemized bill contains the required current billing details;
• the OHI EOB is attached when applicable;
• prescription documentation is complete when the claim is for medication;
• copies of the backs of double-sided documents are included when needed;
• the claim is within the applicable filing period; and
• direct deposit is set up so VA can issue beneficiary reimbursement.