VA Form 10-7959a: How to Fill Out a CHAMPVA Claim

Before you start

Download a fresh copy from VA's Form 10-7959a page. Don't use it until you've received your CHAMPVA enrollment packet.

In most cases, your provider should file instead. More here: Who files the CHAMPVA claim?

Have ready:

1. proof of payment,
2. an itemized bill or superbill,
3. your other insurance's EOB, if any,
4. pharmacy records, for prescriptions, and
5. the Veteran's name.

Section I: Patient

• Name (required).
• CHAMPVA member number (required). The form says this is the patient's Social Security number, so treat the form as sensitive.
• Check if new address, then address, birth date, phone, and email.

Section II: Other health insurance

• Is the patient covered by other insurance? Answer yes or no, even if no. Don't count a CHAMPVA supplement policy.
• Type: job-based, private, Medicare (A or B), or other.
• For each plan: name, policy number, start date, end date if it ended, and phone. Use a separate sheet for more than two.
• Work-related injury? and injury or accident outside work? Answer honestly. Other payers may be responsible. More here: CHAMPVA after an accident.

Attach the other plan's EOB. VA's claim page says it should show the date, provider, NPI if not on the bill, services, and amount paid.

Section III: Veteran (sponsor)

The Veteran's first name, last name, and middle initial.

Section VI: Signature

The form jumps from Section III to VI. Nothing's missing.

Sign (typed or electronic is OK) and date. If someone other than the patient signs, fill in their name, relationship, address, phone, and email. The patient, Veteran, or a guardian can sign.

What the itemized bill must show

A balance-due statement isn't enough. VA asks for:

• patient name and birth date,
• provider name and title,
• provider tax ID,
• the address where care was given,
• each charge with its date,
• quantities,
• ICD-10 diagnosis codes, and
• CPT or HCPCS procedure codes.

The March 2025 form still shows an old ICD-9 example. VA's newer claim page says ICD-10. Don't make up codes. Ask the provider for a current superbill.

Prescriptions

Use pharmacy records instead of a medical bill, with the pharmacy's contact information, drug, dosage, strength, quantity, cost and copay, 11-digit NDC, fill date, and prescriber. More here: CHAMPVA prescription reimbursement.

Common mistakes

• A provider using this form (it's for beneficiaries)
• An old saved copy
• A regular bill instead of itemized
• No proof of payment
• Other insurance EOB missing or not matching
• Missing codes or tax ID
• Unsigned, or signer section incomplete
• Insurance question left blank
• Back sides of two-sided papers not copied (VA scans one side)
• Filing after the 1-year deadline

Where to send it

VHA Office of Integrated Veteran Care, CHAMPVA Claims, PO Box 500, Spring City, PA 19475. Or file online. Set up direct deposit so VA can pay you. Processing takes about 90 days.