The short answer
It isn't automatically denied. If CHAMPVA turns out to be the payer and the claim is filed within one year, CHAMPVA reviews the care for medical necessity after the fact. That review can still say no. First, check whether approval was really needed. Care through CITI, care your other insurance approved, and emergencies are often exceptions.
Was preauthorization actually required?
Check this first. Only some services need CHAMPVA approval in advance. More here: Which CHAMPVA services need preauthorization?
Three common exceptions:
- CITI. The CHAMPVA Guidebook says listed services don't need CHAMPVA approval when provided through CITI at a VA facility.
- Other insurance approved it. If your other plan pays first and authorized the service, CHAMPVA doesn't need its own approval.
- Emergencies. The inpatient mental health and substance use rule in 38 CFR 17.273 covers non-emergency care only.
What is retrospective review?
It's CHAMPVA looking at the care after it happened. Under 38 CFR 17.273, CHAMPVA does a medical-necessity review when:
- CHAMPVA is the payer responsible for the care,
- the required preauthorization wasn't obtained beforehand, and
- the claim is filed within the one-year deadline.
The review can approve or deny. It's a second chance, not a guarantee.
Is it the same as an appeal?
Not exactly. VA's family member care review page says clinical appeals of preauthorization are for care that hasn't happened yet. Requests about care that already happened go through the decision review process on that page.
What should you do?
- Confirm the rule. Write down the service, the level of care, the date, and why approval was required.
- Gather records:
- any authorization request or number,
- medical records showing why the care was needed,
- admission and discharge dates,
- the provider's itemized bill,
- your other insurance's EOB and any approval or denial, and
- any CHAMPVA EOB or letter.
- File the claim on time. Generally within 1 year of the care, or 1 year from discharge for a hospital stay. Don't let a dispute eat the deadline. More here: CHAMPVA claim filing deadlines.
- Include the other plan's EOB if it paid first.
- If you get an adverse decision, follow the review steps and deadline in the letter. Call CHAMPVA at 800-733-8387 if you're not sure which route applies.
Is a request for documents a denial?
No. VA's review page says you don't need a formal review just to send missing documents, an EOB from other insurance, or proof of payment. Send what's asked for.
What if the other insurance denied it?
The Guidebook says if your other plan denied because its rules weren't followed or it found the care unnecessary, CHAMPVA will also deny. An other-insurance denial doesn't shift the bill to CHAMPVA.
Is this the same as retroactive eligibility?
No. Missed preauthorization is about approval for a service. Retroactive eligibility is when VA sets your CHAMPVA start date in the past. They have different rules. More here: Retroactive CHAMPVA eligibility.
Avoiding it next time
For scheduled care that might need approval, have the provider call 833-930-0816 before the first visit, and keep the approval in writing.