The short answer
CHAMPVA covers medically necessary doctor and specialist visits, office procedures, and related tests from any qualified provider. You don't need a referral. When CHAMPVA is your only coverage, you pay your yearly deductible, then 25% of CHAMPVA's allowable amount. The office should usually bill CHAMPVA for you under payer ID 84146.
What's covered?
VA's CHAMPVA care page lists outpatient care and procedures, like office visits, as covered. That includes:
- primary care visits,
- specialist visits,
- minor office procedures,
- lab work and X-rays tied to a symptom or condition, and
- covered preventive care.
The care has to be medically necessary and not excluded under 38 CFR 17.272. A doctor's order alone doesn't guarantee coverage.
Do you need a referral?
No. CHAMPVA isn't an HMO and doesn't require referrals for most care. The specialist's office or your other insurance might still ask for one. More here: Do you need a referral with CHAMPVA?
Who can you see?
Any provider licensed for the care who's willing to bill CHAMPVA. There's no network. More here: How to find a provider that takes CHAMPVA.
What will you pay?
When CHAMPVA is your only coverage:
- Deductible: $50 per person, $100 per family each year.
- Then: 25% of CHAMPVA's allowable amount.
- Yearly cap: $3,000 per family.
Listed preventive care, like yearly physicals, has no cost. If you have other insurance, it pays first and you often owe less.
For doctors' services, 38 CFR 17.275 sets the allowable amount as the lowest of CHAMPVA's maximum allowable charge, the usual local rate, or the amount billed. If the office accepts assignment, that's all they can collect, apart from your share. More here: CHAMPVA assignment and balance billing.
Why did one visit produce two bills?
A visit at a hospital-owned clinic can produce a facility bill and a separate doctor's bill. Labs, imaging, and pathology often bill separately too. Match each bill to its EOB.
For office billing staff
VA's CHAMPVA provider page says to:
- Verify eligibility (payer ID VAHAC or 888-820-1756) and ask about other insurance.
- Bill other insurance first and include its EOB.
- Send 837 claims to payer ID 84146.
- Bill facility and professional fees on separate claims.
- List each service and date separately with accurate diagnosis codes.
- Enroll in electronic funds transfer. VA requires it to get paid.
More here: CHAMPVA provider quick start.
What if the office won't bill CHAMPVA?
You can pay and file the claim yourself. You'll be reimbursed based on CHAMPVA's allowable amount. File within 1 year of the visit. More here: Who files the CHAMPVA claim?
Before an appointment
- Ask if they bill CHAMPVA and accept assignment.
- Bring your CHAMPVA card and any other insurance cards.
- Follow your other insurance's rules if it pays first.
- For planned tests, make sure the reason is documented.
- Keep EOBs and receipts.