Quick answer
If CHAMPVA denies preauthorization for a covered service or supply that has not yet occurred, VA's current family-member appeal guidance uses a written clinical appeal. This is different from appealing a paid or denied claim after treatment.
For the first-level clinical appeal, VA currently says to submit in writing:
- an explanation of why you believe the preauthorization decision is wrong; and
- any new and relevant information that VA did not previously consider.
The current CHAMPVA Guidebook also says to include a copy of the preauthorization denial notice. If you disagree with the first-level clinical review, VA allows a written request for a second-level clinical review.
VA's current family-member appeal page directs both levels to:
VFMP Appeals
P.O. Box 600
Spring City, PA 19475
The CHAMPVA Guidebook labels the same destination CHAMPVA Appeals and uses the same P.O. Box.
A phone call can help clarify the case, but the published clinical-appeal instructions require the appeal itself in writing.
First identify which review path applies
The correct path depends on whether the requested care has happened yet and what VA actually decided.
| Situation | Current path |
|---|---|
| CHAMPVA denied preauthorization and the service has not occurred | Written clinical appeal |
| First-level clinical appeal was denied | Written request for second-level clinical review |
| The service already occurred and preauthorization was missing or denied retroactively | Post-service claim/decision-review process; the pre-service clinical-appeal process no longer applies |
| VA made a payment decision on a claim | Use the applicable decision-review option, such as a Supplemental Claim, Higher-Level Review, or Board appeal when legally available |
| The dispute is about CHAMPVA eligibility | Use the eligibility decision-review process, not the preauthorization clinical-review lane |
That distinction matters because VA expressly says clinical appeals of preauthorization are for services that have not yet occurred. VA also says retroactive preauthorization requests for services that already occurred follow the separate decision-review and appeal process.
If care already happened without required approval, see Missed CHAMPVA Preauthorization: What Happens Next?. If you are still determining whether advance approval was required in the first place, see Which CHAMPVA Services Require Preauthorization?.
What to include in a first-level clinical appeal
VA's current public instructions require a written explanation of the alleged error plus new and relevant information that was not previously considered. The current CHAMPVA Guidebook adds that you should include a copy of the denial notification.
A practical submission packet can include:
- A copy of the denial notice.
- A short written statement identifying the requested service or supply and explaining why you believe the preauthorization decision should be changed.
- New and relevant clinical information that bears on the reason for denial.
- A treating-provider statement or records, when available, explaining the diagnosis, medical necessity, prior treatment, expected benefit, and why the requested level or type of care is appropriate.
- Clear contact information for the beneficiary and treating provider.
- Any timing information that matters clinically, especially when delay could affect treatment planning.
Items 3 through 6 are practical ways to make the record easier to review; VA's public clinical-appeal page does not say that every one of those items is mandatory in every case.
"New" means information VA has not previously considered. "Relevant" means information that tends to prove or disprove something material to the decision. A large stack of records is less useful than records that directly address the reason VA gave for denying preauthorization.
Where to send the appeal
VA's current family-member appeal page directs first- and second-level clinical appeals to:
VFMP Appeals
P.O. Box 600
Spring City, PA 19475
The current CHAMPVA Guidebook identifies the destination as:
VHA Office of Integrated Veteran Care
CHAMPVA Appeals
P.O. Box 600
Spring City, PA 19475
These instructions point to the same P.O. Box. Keep a copy of the complete submission and a record of when and how it was mailed.
Is there a form for a CHAMPVA preauthorization clinical appeal?
VA's current clinical-appeal instructions do not identify VA Form 20-0995 or VA Form 20-0996 as the required form for a pre-service preauthorization clinical appeal. Instead, VA instructs the requester to submit the clinical appeal in writing with the explanation and supporting information.
That is different from the modern decision-review lanes used for many payment and eligibility decisions:
- a CHAMPVA Supplemental Claim uses VA Form 20-0995 when that lane applies;
- a CHAMPVA Higher-Level Review uses VA Form 20-0996 when that lane applies; and
- a CHAMPVA Board appeal uses VA Form 10182 when the Board has jurisdiction.
Do not substitute one of those forms for the current written clinical-appeal process merely because the word "appeal" appears on both.
What happens after the first-level review?
If you disagree with the first-level clinical-review outcome, VA's current family-member appeal page says you may submit a written request for a second-level clinical review.
The public page does not publish a separate form or a separate expedited filing method for the second-level request. A useful second-level packet should identify the first-level decision, explain what you still believe was decided incorrectly, and include any additional relevant clinical information that is appropriate for VA to consider.
Send the second-level clinical-review request to the same VFMP Appeals address listed above unless VA's decision letter gives you newer or more specific instructions.
What if the care is urgent or time-sensitive?
VA's current public family-member clinical-appeal instructions do not list a separate expedited or "urgent clinical appeal" lane, and they do not publish a guaranteed turnaround time for these appeals.
If the requested care is time-sensitive:
- ask the treating provider to clearly document why timing matters clinically;
- call the current CHAMPVA preauthorization line at 833-930-0816 to discuss the pending authorization issue;
- contact VA Customer Support at 800-733-8387 if you need help confirming the current review route; and
- still preserve the required written clinical-appeal record.
A call does not replace the written appeal. And a pending appeal does not guarantee that a service will later be covered or paid.
If the situation is a medical emergency, obtain appropriate emergency evaluation rather than waiting for an administrative appeal decision. Coverage and reimbursement are separate questions and depend on the facts and CHAMPVA rules that apply.
How long do you have?
The current CHAMPVA Guidebook says a requester who disagrees with a preauthorization determination has one year from the date of VA notification to submit the written challenge and supporting new or relevant documentation.
The newer public family-member appeal webpage explains the clinical-review process but does not restate that deadline. Because treatment may still be pending, do not treat the one-year period as a reason to delay. Use the date and instructions on the actual VA denial notice, and submit promptly.
The next decision letter may also contain instructions that are more specific to your case. Follow newer case-specific instructions when they conflict with a general guide.
How 38 CFR § 17.273 fits in
38 CFR § 17.273 governs when CHAMPVA preauthorization or advance approval is required and also addresses retrospective medical-necessity review when required preauthorization was not obtained before care and CHAMPVA later becomes the responsible payer.
The regulation is important, but it does not by itself provide the full current operational instructions for a pre-service clinical appeal. For that, VA's current family-member review page and CHAMPVA Guidebook provide the practical filing process.
This is also why preauthorization, coverage, medical necessity, and payment should not be treated as interchangeable terms. Advance approval addresses one stage of the process; final payment can still depend on eligibility, coverage, other insurance, claim filing, and other CHAMPVA rules.
Common mistakes to avoid
- Using a paid-claim review form for a pre-service clinical appeal without checking the decision type first.
- Waiting until after the service occurs and then trying to use the pre-service clinical-review process.
- Sending only a disagreement statement without addressing the reason VA denied the request.
- Leaving out the denial notice when the CHAMPVA Guidebook specifically tells requesters to include it.
- Assuming a phone call is the appeal. The current instructions require a written clinical appeal.
- Assuming "urgent" creates an unpublished fast-track appeal. VA's public family-member guidance currently provides no separate expedited lane.
- Assuming preauthorization guarantees payment. Coverage, eligibility, coordination of benefits, and claim requirements still matter.
A simple appeal checklist
Before sending a first-level clinical appeal, confirm that:
- the service or supply has not yet occurred;
- you have the VA preauthorization denial notice;
- your written explanation identifies the exact decision you challenge;
- the treating provider has supplied focused clinical support when it would help address the denial reason;
- new and relevant information is clearly identified;
- beneficiary and provider contact information are included;
- the packet is going to the current VFMP/CHAMPVA Appeals P.O. Box; and
- you keep a complete copy and proof of submission.
If the first-level review is unfavorable, use the same records to build a concise second-level written request focused on what remains disputed.