The short answer
First decide what VA actually did. If VA only needs records, an other insurance EOB, or proof of payment, send them; no appeal is needed. If you disagree with a payment decision, use a Supplemental Claim with new evidence or a Higher-Level Review on the existing record. A preauthorization denial before care uses a separate written clinical appeal.
Which route should a provider use?
It depends on what VA decided. Sending missing records or fixing claim data is not an appeal. A formal review is for an actual decision you disagree with. VA's family member reviews and appeals page has the forms and addresses. Your EOB or decision letter controls for your case.
Is this a correction, a review, or a clinical appeal?
Pull the original claim, the CHAMPVA EOB or letter, and the clinical and billing records. Then sort the case:
| What happened | What to do | Why |
|---|---|---|
| VA asked for records, an other insurance EOB, or proof of payment | Send them for the existing claim | VA says this does not need a decision review |
| Billing or diagnosis data was wrong | Correct the real error and resubmit as instructed | A correction is not a dispute |
| Claim marked duplicate, or payment held for EFT | Check the related claim or finish EFT setup | Resubmitting creates another duplicate |
| VA made a payment or eligibility decision you dispute | Pick a decision review option below | This is a real adverse decision |
| VA denied preauthorization and care has not happened | Written clinical appeal | Separate pre-service process |
| Care already happened, including retroactive authorization | Decision review process | VA says the clinical appeal is not for completed care |
VA's family member claim denial explanations describe common codes. For correction steps, see Correcting or Resubmitting a CHAMPVA Claim.
Which decision review fits a disputed payment?
The one that matches your evidence. VA allows only one review option at a time on the same issue.
| Option | When it fits | Form and timing |
|---|---|---|
| Supplemental Claim | You have new and relevant evidence, or the law changed | VA Form 20-0995. Can be filed anytime, though late filing can affect an effective date. |
| Higher-Level Review | You think VA erred based on the existing record | VA Form 20-0996. Within 1 year of the decision. No new evidence. |
| Board Appeal | The issue is a legal or eligibility question the Board can decide | VA Form 10182. Generally within 1 year of the decision. |
| Pre-service clinical appeal | VA denied preauthorization for care not yet given | Written appeal with new clinical information. Within 1 year of the denial notice, per the CHAMPVA Guidebook. |
The Board cannot review pure medical judgments, so a medical-necessity dispute may not belong there. See CHAMPVA Board Appeals, CHAMPVA Supplemental Claims, and CHAMPVA Higher-Level Review.
What goes in a review packet?
A short packet that answers the specific denial:
- The decision. The full EOB or letter, its date, the claim reference, dates of service, and the disputed line.
- The disagreement. What VA decided, which finding you challenge, and what result you want.
- Evidence that fits the route. New and relevant evidence for a Supplemental Claim. A clear statement of the error, with no new evidence, for a Higher-Level Review. New clinical information and a copy of the denial for a clinical appeal.
- Identifiers. The beneficiary and provider details the form asks for. Protect patient information in transit.
- Proof. A full copy of what you sent and proof of when you sent it.
Where do providers send reviews?
VA's family member review page lists this address for Supplemental Claims, Higher-Level Reviews, and first- and second-level pre-service clinical appeals:
VFMP Appeals
PO Box 600
Spring City, PA 19475
Board Appeals follow the address on VA Form 10182, which goes to the Board, not to this box. Initial provider claims use a different address in Tampa. Providers can call 800-733-8387 with questions about claim processing and review options.
How does a pre-service clinical appeal work?
It is a written appeal for a preauthorization denial before care.
- Explain in writing why the denial is wrong and add any new and relevant clinical information.
- Include a copy of the denial notice. The CHAMPVA Guidebook gives 1 year from the notice.
- If the first level is denied, you can ask in writing for a second-level clinical review. VA does not publish a separate deadline for it, so act promptly and check the first-level letter.
- Send both levels to VFMP Appeals.
If the care already happened, VA treats the request as retroactive and it goes through the decision review process instead. An approved authorization still does not guarantee payment. Eligibility, coverage, other insurance, and claim rules still apply. See How to Appeal a CHAMPVA Preauthorization Decision.
Which deadline applies?
Three clocks run separately. Record each date:
- Original claim filing: generally 1 year from the date of service or discharge. See CHAMPVA Claim Filing Deadlines.
- Decision review: 1 year from the decision for a Higher-Level Review or Board Appeal; anytime for a Supplemental Claim.
- Clinical appeal: 1 year from the preauthorization denial notice.
The 90-day reconsideration rule in 38 CFR 17.277 applies only to legacy claims. For more, see CHAMPVA Appeal Deadlines.
Final check before sending
- Is this a real adverse decision or a request for missing information?
- Is the dispute about payment, eligibility, or pre-service preauthorization?
- Does the route match whether you have new evidence?
- Is another review already pending on this issue?
- Do you have the right form, date, address, and proof of sending?