The short answer
Most CHAMPVA care doesn't need approval first. The exceptions are non-emergency inpatient mental health and substance use care, residential treatment, partial hospitalization, intensive outpatient programs, ABA treatment, covered dental care, and organ or bone marrow transplants. If your other insurance already approved the care, or it's through CITI at a VA facility, CHAMPVA doesn't need its own approval.
What needs preauthorization?
38 CFR 17.273 lists:
- Non-emergency inpatient mental health and substance use care, including residential treatment centers for children and teens,
- Partial hospitalization programs, including alcohol rehab,
- Covered dental care, which is very limited under CHAMPVA, and
- Organ transplants.
The CHAMPVA Guidebook adds:
- Intensive outpatient programs (IOP), and
- Applied behavior analysis (ABA) treatment. The ABA evaluation doesn't need approval.
VA's CHAMPVA provider page also names bone marrow transplants.
Regular outpatient therapy doesn't need preauthorization. Older handouts mention a 23-visit limit. That rule isn't in the current regulation.
Does an emergency need approval first?
No. The rule covers non-emergency care. Get emergency care when you need it. If you or someone you love is in crisis, call 988 and press 1, or text 838255.
When is CHAMPVA's approval not needed?
Your other insurance approved it. If your other plan pays first and authorized the care, CHAMPVA doesn't need its own approval. But follow that plan's rules. The Guidebook warns that if the other plan denies for not following its rules, CHAMPVA may deny too.
It's through CITI. Care on the list doesn't need CHAMPVA approval when you get it at a VA facility through CITI. More here: CHAMPVA CITI.
How do you request it?
Usually the provider does this. The Guidebook lists:
- Phone: 833-930-0816
- Email: VHAHAC.preauthorizationFM@va.gov
- Mail: VHA Office of Integrated Veteran Care, CHAMPVA Beneficiary Claims, PO Box 500, Spring City, PA 19475
The provider should be ready to explain the service, the diagnosis, and why the care is medically necessary.
What about prescriptions?
Some drugs have their own pharmacy approval process. VA's provider page says Wegovy and Zepbound, when covered for qualifying conditions, need prior authorization through OptumRx at 844-403-1029. That's separate from medical preauthorization. More here: CHAMPVA and GLP-1 medications.
Before scheduled care
- Name the exact service. "Mental health treatment" is too broad. Inpatient, residential, PHP, IOP, outpatient therapy, and ABA all have different rules.
- Figure out who pays first. If other insurance is primary, follow its rules.
- Ask if it's through CITI.
- Get the approval in writing and keep the authorization number.
Approval doesn't guarantee payment. You still need to be eligible, the service has to be covered, and the claim has to be filed correctly.
What if nobody got approval?
Call CHAMPVA right away. In some situations, CHAMPVA can review the care for medical necessity after the fact, but it's not guaranteed. More here: Missed CHAMPVA preauthorization.
Is a referral the same thing?
No. CHAMPVA doesn't require referrals for most care. Preauthorization is a different step. More here: Referrals and preauthorization.