VA Form 10-7959a: CHAMPVA Claim Form

Filing instructions

Notes on claim form usage, other health insurance, the timely filing requirement and what an itemized billing statement contains. Pharmacy claims include the name, quantity, strength and National Drug Code (NDC) of each drug.

Section I: patient information

Last name, first name and CHAMPVA Member Number (required fields), middle initial, street address with a new address box, city, state, zip code, date of birth, phone number and email address.

Section II: other health insurance

Whether the patient is covered by OHI, including coverage through a family member, with supplemental or secondary insurance excluded. If yes, the type, names, policy numbers, dates and phone numbers for two insurers, plus work injury and accident questions.

Section III: sponsor information

The sponsor's last name, first name and middle initial.

Section VI: claimant certification

A certification that the information and attachments are correct and represent actual services, dates and fees charged, a signature (electronically or typed) and date, and details for a signer other than the patient.

Page 2 notices

A notice that divorce or annulment from the qualifying sponsor ends CHAMPVA eligibility as of midnight on the effective date of the dissolution, the Privacy Act information and a burden estimate of 10 minutes.

The form says to print or type only.

1. 1

   Gather itemized bills

   The form says an itemized statement is attached with the patient's name, date of birth and member number, the provider's name, NPI, TIN, address and phone, and service dates, charges and procedure and diagnosis codes.

2. 2

   Add other insurance details

   If other health insurance exists, the form says to attach an Explanation of Benefits (EOB) from it to the provider's itemized billing statement, with dates of service and charges that match.

3. 3

   Fill in Sections I to III

   Print or type the patient, other health insurance and sponsor information. If more space is needed for OHI, the form says to continue in the same format on a separate sheet.

4. 4

   Sign the certification

   Sign electronically or typed and date Section VI. A person other than the patient who signs adds their name, relationship to patient, address and contact details.

5. 5

   Send it on time

   The form says claims must be received no later than one year after the date of service or, for inpatient care, within one year of the discharge date. Mail it to the address on page 1 or file online.

• 

  10-7959C

  CHAMPVA Other Health Insurance (OHI) Certification (VA Form 10-7959c)

  51 fields, 2 pages

• 

  10-10d

  Application for CHAMPVA Benefits (VA Form 10-10d)

  73 fields, 3 pages

• 

  10-7959D

  CHAMPVA Potential Liability Claim

  57 fields, 2 pages

• 

  10-7959e

  Claim for Miscellaneous Expenses

  58 fields, 2 pages

• 

  10-7959f-2

  Foreign Medical Program (FMP) Claim Cover Sheet (VA Form 10-7959f-2)

  15 fields, 2 pages

• CHAMPVA patients

  VA's page points to the form for people currently enrolled in CHAMPVA who are filing a claim for reimbursement. Section I identifies the patient by CHAMPVA Member Number.

• A sponsor or guardian

  The form says it is completed by the patient, sponsor or guardian. If someone other than the patient signs the certification, the form asks for their name, relationship to patient, address, phone and email.

• Claimants adding documents

  VA's page says the form is also used to submit more documents for a claim you already filed.

• Not for providers

  The form says this claim form is not to be used for provider submitted claims.

The form and VA's page describe who completes it.

• Official VA form page

  The agency’s own page for Form 10-7959A.

• Blank PDF

  The official blank form, to print or fill by hand.

  Download blank PDF

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