United States Department of Veterans Affairs

Rejected Claims

These are the top 10 CHAMPVA rejected codes with additional text that further explains the rejections and indicates what a beneficiary/provider needs to do to get the claim processed correctly.

If the denial code on you explanation of benefits form is not listed below, you can request information by contacting us via the Inquiry Routing & Information System (IRIS). IRIS is a tool that allows us to communicate in a secure format and will be used instead of our traditional email links. You can call us at 1-800-733-8387 between the hours of 8:05 a.m. and 6:45 p.m. Eastern Time.

Rank Code Reason / Detail

1

65

Duplicate claim - previously processed.

An automated matching process in our payment system determined that this claim is an exact match of a claim that we previously processed. Our claim number for the duplicate claim should be shown in the comment at the bottom of the CHAMPVA Explanation of Benefits (EOB). If you do not believe that this is correct, you will need to contact us by phone at 1-800-733-8387 to resolve this issue. Do not resubmit this claim without contacting us, as it will only result in another denial.

2

78

EOB from other insurance required- CHAMPVA secondary payer (when resubmitting enclose this form)

We need to see the Explanation of Benefits (EOB) generated by the primary health plan before we can process this request. Our files indicate that the patient is enrolled in a health insurance plan that, by law, must process this request prior to the CHAMPVA program. Please resubmit this request with the EOB from the primary plan and include a copy of this CHAMPVA EOB, or have the patient contact us to update their Other Health Insurance (OHI) status. We accept OHI updates by phone at 1-800-733-8387.

3

124

Claim not timely filed. (See CHAMPVA handbook.)

A beneficiary or health care provider must file claims for current treatment within 365 days of the date of service. Upon initial enrollment into the plan, we grant a 180 day grace period for the enrollee to file any applicable claims that were more than 365 days old. Based on the date this claim arrived at our mail room, it did not meet these requirements. You may submit a written appeal if you were unable to file the claims due to exceptional circumstances. Send your written appeal to; VA Health Administration Center, CHAMPVA, ATTN: Appeals, PO Box 460948, Denver, CO 80246. Do not send it to the claims processing address, as this will only delay your appeal.

4

159

Claim denied - duplicate of previously processed claim.

A secondary review in our claims payment area determined that this claim or service is an exact match of a claim or service that we previously processed. If this is an exact match of a previous claim, the matching CHAMPVA claim number will be shown in the comments at the end of the CHAMPVA Explanation of Benefits (EOB). If you do not believe that this is correct, you will need to contact us by phone at 1-800-733-8387 to resolve this issue. Do not resubmit this claim without contacting us, as it will only result in another denial.

5

137

Beneficiary not eligible on date of service claimed.

This claim is for a date of service or period of hospitalization that is not covered under the CHAMPVA health plan. Please consult the period of eligibility listed on the member card, and check the date of service or period of admission in your records. If the bill was submitted with an incorrect date, please send a corrected bill. If the service or admission date is correct, then we can not honor your request, since the patient was not covered by our plan at that time.

6

220

Claim denied - requesting OHI clarification not received.

Our records show that we have previously requested the beneficiary/patient to submit an update to their Other Health Insurance (OHI) status. This can be done by mail or phone at 1-800-733-8387. Forms for the update are available on the HAC Web site at: /forms/forms.asp. We will continue to deny payment on any future claims until the patient's OHI status is validated.

7

177

Claim denied - duplicate of previously processed claim.

A secondary review in our claims payment area has determined that this claims is associated to a copy of a bill that is identical to a bill that was previously processed. We have systematically denied all claims that were created when we processed the second bill. You should already have received the results from the first time we processed this bill. If you do not believe that this is correct, you will need to contact us by phone at 1-800-733-8387 to resolve this issue. Do not resubmit this bill without contacting us, as it will only result in a series of one or more denied claims when we process the bill again.

8

27

Not a covered service and/or benefit for diagnosis listed.

Some services/procedures are only covered for specific conditions as outlined in the CHAMPVA Policy Manual. Services which do met these conditions will be denied. You can access our policy manual on line at: /forbeneficiaries/champva/policymanual.asp
There is a searh to help you to quickly locate the section of our policy that covers this request.

9

218

Clarification of OHI information required; certification sent to beneficiary.

We do not have an Other Health Insurance (OHI) Certification on file for the patient/beneficiary. We can not process any claims until we know if this individual is covered by another health plan. Even if the individual has no OHI coverage, we still need them to attest to this fact. Please resubmit an OHI Certification VA Form 10-5959c or call 1-800-733-8387 and a Customer Service Representative can help complete the certification over the phone.

10

270

ICD diagnostic code(s) missing/unreadable/ invalid, resubmit with this form.

A diagnosis is required to determine if the service denied on this claim is covered under the CHAMPVA program. We were unable to pay this claim due to a missing/unreadable/or invalid ICD code. Please check the accuracy and readability of you claim, and resubmit it with a copy of the CHAMPVA Explanation of Benefits (EOB) form for reconsideration.