The U.S. Department of Veterans Affairs (VA) is dedicated to providing healthcare services to veterans. However, navigating the claims process can sometimes be complex for healthcare providers. While the Veterans Health Care program aims to serve those who have served, it’s important to understand the system isn’t always straightforward and that claim rejections are a reality. This guide breaks down common reasons for claim rejections within the VA system, offering insights for providers to ensure smoother processing and payment. Understanding these issues is crucial for healthcare providers working with veterans and sheds light on the practicalities of whether the veterans health care program is universal care in its application.
Decoding VA Claim Processing: Acceptance, Denial, and Rejection
When healthcare providers submit claims to the VA, these claims are categorized into three distinct statuses: accepted, denied, or rejected. Each status has significant implications for payment and further action.
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Accepted Claims: These are correctly submitted claims for care that the VA has pre-authorized. Providers can expect prompt payment for accepted claims, ensuring efficient revenue cycle management. This smooth process represents the ideal scenario within the VA healthcare system.
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Denied Claims: Claims face denial when the necessary pre-authorization was not secured, or if the veteran does not meet the specific eligibility criteria for emergency care. Denials highlight that access to VA healthcare is not automatically universal; it’s contingent on meeting specific requirements and procedures.
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Rejected Claims: Rejection occurs when claims contain errors in billing or lack essential information required for processing. Rejected claims are neither paid nor denied; instead, they offer an opportunity for providers to correct the identified issues and resubmit the claim for reconsideration. This process of rejection and resubmission underscores that even within a system designed for veterans’ care, administrative accuracy is paramount.
For providers encountering remark codes CARC 299 and RARC N24, enrollment in Electronic Funds Transfer (EFT) is often a solution. The VA Financial Services Center (FSC) Customer Engagement Portal offers resources and a webform for Payment Account Setup to facilitate EFT enrollment. Detailed instructions are available in the Vendor Webform User Guide, and the FSC Customer Support Help Desk is available for direct assistance.
Should you require information beyond the Preliminary Fee Remittance Advice Report (PFRAR) or the Customer Engagement Portal (CEP), contacting the designated customer service support unit responsible for adjudicating your claim is advisable. These units are equipped to provide specific guidance for claim reprocessing.
Navigating Electronic Conversion Rejections in Veteran Care Claims
The VA mandates that all paper claims undergo electronic conversion to the 837 electronic format. This conversion process includes two error reviews: one during the electronic conversion itself and a subsequent review during the formal claims processing stage. Claims that fail to meet standardized billing requirements during the initial conversion are rejected until the identified errors are rectified. Providers are notified of these conversion-related rejections via a letter from the VA, detailing the error and the reason for rejection.
Top 10 Reasons for Claim Rejection in Veteran Care (HCFA/CMS-1500)
For HCFA/CMS-1500 paper claims, which are commonly used for professional medical services, certain errors frequently lead to rejections. Understanding these common pitfalls is key to minimizing claim rejections and ensuring timely payment.
| Rank | Code | Reason/Detail |
|---|---|---|
| 1 | 016 | Missing/Incomplete/Invalid Insured ID: This is the most frequent cause of rejection. The VA requires a specific 17-character alphanumeric Internal Control Number (ICN) format (10 digits + “V” + 6 digits) or a 9-digit Social Security Number (SSN) without any special characters. Incorrect or missing IDs immediately flag a claim for rejection. |
| 2 | 086 | Missing Insurance Plan Name or Program Name: Claims must clearly identify the relevant insurance plan or program name. Omission of this information results in rejection, as it is crucial for proper claim routing and processing within the VA system. |
| 3 | 092 | Missing/Invalid Admission Date for POS 21: For Place of Service (POS) code 21 (Inpatient Hospital), the admission date is mandatory. Claims lacking or having an invalid admission date in Box 18 are rejected, particularly affecting facility claims. |
| 4 | 088 | Invalid Service Facility Address: The service facility address provided must be a valid street address. PO Boxes or incomplete addresses are not acceptable and will lead to claim rejection. This ensures proper facility identification and verification. |
| 5 | 005 | Missing NDC Units: For claims involving drugs, the National Drug Code (NDC) units must be specified. Missing NDC units for pharmaceutical services are a common rejection reason, particularly in outpatient settings. |
| 6 | 002 | Missing/Incomplete/Invalid Place of Service Codes: Accurate Place of Service (POS) codes are essential to categorize the location where the service was rendered. Incorrect, incomplete, or missing POS codes are a frequent source of rejection across various claim types. |
| 7 | 081 | Invalid Rendering NPI: The National Provider Identifier (NPI) of the rendering provider must be valid. Claims with invalid rendering NPIs, often due to typos or incorrect information, are rejected to ensure provider legitimacy. |
| 8 | 034 | Claim contains ICD9 Principal Dx code: The VA mandates the use of ICD-10 codes for diagnoses for dates of service after September 30, 2015. Claims still using outdated ICD-9 codes are rejected for non-compliance with current coding standards. |
| 9 | 105 | Invalid Service Line Provider Taxonomy Code: Provider taxonomy codes, classifying the provider’s specialization, must be valid at the service line level. Invalid taxonomy codes can cause rejections, especially in specialized service claims. |
| 10 | 004 | Invalid/Incomplete CPT/HCPCS codes: Correct Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes are fundamental for service billing. Claims with invalid or incomplete procedure codes are rejected due to inability to identify services rendered. |
Top 10 Reasons for Claim Rejection in Veteran Care (UB/CMS-1450)
For UB/CMS-1450 claims, typically used by hospitals and facilities, a different set of common rejection reasons emerges. These are often related to institutional billing specifics.
| Rank | Code | Reason/Detail |
|---|---|---|
| 1 | 016 | Missing/Incomplete/Invalid Insured ID: Similar to HCFA-1500 claims, incorrect or missing Insured IDs are the top rejection reason for UB-04 claims. The VA’s required 17-character ICN format or 9-digit SSN must be precisely followed. |
| 2 | 125 | The outpatient claim has a missing “Admission Type” code: For outpatient hospital claims, the “Admission Type” code is required to categorize the nature of the outpatient encounter. Missing admission type codes lead to rejection for outpatient facility claims. |
| 3 | 097 | Missing Admission Type when Admission Date is Present: If an admission date is provided on the claim, an “Admission Type” code becomes mandatory. Inconsistency by providing an admission date without a corresponding type triggers rejection. |
| 4 | 108 | Referring and Attending Physician NPI are equal: In institutional billing, the referring and attending physician NPIs should be distinct when applicable. Using the same NPI for both roles can lead to rejection due to potential billing integrity concerns. |
| 5 | 007 | This claim contains a missing/incomplete/invalid Billing Provider Address: Accurate and complete billing provider addresses are crucial for payment and correspondence. Missing, incomplete, or invalid billing provider addresses are a common rejection point for institutional claims. |
| 6 | 013 | Claim contains missing or invalid Patient Status: Patient status codes, indicating the patient’s disposition after care (e.g., discharged, transferred), are required on institutional claims. Missing or invalid patient status codes cause rejections, affecting claim finalization. |
| 7 | 034 | Claim contains ICD9 Principal Dx code: Just as with professional claims, UB-04 claims must use ICD-10 diagnosis codes for dates of service after September 30, 2015. Claims with outdated ICD-9 principal diagnosis codes are rejected for non-compliance. |
| 8 | 031 | Claim contains invalid or missing “Patient Reason” diagnosis code: “Patient Reason” diagnosis codes, detailing the reason for the patient’s visit, are necessary, particularly in certain institutional claim scenarios. Missing or invalid patient reason diagnosis codes can lead to rejections. |
| 9 | 021 | Missing Patient Account Number: The patient account number is a key identifier for claim processing and reconciliation within the facility’s system. Missing patient account numbers hinder claim matching and result in rejection. |
| 10 | 117 | Invalid “Type of Bill” code: “Type of Bill” codes classify the type of facility claim being submitted (e.g., inpatient, outpatient, skilled nursing). Incorrect or invalid “Type of Bill” codes are a frequent rejection reason for UB-04 claims, miscategorizing the service. |
Top 10 Rejection Reasons for Family Member Care (CHAMPVA)
Claims for family member programs like CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs) have their own set of common rejection reasons. These often relate to program-specific rules and coordination of benefits.
| Rank | Code | Reason/Detail |
|---|---|---|
| 1 | 65/159/177 | Duplicate claim – Previously processed: The system identifies an exact match to a previously processed claim. Resubmitting without contacting the Customer Call Center will lead to repeated rejections. The original claim number should be referenced in the Explanation of Benefits (EOB). IMPORTANT NOTE: Contact customer service to resolve; do not resubmit without consultation. |
| 2 | 78 | EOB from other insurance required – VHA IVC secondary payer: CHAMPVA often acts as a secondary payer. If the patient has primary health insurance, the EOB from the primary insurer is mandatory for CHAMPVA to process the claim. Resubmit with both primary and VHA IVC EOBs. |
| 3 | 124 | Claim not timely filed: CHAMPVA has specific timely filing limits (365 days from service date, with a 180-day grace period upon initial enrollment for older claims). Claims exceeding these limits are rejected. Written appeals for exceptions due to extenuating circumstances can be sent to the VHA Office of Integrated Veteran Care Appeals. NOTE: Appeals should be sent to the specified address, not the claims processing address. |
| 4 | 278 | Multiple primary insurance coverage. Please resubmit EOBs from each payer: If the system detects multiple primary insurance coverages, EOBs from all primary payers are required. Similar to duplicate claims, verify with customer service before resubmitting to avoid repeated rejections. IMPORTANT NOTE: Contact customer service; do not resubmit without consultation. |
| 5 | 148 | Claim denied – Chiropractic services not covered: CHAMPVA may not cover all services, such as chiropractic care in some instances. If chiropractic services are indeed not covered, the claim will be denied. Verify coverage policies or contact customer service to confirm. IMPORTANT NOTE: Contact customer service before resubmitting. |
| 6 | 137 | Beneficiary not eligible on date of service claimed: Eligibility for CHAMPVA benefits is date-specific. If the beneficiary was not eligible on the date of service, the claim will be rejected. Verify beneficiary eligibility dates and correct the date of service if an error occurred. |
| 7 | 224 | Must provide medical history/documentation to support treatment: For certain services or under specific conditions, medical history or documentation may be required to support the necessity of treatment. Resubmit the claim with the requested documentation and a copy of the VHA IVC EOB. |
| 8 | 218/220 | Clarification of OHI information required. Certification sent to beneficiary: CHAMPVA requires Other Health Insurance (OHI) information. If this is missing or unclear, a certification is sent to the beneficiary. Submit the CHAMPVA OHI Certificate, VA Form 10-7959c, or have the beneficiary contact customer service to complete certification. |
| 9 | 27 | Not a covered service and/or benefit for diagnosis listed: CHAMPVA coverage is subject to specific service and diagnosis limitations outlined in VHA IVC policy manuals. Services not meeting these criteria are denied. Consult VHA IVC policy manuals to verify coverage or contact customer service. |
| 10 | 391 | ICD diagnostic code(s) missing/unreadable/invalid. Resubmit with EOB form: Accurate and readable ICD diagnostic codes are essential to determine service coverage. Claims with missing, unreadable, or invalid ICD codes are rejected. Resubmit with accurate codes and a copy of the VHA IVC EOB. |
Contact Information for Claim Inquiries
For further assistance or clarification on claim rejections, several contact options are available.
Ask VA (AVA) provides an online platform for inquiries.
Customer Call Centers:
CHAMPVA: 800-733-8387
Monday – Friday, 8:05 a.m. – 6:45 p.m., ET
Spina Bifida/Children of Women Vietnam Veterans programs: 888-820-1756
Monday – Friday, 8:00 a.m. – 7:00 p.m., ET
Mailing Addresses for Family Member Claims:
VHA Office of Integrated Veteran Care Appeals
PO Box 600, Spring City PA 19475
VHA Office of Integrated Veteran Care Resubmissions
PO Box 500, Spring City PA 19475
While the VA healthcare system strives to provide comprehensive care for veterans and their families, the claim rejection process highlights that it is not a completely universal and barrier-free system. Navigating eligibility, pre-authorization, and accurate claim submission is crucial for both veterans and healthcare providers to effectively access and deliver these essential services. Understanding the common reasons for claim rejections is a vital step towards improving the efficiency and effectiveness of veteran healthcare administration.
