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Vets4veterans is not acting as an attorney and we advise you seek help. This is as a guidelines to help you and help those who are assisting you with your claim..

VA Pension Programs

This web site is intended to be an information resource for veterans, surviving spouses and children who might be eligible for VA's Pension Benefits.  Pension benefits are meant as an assistance for eligible veterans, surviving spouses and children who demonstrate financial need.

VA manages two broad categories of Pension Benefits Programs:

    

Compensation -

This is to be used solely as a Guide before filing your VA -

Make a plan ahead and obtain all information first -

    Write down every issue -

    Write down - Who was there, Where it happed and When it happed

Be honest to VA and to the Organization which is representing you

Bottom line and no matter what you are responsible for your own claim -

CONTENTS

CHAPTER 4.  DEFINITIONS AND GENERAL RULES OF EVIDENCE

        4-i

October 29, 1985                                                                                              M28‑2, Part 1

CHAPTER 4. DEFINITIONS AND GENERAL RULES OF EVIDENCE

 4.01       DEFINITIONS

 A uniform understanding of various terms used in claims processing is essential.  Definitions applicable to the status of claims for chapter 31 benefits are provided below.

        a.    Claim or Application.  A formal or informal written communication requesting a determination of entitlement or evidencing a belief in entitlement to chapter 31 benefits.

        b.    Formal Claim for Chapter 31.  A specific claim in the form prescribed by the VA must be filed for a program of rehabilitation services or employment assistance.  The form used to establish a formal claim is VA Form 28‑1900, Disabled Veterans Application for Vocational Rehabilitation. (38 CFR 21.30)

        c.    Informal Claim for Chapter 31.  Any written communication indicating an intent to apply for rehabilitation services or employment assistance from a veteran, a duty authorized representative, or a Member of Congress on behalf of a veteran may be considered an informal claim. (38 CFR 21.31)

        d.    Original Claim.  The initial formal application. (38 CFR 21.30)

        e.    Pending Claim.  An application, formal or informal, which has not become a finally completed claim.

        f.     Finally Completed Claim.  After a claim has been allowed or disallowed by the agency of jurisdiction, that decision becomes final 1 year after the date of notice of allowance or disallowance, if an appeal is not initiated and perfected.  When an appeal is timely filed and perfected, the decision by the agency of jurisdiction, if affirmed, becomes final the date of the appellate decision. (See 38 CFR 19.153 and 19.154.)

        g.    Reconsideration of Claim Based on Receipt of New and Material Evidence.  Guidelines for the reconsideration of claims are provided in M21-1, chapter 27.  See also 38 CFR 3.156 and 3.400(Q).

        h.    Reopened Claim.  Any application for a benefit received after an earlier claim has become finally completed.

        i.     Claim for Increase.  Any application for an increase in rate of a benefit being paid under a current award or for resumption of payments previously discontinued.

 4.02       DUPLICATE CLAIMS

 If an acceptable VA Form 28‑1900 has been filed, it is generally not necessary thereafter to file another formal claim to receive chapter 31 benefits provided the veteran stays in a chapter 31 program.  If the veteran’s case has been discontinued, however, a new VA Form 28‑1900 will be required to reopen a claim for chapter 31. All reapplications must be forwarded to the VR&C Division for review prior to Adjudication Division action. (For details regarding these referrals, see pt. II, ch. 1, par. 1.02a.)

 4.03       REFERRALS TO ADJUDICATION

        a.    Determination of Infeasibility When Veteran Rated Less Than 100 Percent.  When a counseling psychologist in the VR&C Division determines that vocational rehabilitation is not reasonably feasible for a veteran with a service-connected condition rated less than 100 percent disabling, the counseling psychologist will refer the case to the Adjudication Division with a statement of the facts.

       b.    Veteran Rated 100 Percent Becomes Rehabilitated.  If a veteran rated 100 percent has been declared rehabilitated, the counseling psychologist will refer that veteran’s case to the Adjudication Division.

                                                                                     4-1

M28‑2, Part I                                                                                              October  29, 1985

4.4   ROUTINE PROCEDURES WHEN EVIDENCE MUST BE REQUESTED FROM THE                   CLAIMANT

        a.    Incomplete Claim.  If the claim is not complete at the time of original submission, all evidence necessary, insofar as possible, will be requested simultaneously to avoid piecemeal development.

        (1)  Informal Claim.  Upon receipt of an informal claim, if a formal claim has not been filed, a VA Form 28‑1900 will be forwarded to the claimant.  The date of receipt of the informal claim will constitute date of receipt of claim if the VA Form 28‑1900 is received within 1 year from the date the form is forwarded to the claimant (38 CFR 21.31 and 21.32). The case will not be referred to a rating board or to the VR&C Division until a formal claim has been filed.

        (2)  Unsigned Application.  If an application is received unsigned, a copy showing the date of receipt will be made and retained in the claims folder.  The original will be returned to the claimant for signature.  The file copy will be considered an informal claim under 38 CFR 21.31.

        b.    Controls for Submission of Evidence.  Generally, evidence will be requested to be submitted promptly and a control will be established for 60 days from the date of the letter requesting evidence.  If essential evidence is not received within the control period, the claim will be administratively disallowed on the 408 screen under reason code 16, Failure to Prosecute, without notice to the claimant. (See pt. II, ch. 3.)

        c.    Extension of Controls.  The 60-day control may be extended within the statutory limit when it is expected that the evidence requested will be difficult to obtain or when the claimant or his/her representative indicates that he or she is making an effort to obtain the requested evidence, but needs an extension.

        d.    Returned Correspondence.  If any correspondence to the claimant is returned undeliverable, the file will be reviewed to determine if the claimant’s correct address was used.  If the address used was not correct, the correspondence will be resent; otherwise, the returned correspondence will be backfiled in its original envelope so as to remain on top of all other file material.  If a change of address is subsequently noted, the original correspondence and file will be reviewed.  If still material, the correspondence will be dispatched to the claimant at the new address.

        e.    Address Unknown.  When a request for evidence essential to establish entitlement was addressed to the claimant’s last known address, but has been returned undeliverable, the time limit for submitting the evidence will not be extended. (See 38 CFR 3.109.)

        f.     Request Ignored.  A claimant’s failure to cooperate in providing essential information is adequate reason to deny entitlement or to discontinue or adjust an award of benefits,

        (1)  In the case of a running award, when action to adjust or discontinue the award is required, the claimant will be furnished notice of the proposed adverse action, if the action is determined to be adverse under the provisions of 38 CFR 21.420.  Upon final determination of the adverse action, the claimant will be given notice of procedural and appellate rights.

        (2)  When action to deny entitlement in an original or reopened claim is required because of failure to furnish evidence, a disallowance will be processed in accordance-with part II, chapter 3.

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Disability compensation is a benefit paid to a veteran because of injuries or diseases that happened while on active duty, or were made worse by active military service. It is also paid to certain veterans disabled from VA health care. The benefits are tax-free.

You may be eligible for disability compensation if you have a service-related disability and you were discharged under other than dishonorable conditions.

Chapter 3, Section 1.1

General Claim Filing Instructions

Speed Up Your Claims

1. Your name must be listed on the claim form exactly as it is on the CHAMPVA Authorization Card.
2. Your Social Security number must be on the claim. DO NOT USE the qualifying veteran’s Social Security number.
3. If you have other health insurance (OHI), include a copy of the OHI explanation of benefits.
4. After billing your other health insurance, you can file with CHAMPVA for the remaining balance.
5. Keep copies of all receipts, invoices, etc.
6. Separate claim forms are required for each patient/beneficiary.
7. If you fail to complete the VA Form 10-7959a, payment will be made directly to the health care provider instead of to you.
8. For inpatient hospitalizations, payment will always be made to the hospital whether or not you submit the billing.

Claims Submitted by the Beneficiary/Provider must include the following:

1. CHAMPVA Claim Form, VA Form 10-7959a, (beneficiaries only)
2. Itemized billing statement(s) are required. These can be submitted on a standardized paper form (HCFA-1500, CMS-1500, UB-92, or UB-04). The following information must be provided on the forms:
   • Full name, address, and tax identification number of the provider
   • Address where payment is to be sent
   • Address where services were provided
   • Provider professional status (doctor, nurse, physician assistant, etc.)
   • Specific date of each service provided. Date ranges are acceptable only when they match the number of services/units of services
   • Itemized charges for each service
   • Appropriate medical code (ICD-9, CPT, HCPCS) for each service
3. If other health insurance was billed, a copy of their explanation of benefits detailing what they paid is required. Sometimes the definition or explanation of codes is on the reverse side of their explanation of benefits form. Please include a copy of that information as well.

Pharmacy Claims

Most pharmacies submit claims to CHAMPVA electronically. The following information is required for pharmacy claims regardless of whether submitted electronically or on paper and regardless of whether submitted by the pharmacy or by you.

1. An invoice/billing statement that includes:
   • Name, address, and phone number of the pharmacy
   • Name of prescribing physician
   • Name, strength, and quantity for each drug
   • Eleven (11) digit National Drug Code for each drug
   • Charge for each drug
   • Co-payment for each drug
   • Date prescription was filled
2. Note: Ask your pharmacist to provide you with a signed printout showing all of the necessary information.

Where to Mail Claims

Mail claims to:

VA Health Administration Center
CHAMPVA
PO Box 469064
Denver, CO 80246-9064

How to Get Additional Claim Forms

Additional claim forms can be requested at any time (including evenings and weekends) by calling us at 1-800-733-8387 and selecting the claim form option from our voice-mail menu. You can also contact 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. For specific guidance when using IRIS for your inquiry click here.

Forms | Publications
Speed Up Your Claims!

There are a few simple things that you, the beneficiary, can do in order to expedite the processing of your claim. Here are a few suggestions:

1. Submit pharmacy summaries, not labels. Submit pharmacy summaries. Your pharmacy can give you a printout for the date range you specify. If it is necessary to submit prescription labels, send copies only, making certain they are on pages that are 8-1/2 inches by 11 inches in size. Retain the originals for yourself. It is also unnecessary to send drug descriptions.
    
2. Do not staple your claims. Staples jam machines we use to scan your claims. Do not staple your claims together. It is not necessary as our employees meticulously ensure that claims and all pertinent paperwork will stay together.
    
3. Make sure all papers are 8-1/2 inches by 11 inches. It is easier for us to process your claims if all of the papers you submit are a full 8-1/2 inches by 11 inches. If you have continuous feed documents, separate them along the perforated lines. Additionally, try to ensure that there are no torn or frayed edges.
    
4. Do not tape papers. If a paper is small, frayed, or torn, do not tape it to another paper. Instead, make a copy and submit that. Also, do not submit sticky notes with your claims.
    
5. Make certain that the patient's name and social security number is on the claim. Make certain that it is the name and social security number of the person receiving the medical services that appears on the claim. If a dependant receives medical services, their name and social security number should appear on the claim, not the sponsors. In addition, if two or more people in your family have similar first and last names, have the middle name spelled out on the claim form. It would also be beneficial if you inform whoever is providing the medical services of this so they can bill us correctly.

By following these few simple hints, you can greatly increase the speed in which your claims get processed. Following this advice will help us when we process your claim, although we will always do our best to rapidly process any claim that you submit.

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§42.6  Prerequisites for issuing a complaint against VA.

 (a) The reviewing official may issue a complaint under §42.7 of this part only if:

(1) The Department of Justice approves the issuance of a complaint in a written statement described in 31 U.S.C. 3803(b)(1), and

(2) In the case of allegations of liability under §42.3 of this part with respect to a claim, the reviewing official determines that, with respect to the claim or a group of related claims submitted at the same time such claim is submitted (as defined in paragraph (b) of this section), the amount of money or the value of property or services, or both, demanded or requested in violation of §42.3(a) of this part does not exceed $150,000.

(b) For the purposes of this section, a related group of claims submitted at the same time shall include only those claims arising from the same transaction (e.g., grant, loan, application, or contract) that are submitted simultaneously as part of a single request, demand, or submission

(c) Nothing in this section shall be construed to limit the reviewing official’s authority to join in a single complaint against a person’s claims that are unrelated or were not submitted simultaneously, regardless of the amount of money, or the value of property or services, demanded or requested.

1830!