Navigating the complexities of healthcare claims can be challenging, especially when dealing with the Veterans Affairs (VA) Community Care network. As a provider, understanding why your claims might be rejected is crucial for ensuring timely payments and efficient practice operations. The VA processes claims into three categories: accepted, denied, and rejected. While accepted claims proceed smoothly, rejected claims require immediate attention and correction to avoid payment delays. This guide focuses on unraveling the common reasons behind VA Community Care claim rejections, with a particular emphasis on diagnosis code errors, and provides actionable steps to rectify these issues.
VA categorizes claim outcomes to streamline the payment process:
- Accepted Claims: These are correctly billed claims for services pre-authorized by the VA. Providers can expect prompt payment for accepted claims.
- Denied Claims: Claims are denied when the necessary pre-authorization is absent, or if the veteran doesn’t meet the eligibility criteria for emergency care.
- Rejected Claims: Rejection occurs when claims are unprocessable due to billing inaccuracies or missing information. Importantly, rejected claims can be resubmitted once the identified errors are corrected or the required information is provided.
Crucial Note for CHAMPVA Providers: Encountering remark codes CARC 299 and RARC N24? Enrollment in Electronic Funds Transfer (EFT) is often the solution. Visit the VA Financial Services Center (FSC) Customer Engagement Portal for enrollment and detailed instructions in the Vendor Webform User Guide. Assistance is also available via the FSC Customer Support Help Desk.
For issues beyond the Preliminary Fee Remittance Advice Report (PFRAR) or the Customer Engagement Portal, direct inquiries to the designated customer service unit that handled your claim adjudication. They are best equipped to guide you on the necessary steps for claim reprocessing.
VA FSC Customer Engagement Portal
FSC Customer Support Help Desk: 877-353-9791 Monday – Friday, 7:15 a.m. – 4:15 a.m. CT
Understanding Rejections During Electronic Conversion
To enhance efficiency, the VA mandates electronic submission by converting all paper claims into the 837 electronic format. This conversion process includes two error checks: initially during electronic conversion and subsequently during claim processing. Claims failing to meet standardized billing requirements during conversion are rejected until errors are resolved. Providers will receive a notification letter detailing the error and the reason for rejection, enabling them to make necessary corrections before resubmission.
Top 10 Claim Rejection Reasons for Veteran Care
For healthcare providers serving veterans under VA Community Care, understanding the common pitfalls in claim submissions is essential. Below are the top 10 reasons for rejection of HCFA/CMS-1500 (professional claims) and UB/CMS-1450 (institutional claims) paper claims:
Top Reasons for HCFA/CMS-1500 Rejections:
| Rank | Code | Reason/Detail |
|---|---|---|
| 1 | 016 | Missing/Incomplete/Invalid Insured ID: Requires the 17-digit alphanumeric Internal Control Number (ICN) format (10 digits + “V” + 6 digits) or a 9-digit Social Security Number (SSN) without special characters. Ensure accurate entry of the veteran’s identification. |
| 2 | 086 | Missing Insurance Plan Name or Program Name: Clearly indicate “VA Community Care Network” as the insurance program. Omission of this detail leads to rejection. |
| 3 | 092 | Missing/Invalid Admission Date for POS 21: For Place of Service code 21 (Inpatient Hospital), the admission date (Box 18) is mandatory. Verify and include the correct admission date. |
| 4 | 088 | Invalid Service Facility Address: The service facility address must be a valid street address. PO Boxes are not acceptable. Double-check the physical address of the service location. |
| 5 | 005 | Missing NDC Units: For drugs administered, National Drug Code (NDC) units are required. Ensure accurate units are reported for all pharmaceuticals. |
| 6 | 002 | Invalid Place of Service (POS) Codes: Use only valid and appropriate POS codes. Review the code list and select the correct code reflecting where the service was rendered. |
| 7 | 081 | Invalid Rendering NPI: The National Provider Identifier (NPI) of the rendering provider must be valid. Verify the NPI and ensure it is correctly entered. |
| 8 | 034 | Claim contains ICD-9 Principal Diagnosis Code: For Dates of Service after September 30, 2015, ICD-10 codes are mandatory. Diagnosis code error due to outdated ICD-9 codes will result in rejection. Update to ICD-10. |
| 9 | 105 | Invalid Service Line Provider Taxonomy Code: Ensure the taxonomy code for each service line is valid and corresponds to the provider’s specialty. |
| 10 | 004 | Invalid/Incomplete CPT/HCPCS Codes: Use accurate and complete Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes. Incorrect or incomplete codes lead to rejection. |
Top Reasons for UB/CMS-1450 Rejections:
| Rank | Code | Reason/Detail |
|---|---|---|
| 1 | 016 | Missing/Incomplete/Invalid Insured ID: Similar to HCFA claims, accurate veteran ID (ICN or SSN) is crucial. Verify and correctly input the identification number. |
| 2 | 125 | Missing Outpatient Claim “Admission Type” Code: For outpatient claims, the “Admission Type” code is required. Ensure this field is completed. |
| 3 | 097 | Missing Admission Type when Admission Date is Present: If an admission date is provided, the Admission Type code becomes mandatory. Complete both fields consistently. |
| 4 | 108 | Referring and Attending Physician NPIs are Equal: The NPIs for referring and attending physicians cannot be the same unless they are indeed the same provider. Verify and correct if different providers are involved. |
| 5 | 007 | Missing/Incomplete/Invalid Billing Provider Address: The billing provider’s address must be complete and valid. Ensure accuracy and completeness of the billing address. |
| 6 | 013 | Claim contains missing or invalid Patient Status: Patient status codes are required. Use valid codes accurately reflecting the patient’s status. |
| 7 | 034 | Claim contains ICD-9 Principal Diagnosis Code: As with HCFA claims, UB claims for dates of service after September 30, 2015, must use ICD-10 codes. Diagnosis code error related to ICD-9 usage is a rejection trigger. Transition to ICD-10 coding. |
| 8 | 031 | Claim contains invalid or missing “Patient Reason” Diagnosis Code: Patient Reason diagnosis codes are necessary for institutional claims. Ensure valid and appropriate codes are included. |
| 9 | 021 | Missing Patient Account Number: The patient account number is a required field for claim processing. Do not leave this field blank. |
| 10 | 117 | Invalid “Type of Bill” Code: Use a valid “Type of Bill” code that accurately reflects the nature of the institutional claim. |
Top 10 Rejection Reasons for Family Member Care (CHAMPVA)
Claims for family member programs like CHAMPVA also face rejection if not submitted correctly. Here are the top 10 reasons for claim rejection or denial in CHAMPVA, along with explanations and corrective actions:
Helpful Hints: CHAMPVA Claim Filing for Providers
For denial codes not listed below, the Inquiry Routing & Information System (IRIS) or the Customer Call Center can provide further assistance.
Top 10 Reasons Family Member Program Claims are Rejected or Denied:
| Rank | Code | Reason/Detail |
|---|---|---|
| 1 | 65/159/177 | Duplicate Claim – Previously Processed: The claim is identified as an exact duplicate of a previously processed claim. Check the Explanation of Benefits (EOB) for the original claim number. Do not resubmit without contacting the Customer Call Center. |
| 2 | 78 | EOB from Other Insurance Required – VHA IVC Secondary Payer: If the patient has primary insurance, the primary insurer’s EOB is mandatory for VHA IVC (Integrated Veteran Care) to act as a secondary payer. Resubmit with both primary and VHA IVC EOBs, or have the patient update their Other Health Insurance (OHI) status. |
| 3 | 124 | Claim not Timely Filed: CHAMPVA claims must be filed within 365 days of the service date. A 180-day grace period exists upon initial enrollment for older claims. Check claim submission dates against these timelines. Appeals for exceptions due to exceptional circumstances can be sent to the VHA Office of Integrated Veteran Care Appeals (address provided below). |
| 4 | 278 | Multiple Primary Insurance Coverage: Resubmit EOBs from all primary payers. Similar to duplicate claim issues, check the EOB comments for matching VHA IVC claim numbers and contact the Customer Call Center if needed. Avoid resubmission without prior contact. |
| 5 | 148 | Claim Denied – Chiropractic Services Not Covered: Chiropractic services are not covered under CHAMPVA. Contact the Customer Call Center if you believe this denial is incorrect. Do not resubmit without inquiry. |
| 6 | 137 | Beneficiary not Eligible on Date of Service Claimed: Verify the patient’s eligibility period on their member card against the service date. If the date is correct, the service is not covered. If the date is incorrect, submit a corrected claim. |
| 7 | 224 | Must Provide Medical History/Documentation to Support Treatment: Resubmit the claim with supporting medical documentation and a copy of the VHA IVC EOB for reconsideration. Contact the Customer Call Center for clarification. |
| 8 | 218/220 | Clarification of OHI Information Required. Certification sent to beneficiary: A CHAMPVA Other Health Insurance (OHI) Certification (VA Form 10-7959c) is required. Submit the form or have the patient complete certification via the Customer Service Center. Processing halts until OHI status is confirmed. |
| 9 | 27 | Not a Covered Service and/or Benefit for Diagnosis Listed: Certain services are covered only for specific diagnoses as per VHA IVC policy manuals. Review the policy manuals to confirm coverage based on the diagnosis. |
| 10 | 391 | ICD Diagnostic Code(s) Missing/Unreadable/Invalid. Resubmit with EOB form: Diagnosis code error due to missing, unreadable, or invalid ICD codes. Resubmit with a legible and accurate diagnosis code and a copy of the VHA IVC EOB for reconsideration. |
Contact Us
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
