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

OMB Number 2900-0219
Estimated Burden: 10 minutes
Expiration Date: 09/20/2016

CHAMPVA Other Health Insurance (OHI) Certification

Department of Veterans Affairs

Chief Business Office Purchased Care, PO Box 469063, Denver CO 80246-9063
Customer Service Center: 1-800-733-8387 | FAX: 303-331-7808 | Website: http://www.va.gov/purchasedcare
ATTENTION: Please read the instructions on the reverse side before completing this form. Failure to provide the requested information
will result in a delay or denial of reimbursement until OHI information is received. Return the form and any requested information to the
address shown above. This form is also used to report any changes in your OHI status. Updates can be sent by FAX or call by phone.

SECTION I: BENEFICIARY INFORMATION – Please use a separate form for each family member
Last Name

First Name
City

Street Address (Number, Street name/PO Box, Apt #)
Phone Number (with area code)

MI

Social Security Number
State

Zip Code
Gender

Check if this is a new address

Male

Female

SECTION II: MEDICARE BENEFICIARIES – Attach a copy of your Medicare card
Part A:

Yes

No

Part B:

Yes

No

Part D:

Yes

No

Effective Date (mm-dd-yyyy)

Effective Date (mm-dd-yyyy)

Effective Date (mm-dd-yyyy)

Part A Carrier Name

Part B Carrier Name

Part Carrier Name

Does your Medicare coverage provide pharmacy benefits?

Yes

Yes
No

Do you have health insurance
other than MEDICARE?

No

Did you choose a Medicare Advantage Plan for your Medicare coverage?

Yes

No

If NO, go to Section IV.

SECTION III: OTHER HEALTH INSURANCE
Provide all periods of OHI coverage since becoming CHAMPVA eligible and attach a copy of any active health insurance cards (front and back).

Name of insurance #1
Effective Date (mm-dd-yyyy)
Is this insurance through
employment?
What type of insurance is it?

Only input the termination
date if the policy is inactive.

Termination Date (mm-dd-yyyy)
Yes
No
HMO

Does the insurance cover
prescriptions?
PPO

Prescription Discount

Yes
No

Does the insurance provide an
explanation of benefits for prescriptions?

Medicaid / State Assistance

Yes
No

Medigap (if Medigap, specify [A-J])

Other (specialty, limited coverage, or exclusively CHAMPVA supplemental)

Comments:
Name of insurance #2
Effective Date (mm-dd-yyyy)
Is this insurance through
employment?
What type of insurance is it?

Only input the termination
date if the policy is inactive.

Termination Date (mm-dd-yyyy)
Yes
No
HMO

Does the insurance cover
prescriptions?
PPO

Prescription Discount

Yes
No

Does the insurance provide an
explanation of benefits for prescriptions?

Medicaid / State Assistance

Yes
No

Medigap (if Medigap, specify [A-J])

Other (specialty, limited coverage, or exclusively CHAMPVA supplemental)

Comments:

SECTION IV: CERTIFICATION BY BENEFICIARY, SPONSOR OR LEGAL GUARDIAN
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting or making false, fictitious or
fraudulent statements of claims. I certify that the above information is correct to the best of my knowledge and belief. If there is any
change in insurance status for the above person, I agree to promptly notify the Chief Business Office Purchased Care.
SIGNATURE (type if electronic):
VA FORM
AUG 2013

10-7959c

DATE:

CHAMPVA OTHER HEALTH INSURANCE (OHI) CERTIFICATION
NOTES, DEFINITIONS, AND INSTRUCTIONS
INSTRUCTIONS

Failure to complete all applicable sections on the front can result in a delay or denial of benefits. Use this form to report any
changes in your other health insurance.
--

New beneficiaries - we need OHI information from the date your CHAMPVA eligibility became effective.

--

Re-certification - update OHI information every time a change is made to your OHI coverage.

--

To specify a medicare supplement plan A - J, refer to your policy cover sheet or your insurance membership card.

--

If there are additional policies use plain bond paper and either type or legibly print your name, SSN, and the information for each
item. Attach to this form. If submitting this form electronically add an attachment to the submission.

ITEMS TO RETURN WITH THIS COMPLETED OTHER HEALTH INSURANCE (OHI) CERTIFICATION
--

A COPY of your Medicare card (do NOT send the original).

--

A COPY of your other health insurance (OHI) member ID card (front and back).

--

If your OHI does not issue EOBs, then attach a copy (card or document) of your schedule of benefits that lists your co-payments.

DEFINITIONS
OHI: OHI refers to insurance or benefits you may have other than CHAMPVA called “Other Health Insurance.”
EOB: The abbreviation for an “explanation of benefits” form or letter that must accompany claims submitted to CHAMPVA. An EOB is a
statement or “Remittance Advice” from an insurance carrier or benefit program that summarizes the action taken on a claim.
Note: If you have OHI primary to CHAMPVA you must submit EOB's for each primary insurance along with health care claims. If your
OHI does not issue EOB's i.e. some HMO's and PPO's, you must submit a copy of your active co-payment information shown on your
insurance card or a document showing your co-payments with every health care claim so CHAMPVA can calculate benefit payments.
Carrier: Carrier is the insurance company that provides your medical benefits.
OHI primary to CHAMPVA: CHAMPVA by law is always supplemental or the secondary payer of health care benefits except for
Medicaid, State Victims of Crimes Compensation Programs, and policies purchased exclusively to supplement CHAMPVA benefits.
Supplemental CHAMPVA policies: These are policies specifically purchased for the purpose of covering your cost share after
CHAMPVA has completed adjudication of a claim.
Medicare supplemental policies: These are policies that are specifically for the purpose of covering your Medicare out of pocket
expenses. These Medicare supplemental policies such as “Medigap” or Policies offered through employment are primary to CHAMPVA
and must provide an EOB along with the Medicare EOB (two EOBs) for each claim submitted to CHAMPVA.
Indemnity: Plans that pay a flat fee or daily rate to supplement lost income while hospitalized are called Indemnity Plans.
Termination date: This is the date the policy ended or ceased to be active. The end date for a period shown on a card that will be
reissued is not the termination date. Closing a policy will generate a true termination date.
Privacy Act Information: Information on this form is collected in accordance with the System of Records Notice 54VA10NB3, Veterans
and Beneficiaries Purchased Care Community Health Care Claims, Correspondence, Eligibility, Inquiry and Payment Files-VA
(Published March 3, 2015, FR 80, number 41). Category: Records maintained in the system include program applications, eligibility
information concerning the Veteran, family members, caregivers, other health insurance information to include information regarding
eligibility or entitlement to other federal medical programs. Authority: 38 USC 501 and 1781. Purpose: Records may be used for
purposes of establishing and monitoring eligibility to receive VA benefits, processing claims for medical care and services, and
processing stipends. Routine Use: The Privacy Act permits VA to disclose information about individuals without their consent under the
Privacy Act Routine Use Disclosure when the information will be used for a purpose that is compatible with the purpose for which VA
collected the information. Disclosure: Voluntary. You do not have to provide the requested information on this form but if any or all of
the requested information is not provided, it may delay or result in denial of your request for CHAMPVA benefits. Failure to furnish the
requested information will have no adverse impact on any other VA benefit to which you may be entitled.
Paperwork Reduction Act: This information collection is in accordance with the clearance requirements of Section 3507 of the
Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is estimated to average 10 minutes per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Comments regarding this burden estimate or any other aspect of this collection,
including suggestions for reducing the burden, may be addressed by calling the CHAMPVA Help Line, 800-733-8387. Respondents
should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number. This collection of information is to determine payer
status when other health insurance coverage exists.
VA FORM
AUG 2013

10-7959c