VA Form 10-7959c Champva Other Health Insurance (Ohi) Certification

VA Form 10-7959C, CHAMPVA - Other Health Insurance (OHI) Certificate

The VA Form 10-7959C, CHAMPVA - Other Health Insurance (OHI) Certificate is a Department of Veterans Affairs (VA) document used to collect data required to determine payer status when there are other health insurances present. You may also use this form to provide information about changes in your health insurances.

The latest version of the form was released by the VA in May 2010. An up-to-date fillable version of the VA Form 10-7959C is available for download and digital filing below or can be found on the VA official website.

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a health care program administered by the Veterans Health Administration Office of Community Care in Denver, Colorado. This program is very similar to TRICARE. The CHAMPVA does not have its own network of health-care providers, but it shares the costs of necessary medical procedures and supplies with eligible beneficiaries.

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OMB Number 2900-0219
Estimated burden: 10 minutes
Department of Veterans Affairs
CHAMPVA Other Health Insurance (OHI) Certification
VA Health Administration Center, PO BOX 469063, Denver, CO 80246-9063 1-800-733-8387 www.va.gov/hac FAX: 1-303-331-7808
Failure to provide the requested information will result in a delay or denial of reimbursement until OHI information is received.
This form is also used to report any changes in your other health insurance status. Updates can be sent by FAX or call by phone.
PLEASE READ INSTRUCTIONS AND INFORMATION ON THE REVERSE SIDE BEFORE COMPLETING THIS FORM
SECTION I: BENEFICIARY INFORMATION - PLEASE USE A SEPARATE FORM FOR EACH FAMILY MEMBER
LAST NAME
FIRST NAME
MI
SEX
ADDRESS (NUMBER, STREET, PO BOX, APT #)
Male
Female
CITY
STATE
ZIP CODE
SOCIAL SECURITY NUMBER
PHONE # (INCLUDE AREA CODE)
CHECK IF NEW ADDRESS
SECTION II: MEDICARE BENEFICIARIES: ATTACH A COPY OF YOUR MEDICARE CARD
No
Yes
No
Yes
No
Part A:
Part B:
Part D:
Yes
EFFECTIVE DATE
EFFECTIVE DATE
EFFECTIVE DATE
(MMDDYYYY)
(MMDDYYYY)
(MMDDYYYY)
PART A CARRIER NAME
PART B CARRIER NAME
PART D CARRIER NAME
Did you choose a Medicare Advantage
Does your Medicare provide
Yes
NO
Yes
No
Plan for your Medicare coverage?
Pharmacy benefits?
Do you have health insurance other than MEDICARE?
Yes
No
IF NO, go to Section IV
Provide all periods of other health insurance coverage since you became CHAMPVA eligible.
SECTION III:
Required: Attach a copy of any active health insurance cards (front & back).
Name of insurance # 1
Only put in the termination date if
EFFECTIVE DATE
TERMINATION DATE
the policy is inactive.
(MMDDYYYY)
(MMDDYYYY)
Yes
No
Yes
No
Is this insurance through employment?
Does the insurance cover prescriptions?
Yes
No
Does the insurance provide an explanation of benefits for prescriptions?
What type of insurance?
HMO
PPO
Medicaid/State Assistance
Prescription Discount
Medigap
Other
[if Medigap, specify
(specialty, limited coverage, or exclusively CHAMPVA supplemental)
(A-J)]
Comments
Name of insurance # 2
Only put in the termination date if
EFFECTIVE DATE
TERMINATION DATE
the policy is inactive.
(MMDDYYYY)
(MMDDYYYY)
Yes
No
Yes
No
Is this insurance through employment?
Does the insurance cover prescriptions?
Yes
No
Does the insurance provide an explanation of benefits for prescriptions?
What type of insurance?
HMO
PPO
Medicaid/State Assistance
Prescription Discount
Medigap
Other
[if Medigap, specify
(specialty, limited coverage, or exclusively CHAMPVA supplemental)
(A-J)]
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 VA's Health Administration Center. Sign, date below and return to the address at the top of the form.
DATE
SIGNATURE (type if electronic):
VA FORM 10-7959c
FEB 2017
OMB Number 2900-0219
Estimated burden: 10 minutes
Department of Veterans Affairs
CHAMPVA Other Health Insurance (OHI) Certification
VA Health Administration Center, PO BOX 469063, Denver, CO 80246-9063 1-800-733-8387 www.va.gov/hac FAX: 1-303-331-7808
Failure to provide the requested information will result in a delay or denial of reimbursement until OHI information is received.
This form is also used to report any changes in your other health insurance status. Updates can be sent by FAX or call by phone.
PLEASE READ INSTRUCTIONS AND INFORMATION ON THE REVERSE SIDE BEFORE COMPLETING THIS FORM
SECTION I: BENEFICIARY INFORMATION - PLEASE USE A SEPARATE FORM FOR EACH FAMILY MEMBER
LAST NAME
FIRST NAME
MI
SEX
ADDRESS (NUMBER, STREET, PO BOX, APT #)
Male
Female
CITY
STATE
ZIP CODE
SOCIAL SECURITY NUMBER
PHONE # (INCLUDE AREA CODE)
CHECK IF NEW ADDRESS
SECTION II: MEDICARE BENEFICIARIES: ATTACH A COPY OF YOUR MEDICARE CARD
No
Yes
No
Yes
No
Part A:
Part B:
Part D:
Yes
EFFECTIVE DATE
EFFECTIVE DATE
EFFECTIVE DATE
(MMDDYYYY)
(MMDDYYYY)
(MMDDYYYY)
PART A CARRIER NAME
PART B CARRIER NAME
PART D CARRIER NAME
Did you choose a Medicare Advantage
Does your Medicare provide
Yes
NO
Yes
No
Plan for your Medicare coverage?
Pharmacy benefits?
Do you have health insurance other than MEDICARE?
Yes
No
IF NO, go to Section IV
Provide all periods of other health insurance coverage since you became CHAMPVA eligible.
SECTION III:
Required: Attach a copy of any active health insurance cards (front & back).
Name of insurance # 1
Only put in the termination date if
EFFECTIVE DATE
TERMINATION DATE
the policy is inactive.
(MMDDYYYY)
(MMDDYYYY)
Yes
No
Yes
No
Is this insurance through employment?
Does the insurance cover prescriptions?
Yes
No
Does the insurance provide an explanation of benefits for prescriptions?
What type of insurance?
HMO
PPO
Medicaid/State Assistance
Prescription Discount
Medigap
Other
[if Medigap, specify
(specialty, limited coverage, or exclusively CHAMPVA supplemental)
(A-J)]
Comments
Name of insurance # 2
Only put in the termination date if
EFFECTIVE DATE
TERMINATION DATE
the policy is inactive.
(MMDDYYYY)
(MMDDYYYY)
Yes
No
Yes
No
Is this insurance through employment?
Does the insurance cover prescriptions?
Yes
No
Does the insurance provide an explanation of benefits for prescriptions?
What type of insurance?
HMO
PPO
Medicaid/State Assistance
Prescription Discount
Medigap
Other
[if Medigap, specify
(specialty, limited coverage, or exclusively CHAMPVA supplemental)
(A-J)]
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 VA's Health Administration Center. Sign, date below and return to the address at the top of the form.
DATE
SIGNATURE (type if electronic):
VA FORM 10-7959c
FEB 2017
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: The authority for collection of the requested information on this form is 38 USC 501 and 1781. The
purpose of collecting this information is to determine payer status when other health insurance coverage exists. The information you
provide may be verified by a computer matching program at any time. You are requested to provide your Social Security number as
your VA record is filed and retrieved by this number. 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. The responses
you submit are considered confidential and may be disclosed outside VA only if the disclosure is authorized under the Privacy Act,
including the routine uses identified in the VA system of records number 54VA16, titled "Health Administration Center Civilian
Health and Medical Program Records -VA", as set forth in the Compilation of Privacy Act Issuances via online GPO access
at http://www.gpoaccess.gov/privacyact/index.html. For example, information including your Social Security number may be
disclosed to contractors, trading partners, health care providers and other suppliers of health care services to determine your
eligibility for medical benefits and payment for services.
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 10-7959c
FEB 2017

Download VA Form 10-7959c Champva Other Health Insurance (Ohi) Certification

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Form 10-7959C Instructions

The VA CHAMPVA Form 10-7959C instructions are provided on the second page of the document. They should be read carefully before completing the paper. The general instructions are as follows:

  • The requested information must be provided in full, since failure to furnish necessary details may result in a delay or complete rejection of benefits;
  • The indicated data must be true and correct. If you knowingly make false statements in this document, you may be subject to criminal penalties;
  • The new beneficiaries must provide the Other Health Insurance (OHI) information from the date the CHAMPVA eligibility became effective;
  • The current beneficiaries are obliged to update OHI information every time it changes;
  • The Medicare supplement plan details can be found on the policy cover sheet or insurance membership card;
  • The information about additional policies can be typed or legibly printed on the plain bond paper and attached to this certificate;
  • The completed document should be submitted to the Health Administration Center in Denver via mail or fax. The address and fax number can be found on the top of the paper.

When submitting the completed 10-7959C VA form it is necessary to attach also:

  • a copy of front and back of the OHI member ID card;
  • a copy of Medicare card.

If the OHI does not provide its customers with the Explanation of Benefits paper, the copy of the schedule of benefits may be attached to this document.

How to Fill out VA Form 10-7959C?

It usually takes about 10 minutes to complete the document. Most of its fields are self-explanatory. The CHAMPVA - Other Health Insurance Certificate consists of three sections:

  1. Section I should contain personal data of the beneficiary including name, sex, address, phone number, and SSN. It is necessary to complete a separate form for each member of the veteran's family;
  2. Section II requires details about Medicare supplement plan;
  3. Section III is designed for all other types of medical insurance if any. In case the policy is currently inactive, it is necessary to indicate the termination date only;
  4. The last Section is designed for certification and requires the signature of the beneficiary, sponsor, or legal guardian and the date of completing.

VA 10-7959C Related Forms

The VA 10-7959C has several related documents:

  • The VA Form 10-7959a, CHAMPVA Claim Form is a paper completed by the patient, sponsor or guardian. The information provided in it is necessary to process claims for CHAMPVA benefits;
  • The VA Form 10-7959D, CHAMPVA Potential Liability Claim is used to collect information required to assess potential liability;
  • The VA Form 10-7959E, Claim for Miscellaneous Expenses is necessary to fill out when claiming reimbursement of miscellaneous expenses of health care benefits for veteran's children;
  • The VA Form 10-7959f-1, Foreign Medical Program (FMP) Registration Form is used to provide information necessary for the determination of veteran's eligibility to participate in the VA Foreign Medical Program;
  • The VA Form 10-7959f-2, Claim Cover Sheet - Foreign Medical Program (FMP) is filled out in order to receive reimbursement for medical services outside the United States.

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