Virginia Birth Injury Program Portal

Program Portal

Complete the form below to receive information, get questions answered, learn more about claim reimbursements and Program benefits, or submit general inquiries.
--> Want to file a claim? Complete this Form, Select Inquiry Type and select Claim Reimbursement Form (2024 or 2025) and hit Submit. You will be redirected to the Claim Reimbursement Form.
Instructions: Go to the text boxes and dropdown options below to make your selection. The above progress bar will provide a status for completion of the submission.

1. In the text box, enter your First Name and Last Name.

2. Enter the name of the Admitted Claimant. If not applicable for general/other inquiries, please enter N/A.

3. Enter your affiliation with the Program. Options include:

4. Select your Inquiry or Claim Type. Click on the dropdown arrow on the right to select the type of inquiry. Press your Control key (CRTL) and plus sign (+) simultaneously to make more than one selection.

5. Enter your Telephone Number.

6. Enter your Email Address.

7. If your inquiry is regarding a reimbursement claim submitted to BPA, the Program's third-party administrator, prior to November 2024, please use your mouse to click/select the Yes button.

8. Enter a(n) message/explanation/question(s) about your inquiry (optional).

9. Upload documentation (up to 25 documents) from your device or desktop. Hoover your mouse or device pointer to click on the Browse Files text box to access your device or use the drag and drop method. Documents may be in PDF (portable files), JPG (photos) or Word (character-based) formats.

10. Prepare to Print, Save or Submit your request (see next section below).

Save & Submit Options

1. Select the Print Form button to print (paper or a PDF version) of your selection before submission. Click the Back to Form arrow button in the top left corner to return to your file screen. Click Submit.

2. Click Save if you need to start and return to the form later. You have 90 days to save and return to the form.

3. Click the Submit to submit your form.

Note:

* You will receive an automatic (instant) email confirmation page acknowledging your submission.

* You may print this form, save it online (for up to 90 days), access it via desktop/ tablet or mobile device.
1. Your First Name and Last Name*

First NameLast Name
2. Admitted Claimant First Name and Last Name*
Bill Smith (or if a general request type N/A)
3. Program Affiliation*
4. Request Type or CLAIM Type (please select one option)*
If you have multiple inquiries, you will have another opportunity to submit requests at the end of this form.
4a. Agency/Facility or Caregiver Name (if applicable)
Agency ABC
4b. Vendor Name (if applicable)
ABC Vendor/Consultant
5. Phone Number*
6. E-mail Address*
example@example.com
7. Is your inquiry regarding a claim reimbursement processed by the Program's third-party administrator, Benefit Plan Administrators (BPA)? If so, then check the appropriate box below. (Optional)

Yes, this inquiry is regarding a claim reimbursement submitted to Benefit Plan Administrators (BPA) before the November 2024 Program correspondence.
8. What support are you requesting? Explain below. Message or Detailed Questions or write N/A if no questions/comments. (Optional)*

Example: I have a question about a claim to file or xyz benefit.0/160
Looking to submit Caregiver Timesheets and the Monthly Care Summary? Click these shortcut links below.

Click this LINK --> Caregiver Timesheets (Or See the Form below)
Click this LINK --> Monthly Care Summary
Click this LINK --> Program's Claim Reimbursement Form
9. Please upload in the link below any additional documentation to expedite your request for review. (Optional)

Format: PDF (desktop or mobile uploads), Word, JPG or PNG (scanned, digital images, etc.)
Cancelof
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