VHA Office of Community Care
Emergency Medical Care
Emergency Care of Service Connected Conditions
In some situations, VA can pay for emergency care for a Veteran’s service connected (SC) condition. VA is authorized to pay emergency care claims for a:
- VA-adjudicated, SC condition
- Non-service connected (NSC) disability associated with and held to be aggravating a service connected condition
- Condition of a Veteran who is considered permanently and totally (P&T) disabled from a service connected disability
- Condition of a Veteran participating in a Chapter 31 Vocational Rehabilitation program
After emergency care has been provided, the Veteran, his or her family members, friends or medical facility staff should notify the nearest VA medical facility immediately (preferably within 72 hours). VA staff will be able to assist to ensure Veterans receive immediate medical attention without interruption. After the emergency condition has been treated and the Veteran is stable, a Veteran can be transferred to VA if the care and treatment is available.
Although highly recommended, contacting VA is not required for VA to adjudicate and pay emergency care claims. Claims should be submitted to VA as soon as possible after emergency care has been provided. This ensures that all information is readily available and payments are made in a timely fashion (in most cases, providers of emergency care file the claim directly with VA and Veterans will not have to take further action). Emergency care claims for SC conditions must be filed with VA within two years of the date treatment was received.
Emergency Care of Non-Service Connected Conditions
Beginning January 9, 2018, in accordance with an amended regulation, VA will begin processing claims for reimbursement for reasonable costs that were only partially paid by the Veteran’s other health insurance (OHI). Those costs may include hospital charges, professional fees and emergency transportation such as ambulances.
The amended regulation, published in a Federal Register notice, establishes the methodology VA will use to process and pay these claims. VA will apply the updated regulations to claims pending with the VA on or after April 8, 2016, and to new claims.
Claims for emergency treatment, or travel, related to a non-service connected condition provided on or after January 9, 2018, must be submitted within 90 days of the latest: date of discharge; the date of death (if death occurred during treatment or transportation); or the date that all efforts to obtain payment or reimbursement from a third party have been exhausted. The results do not fully eliminate the Veteran’s liability for the emergency treatment or transportation.
VA payment is the lesser of the amount for which the Veteran is personally liable or 70 percent of the applicable Medicare fee schedule amount, excluding copayment, cost share or deductible associated with the Veteran’s OHI. By law, VA cannot reimburse remaining costs such as copayments, cost shares or deductibles associated with a Veteran’s OHI. An example is when a claim is made against a Veteran’s OHI as a primary payer. If the OHI payment does not eliminate the Veteran’s liability to the provider, a claim may be submitted to VA for potential payment.
VA may only act as a secondary payer to any other health insurance (OHI) or other liable third party after that entity has adjudicated and paid (or denied) the claim. If a claim has not first been submitted to OHI or other liable third party, VA cannot adjudicate or pay the claim.
Claims should be submitted to VA as soon as possible after emergency care has been provided and subsequently after any OHI or other liable third party has adjudicated and paid (or denied) the claim.
A dedicated hotline is available at 1-877-466-7124 to speak to customer service representatives specifically about this issue, Monday through Friday, between the hours of 8:00 a.m. to 5:00 p.m. Eastern Standard Time (EST). Providers can also find more information on how the amended regulation affects them at https://www.va.gov/COMMUNITYCARE/providers/info_payments.asp.