Citation Nr: 18149073 Decision Date: 11/08/18 Archive Date: 11/08/18 DOCKET NO. 16-15 360A DATE: November 8, 2018 REMANDED Entitlement to payment or reimbursement for unauthorized medical expenses incurred at Ocala Regional Medical Center (ORMC) from July 29-31, 2015, is remanded. REASONS FOR REMAND The Veteran had active duty service from September 1968 to January 1972. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2015 letter of determination by a Department of Veterans Affairs (VA) Medical Center. This appeal arises from an initial denial based on the lack of a timely filed claim; the Agency of Original Jurisdiction (AOJ) indicated that the Veteran did not file his claim within 90 days of his discharge from the private medical facility. The basis of that denial is that the Form UB-04 that is of record as received from the medical facility in this case is date stamped as received on November 6, 2015, which is more than 90 days after the Veteran’s date of discharge, July 31, 2015. In order to obtain payment or reimbursement under 38 U.S.C. § 1725, a claimant must submit to the VA medical facility of jurisdiction a completed standard billing form (such as a UB92 or a HCFA 1500). See 38 C.F.R. § 17.1004(b). Also, to receive payment or reimbursement, a claimant must file a claim within 90 days after the latest of the following: (1) the date that the veteran was discharged from the facility that furnished the emergency treatment; (2) the date of death, but only if the death occurred during transportation to a facility for emergency treatment or if the death occurred during the stay in the facility that included the provision of the emergency treatment; or, (3) the date the veteran finally exhausted without success, action to obtain payment or reimbursement for the treatment from a third party. See 38 C.F.R. § 17.1004(d). A review of the claims file, however, indicates that on August 3, 2015—well within the 90-day deadline—it appears that the VA Medical Center received a fax notification and indicated that there was an “eligible as Mill Bill USC 1725” received. It further appears that the VA Medical Center’s personnel initially determined in September 2015 that a timely claim was received, noting: “CLAIM TIMELY FILED: Yes.” It is noted that the AOJ found the claim untimely based on the date stamped Form UB-04 instead finding that a timely claim was filed based on its own personnel’s finding that a fax notification received in August 2015 was a timely filed claim. By resolving reasonable doubt in the Veteran’s favor, the Board finds that a timely claim for benefits was received based on the information noted above and the favorable finding by the VA Medical Center personnel in September 2015. Accordingly, as the Board has found that a timely claim has been filed in this case, the AOJ’s reasoning for denial in this case is invalid and a discussion of the merits of the case is warranted. Consequently, the claim must be remanded in order for the AOJ to complete proper development of this case, to include obtaining any bills from the Veteran indicating that he is personally liable for any portion of the remaining medical expenses (outside of any co-insurance payments, copayments, etc.) and adjudication of the claim on the merits. The matter is REMANDED for the following action: The AOJ should properly develop the record and evidence in the claims file with regards to the merits of this claim under 38 C.F.R. § 1725, to include obtaining any evidence from the Veteran regarding any outstanding medical expenses associated with this episode of care for which he is personally liable that were not extinguished by his Medicare Part A coverage absent any deductible, co-insurance payments, copayments, or other similar payments that the Veteran owed under his third-party insurance contract. Following any additional indicated development, the AOJ should review the claims file and readjudicate the Veteran’s claim for payment or reimbursement for unauthorized medical expenses incurred at Ocala Regional Medical Center (ORMC) from July 29-31, 2015. If the benefits sought on appeal remain denied, the Veteran and his representative, if any, should be furnished a supplemental statement of the case and given the opportunity to respond thereto before the case is returned to the Board. JAMES G. REINHART Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Peters, Counsel