Citation Nr: 18153820 Decision Date: 11/28/18 Archive Date: 11/28/18 DOCKET NO. 16-40 554A DATE: November 28, 2018 REMANDED Entitlement to payment or reimbursement for unauthorized medical expenses incurred at Tallahassee Memorial Healthcare (TMH) from January 1-12, 2016, is remanded. REASONS FOR REMAND The Veteran had active duty service from September 1967 to September 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from April and May 2016 letters of determination by a Department of Veterans Affairs (VA) Regional Office (RO). 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. 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). In this case, the April 2016 letters of determination—issued 93 days after the Veteran’s discharge from the private facility—indicate that the claims were “abandoned” because “payment is prohibited when the supporting documentation needed to consider the claim was not received within 30 days from the date requested.” The May 2016 letter of determination and the August 2016 statement of the case explained that the claim was received 90 days after discharge from the private medical facility. Initially, the AOJ’s rationale appears to indicate that because a third-party medical provider filed a bill after the 90-day deadline that the Veteran’s right to seek payment or reimbursement in this case is nullified. This is clearly antithetical to the provisions of 38 C.F.R. § 17.1004(d)(3), which indicates that the Veteran has 90 days to file a claim in his own right after exhausting without success to obtain payment or reimbursement from a third-party. The rationale is also inconsistent with the record as it appears that VA personnel were aware of this claim within 10 days after the Veteran’s discharge from the private facility, initiating review of the claim on January 21, 2016. Additionally, it appears that the AOJ requested additional information directly from the private facility 30 days prior to April 14, 2016, as the rationale at that time was that they had requested additional information and had not received that information within the time period prescribed by statute; those letters are not of record and the Board is unable to ascertain whether any notification of missing information was given to the Veteran in this case regarding the need to provide documentation within 30 days before proceeding with adjudication of his claim. In any event, the AOJ conceded in the August 2016 statement of the case that claims for payment were received from TMH on February 20, 2016. Thus, the evidence of record is clear that VA began working on this claim well before the expiration of the 90-day window to file a claim, regardless of the provisions of the Veteran’s ability to file a claim in his own right under 38 C.F.R. § 17.1004(d)(3). The Board therefore concludes that the facts demonstrate that there was a timely filed claim in this case. Thus, 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 Tallahassee Memorial Healthcare (TMH) from January 1-12, 2016. If the benefits sought on appeal remain denied, the Veteran and his representative 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