Citation Nr: A21016350 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 200331-179637 DATE: October 5, 2021 REMANDED Entitlement to payment for non-VA medical services provided to the Veteran on February 26, 2020 is remanded. REASONS FOR REMAND This matter is before the Board of Veterans' Appeals (Board) pursuant to a VA Form 10182 Decision Review Requests: Notice of Disagreement (NOD) submitted by the appellant and received by the Board in March 2020. On the VA Form 10182, Decision Review Request: Board Appeal, the appellant elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ) decisions on appeal. 38 C.F.R. § 20.301. The appellant in this matter is the non-VA vendor who provided the medical services in question to the Veteran on February 26, 2020. See 38 U.S.C. § 1703. The NOD identified the date of decision on appeal as March 13, 2020, and the issue as "claim was denied stating missing prior authorization." While the record does not include a document dated March 13, 2020 which could be clearly understood as a decision, the appellant included several attachments with the facsimile of the 10182 that identify the date of service for which payment is being sought as February 26, 2020. Generally, a claimant is entitled to receive notice of a decision by the Secretary, which must include particular information, as provided by statute. 38 U.S.C. § 5104. Following implementation of the Appeals Modernization Act, such notice must include the following: (1) Identification of the issues adjudicated. (2) A summary of the evidence considered by the Secretary. (3) A summary of the applicable laws and regulations. (4) Identification of findings favorable to the claimant. (5) In the case of a denial, identification of elements not satisfied leading to the denial. (6) An explanation of how to obtain or access evidence used in making the decision. (7) If applicable, identification of the criteria that must be satisfied to grant service connection or the next higher level of compensation. Id. Without adequate notice of the basis for the denial, a claimant cannot make an informed decision as to whether or not to accept or appeal the decision, or know what evidence they need to submit in order to substantiate their appeal. See Ingram v. Nicholson, 21 Vet. App. 232, 252 (2007) (discussing the legislative history of 38 U.S.C. § 5104 and the importance of clear and informative notice of decisions). Per 38 C.F.R. § 20.802, the Board may remand for correction of any error by the AOJ in satisfying a regulatory or statutory duty, if correction of the error would have a reasonable possibility of aiding in substantiating the appellant's claim. The file contains a March 10, 2020 Explanation of Benefits demonstrating nonpayment for the February 26, 2020 episode of care. However, other than the fact that it demonstrates that $0 was paid, this printout includes none of the other information required by statute under the Appeals Modernization Act. See 38 U.S.C. § 5104 (requiring that such notice include, among other information, a summary of the evidence considered, a summary of the applicable laws and regulations, and identification of favorable findings and elements not satisfied leading to a denial). As noted above, the Board is unable to locate the identified March 13, 2020 decision pertaining to the claim for payment for the non-VA medical services provided to the Veteran on February 26, 2020. It remains unclear whether or not a decision was rendered by the AOJ on the date identified in the appellant's NOD. If so, a copy is not presently of record. In light of this, the Board finds that remand is warranted for the AOJ to associate with the electronic claim file all relevant notices and adjudicatory documents pertaining to the claim on appeal, as well as copies of any evidence before it in rendering the decision. If such records are unable to be located, the AOJ should make a formal finding of unavailability and provide the appellant with notice of the unavailability of records. If the AOJ is unable to locate the decision identified in the March 2020 NOD, or if such decision does not include notice of the decision adhering to the content requirements of 38 U.S.C. § 5104, the appellant must be provided with complete notice of the decision affecting the payment of benefits. The appellant is notified that under the modernized appeal system, remands do not automatically return to the Board for additional adjudication. Should the AOJ deny the claim in whole or in part and the appellant wish to continue its appeal before the Board, the appellant should file an appropriate NOD (VA Form 10182) within the applicable appeal period after the AOJ's readjudication of the claim. The matter is REMANDED for the following action: 1. Associate with the electronic claim file all relevant notices, adjudicatory documents, and evidence considered in connection with the claim for payment for non-VA medical services provided to the Veteran on February 26, 2020. Please note that providing a copy of the entire medical record will not be a sufficient response to this request. Instead, the record should include (but is not limited to): all notices sent to the appellant informing it of the evidence necessary to constitute a complete claim and the evidence necessary to substantiate the claim; all decisions regarding the claim for medical reimbursement; any notice of decision provided to the appellant (specifically including the March 13, 2020 decision identified by the appellant in its NOD); any evidence submitted by the appellant in connection with the claim; any relevant VA and private medical records obtained or received in connection with the claim, including any authorizations or referrals for care; and any other relevant documents received or generated in connection with the claim. 2. If any such records are unable to be located, the AOJ should make a formal finding of unavailability and provide the appellant with notice of the unavailability of records. 3. If the March 13, 2020 decision affecting the payment of benefits referenced in the March 2020 NOD is unable to be located (or is located but does not comply with the provisions of 38 U.S.C. § 5104 pertaining to notice of decisions), the AOJ must issue the appellant a decision and notice of decision on these matters which adheres to the content requirements of 38 U.S.C. § 5104, including but not limited to a summary of the applicable laws and regulations, identification of findings favorable to the claimant, and identification of whether or not the claim meets the specific criteria necessary for payment under 38 U.S.C. § 1703. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Solomon, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.