Citation Nr: A21016594 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 210520-179392 DATE: October 12, 2021 ORDER Payment under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) for medical services provided September 12, 2019 is denied. FINDING OF FACT The appellant's claim for payment was received October 21, 2020, more than one year after the date of service, September 12, 2019. CONCLUSION OF LAW The criteria for payment under CHAMPVA for medical services provided September 12, 2019 are not met. 38 U.S.C. § 501, 1781; 38 C.F.R. § 17.275(a)(1). REASONS AND BASES FOR FINDING AND CONCLUSION Introduction On August 23, 2017, the President signed into law the Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (to be codified as amended in scattered sections of 38 U.S.C.), 131 Stat. 1105 (2017), also known as the Appeals Modernization Act (AMA). This law creates a new framework for Veterans dissatisfied with the Department of Veterans Affairs (VA)'s decision on their claim to seek review. This decision has been written consistent with the new AMA framework. The appellant submitted their VA Form 10182, Notice of Disagreement, in May 2021 and selected the Board's evidence docket, affording them 90 days from the date of the Notice of Disagreement to submit additional evidence in support of their appeal. In adjudicating this appeal, the Board may consider evidence associated with the record on or before May 1, 2021, the date of the decision on appeal, and any evidence submitted by the appellant between May 20 and August 18, 2021that is, on or within 90 days of the date of receipt of the appellant's Notice of Disagreement. Entitlement to Payment under CHAMPVA for Medical Services Provided September 12, 2019 Under CHAMPVA, VA is authorized to provide certain medical care to a Veteran's spouse or child (or surviving spouse or child) under particular circumstances. See 38 U.S.C. § 1781. Those eligible for CHAMPVA benefits include the spouse or child of a Veteran who has been adjudicated by VA as having a permanent and total service-connected disability; and the surviving spouse or child of a Veteran who: (A) died as a result of a service-connected disability, or (B) at the time of death had a total disability permanent in nature. 38 U.S.C. § 1781 (a); 38 C.F.R. § 17.271 (a). Unless an exception is granted by the Health Administration Center, Denver, Colorado, claims for outpatient medical services must be filed no later than the date of service. 38 C.F.R. § 17.275(a)(1). Here, the evidence reflects that the appellant's claim was filed October 21, 2020, more than a year after the relevant date of service, September 12, 2019. Nor has any exception been granted by the Health Administration Center. See May 2021 Veterans Health Administration (VHA) Decision. The appellant does not contend that they timely filed their claim with VHA. Rather, they have submitted evidence showing that they submitted their claim to Medicare in September 2019, and that information received from Medicare and from a third-party clearinghouse indicated that Medicare had forwarded their claim to be processed by VHA. See September 2019 Trizetto Solutions Printout; October 2019 Medicare eRemittance Printout. Despite corresponding with VHA about the status of the claim, the appellant submitted the claim to VHA for the first time only in October 2020. See Telephone Records dated November 2019 January 2021; October 2020 Claim. The appellant asserts that they relied on information received from an automated VHA customer service message in November 2019 to the effect that VHA was behind in claims processing CHAMPVA claims and the appellant should be patient. However, the appellant's phone records show that they did not follow up again with VHA until September 30, 2020, after the deadline for filing had passed. Nothing prevented the appellant from timely filing in the ten months they waited to follow up, and they had no assurances from CHAMPVA in the meantime that their claim had been received and was being processed. Moreover, although 38 C.F.R. § 17.275(b) allows the Health Administration Center to make exceptions to the claim filing deadline, the example given in the regulation is for instances when the claimant misses the filing deadline while waiting for a primary insurance carrier to process their claim. The evidence here indicates that Medicare, the primary insurance carrier, had finished processing the claim the same month it was filed, and accordingly the Health Administration Center declined to allow an exception to the claim filing deadline. See May 2021 VHA Decision. The Board acknowledges the difficulty of the appellant's situation, having relied on the information received from Medicare indicating that the claim had been forwarded to CHAMPVA. However, the record does not show that any similar indication was provided by VHA. In any event, the Board is bound by the law and regulations governing VA and cannot grant relief contrary to law. Accordingly, because the appellant's claim was received more than one year after the date of service, the claim was untimely and must be denied. S.C. KREMBS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Timmerman, Associate 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.