Citation Nr: A21016972
Decision Date: 10/20/21	Archive Date: 10/20/21

DOCKET NO. 210106-179232
DATE: October 20, 2021

REMANDED

Entitlement to payment or reimbursement for the cost of medical services provided by the appellant on June 23, 2020, is remanded.

REASONS FOR REMAND

The Veteran had active service from May 1955 to March 1957.  The appellant provided medical treatment to the Veteran on June 23, 2020.

Entitlement to payment or reimbursement for the cost of medical services provided by the appellant on June 23, 2020 is remanded.

A July 2021 memorandum for the record states that the explanation of benefits (EOB), the denial or rejection letters, and preliminary fee remittance advice reports (PFRARs) are missing and that further efforts to obtain them would be futile.  It is not clear from the record whether the EOB was ever of record, and whether there were efforts to obtain it.  Furthermore, the record does not show that the appellant was notified of the missing records and given an opportunity to submit any copies in their possession.  It is noted that based on documents in the record, the decision on appeal appears to be dated September 14, 2020.

The pre-decisional duty to assist requires that there be a remand to allow VA to obtain the EOB from the Veteran's outside health insurance, which is Blue Care Network Advantage.  See 38 C.F.R. § 3.159(c).  Furthermore, the appellant should be notified of the unavailability of the EOB, the September 14, 2020 decision, and the PFRARs, and be given an opportunity to submit any copies of these documents in their possession.

The matters are REMANDED for the following action:

1. Notify the appellant that they may submit a copy of the EOB in their possession for the June 23, 2020, treatment from the Veteran's outside health insurer, Blue Care Network Advantage, and a copy of the September 14, 2020, decision.  The appellant should also be asked to complete and return the necessary authorization for VA to obtain the EOB on their behalf (VA Form 21-4142).

2. After an appropriate period for the appellant to respond, perform the necessary development to obtain the EOB from the Veteran's outside health insurer for the June 23, 2020, treatment at Henry Ford Health System, including requesting it from the insurer.  The EOB should be requested even if VA Form 21-4142 is not returned.

Adjudicate the claim for payment or reimbursement for the cost of medical services provided by Henry Ford Health System on June 23, 2020, and associate the decision with the claims file. 

 

 

Michael J. Skaltsounis

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Scott Shoreman, 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.