Citation Nr: A21017497 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 200318-186533 DATE: October 28, 2021 REMANDED The issue of entitlement to payment of cost of non-Department of Veterans Affairs (VA) medical services provided to the Veteran on December 2, 2019, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 2002 to April 2003. The appellant, Aegis Sciences Corporation, is the vendor who provided the medical services in question on December 2, 2019. This appeal before the Board of Veterans' Appeals (Board) arose from a December 2019 determination by a Department of Veterans Affairs (VA) Veterans Health Administration (VHA) in which the appellant's claim for payment of cost of non-VA medical services provided to the Veteran on December 2, 2019, was denied. On March 18, 2020, the appellant filed a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement (NOD)) in which the appellant elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the December 2019 VHA determination, which is the Agency of Original Jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. The Board notes that the December 2019 determination is not of record. The Board can discern, however, from other evidence of record, that December 2, 2019, is the correct date of the services rendered for which payment is sought in this appeal. The appellant's NOD also identifies that December 2019 is the date of the determination from which this appeal stems. The appellant's NOD further indicates that a missing authorization was basis for the denial of the claim. Moreover, the Board notes that the appellant has submitted multiple claims for payment of identical services provided on dates other than December 2, 2019, and an "Explanation of Benefits" related to one of those claims identifies the basis for the denial. Accordingly, as the Board can discern from the evidence of record the facts necessary to adjudicate the claim on appeal, and because the matter on appeal must be remanded for the reasons set forth below, the Board finds no reason to delay adjudication of this appeal to attempt to obtain a copy of the December 2019 determination at this time. Lastly, the Board notes that any additional perfected appeals related to the provision of services similar to those provided to the Veteran on December 2, 2019, will be docketed and adjudicated separately. Entitlement to payment of cost of non-VA medical services provided to the Veteran on December 2, 2019, is remanded. Unfortunately, the Board finds that remand is necessary to (1) obtain information necessary to determine its jurisdiction to reach the merits of the appeal, and (2) provide adequate notice to the appellant concerning the authority under which payment of the medical reimbursement sought may be made and the reason for the denial of the claim. In the instant matter, the appellant seeks reimbursement for medical care provided on December 2, 2019. The appellant has indicated that the claim was denied because no authorization number was submitted on the claim. An Explanation of Benefits denying payment for identical services rendered on a different day notes that provisions of an authorization number "is a billing requirement for pre-approved care." In the instant case, it is unclear under what authority the appellant seeks or may otherwise be entitled to payment. While the Board has jurisdiction to address eligibility for payment or reimbursement for medical expenses in some instances, it does not have jurisdiction to determine eligibility for referral to a community care network pursuant to 38 U.S.C. § 1703 or eligibility for payment under a Veterans Care Agreement. See 38 U.S.C. §§ 1703(f), 1703A; 38 C.F.R. § 17.4135. Likewise, the Board cannot review a decision of a third-party administrator regarding the processing of invoiced claims for payment to non-VA providers under the community care network, because those decisions are subject to the specific claims processing and dispute resolution provisions laid out in the contracts with those providers. See 38 U.S.C. §§ 1703D(g)(1), 7104(a); 38 C.F.R. § 17.4030. The Board shall decide all questions pertaining to its jurisdictional authority to review a particular case. 38 C.F.R. § 20.104(c). Additionally, decisions of the Board must be based on a de novo review of the evidence of record at the time of the agency of original jurisdiction (AOJ) decision on the issue or issues on appeal, and any additional evidence considered as part of the evidentiary record pursuant to applicable statute and regulation. 38 U.S.C. §§ 7104(d), 7113; 38 C.F.R. § 20.801(a). In this case, the Board does not have before it the evidence necessary to determine its jurisdiction, such as the type of service provided, or the referral or authorization under which the service was provided (if any). Thus, the Board cannot determine whether it has jurisdiction to adjudicate the instant appeal and cannot fulfill its statutory and regulatory requirement to base its decision on a review of the evidence of record at the time of the AOJ decision on the issue or issues on appeal. 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 Board finds that the AOJ erred in not ensuring that all the necessary evidence was of record for review by the Board. Accordingly, a remand is necessary in this case. On remand, the AOJ must provide the appellant with complete notice of the decision as required by 38 U.S.C. § 5104. If the claim is for reimbursement for medical services provided pursuant to a referral to the community care network under 38 U.S.C. § 1703, the notice should explain this to the appellant and inform the appellant how a claim for reimbursement should be submitted. Additionally, the AOJ should ensure that all evidence upon which the decision is based is identified in the notice and made part of the electronic record for review by the Board should the appellant submit an additional notice of disagreement to the Board. The matter is REMANDED for the following action: Readjudicate the claim and issue to the appellant a decision and notice of decision on this matter 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. Ensure that all evidence upon which the decision is based is identified in the notice and made part of the electronic record for review by the Board. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Neilson, 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.