Citation Nr: 21026007 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 19-18 750A DATE: April 29, 2021 ORDER Payment or reimbursement of medical expenses incurred on February 11, 2014, at Memorial Health System (MHS) is denied. Payment or reimbursement of medical expenses incurred on March 11 and 12, 2014, at MHS is denied. FINDINGS OF FACT 1. The earliest claim filed for payment of medical expenses incurred from MHS for the Veteran’s February 11, 2014, treatment was not within 90 days of either that treatment date or a date on which the Veteran or any provider exhausted action to obtain payment or reimbursement from a third party. 2. The earliest claim filed for payment of medical expenses incurred from MHS for the Veteran’s March 11 and 12, 2014, treatment was not within 90 days of either those treatment dates or a date on which the Veteran or any provider exhausted action to obtain payment or reimbursement from a third party. CONCLUSIONS OF LAW 1. The criteria for payment or reimbursement of medical expenses incurred on February 11, 2014, at MHS are not met. 38 U.S.C. §§ 1725, 5107; 38 C.F.R. §§ 17.1000-1008. 2. The criteria for payment or reimbursement of medical expenses incurred on March 11 and 12, 2014, at MHS are not met. 38 U.S.C. §§ 1725, 5107; 38 C.F.R. §§ 17.1000-1008. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1966 to April 1971. This appeal is before the Board of Veterans’ Appeals (Board) from September 2017 decisions of the Department of Veterans Affairs (VA) Veterans Health Administration (VHA). Medical Expense Reimbursement The Veteran seeks payment of expenses incurred for medical treatment on February 11 and March 11 and 12, 2014, at MHS. Initially, the Veteran did not have any service-connected disabilities during the treatment dates in question, and his treatment was not for any injury or illness contracted in the course of a rehabilitative program. Therefore, the Veteran is not eligible for payment or reimbursement under 38 U.S.C. § 1728. See 38 U.S.C. § 1728; 38 C.F.R. § 17.120. The Veterans Millennium Health Care and Benefits Act provides general authority for reimbursement for the reasonable value of emergency treatment furnished in a non-VA facility to those Veterans who are active VA health-care participants (i.e., enrolled in the annual patient enrollment system and recipients of a VA hospital, nursing home, or domiciliary care under such system within the last 24-month period) and who are personally liable for such non-VA treatment and not eligible for reimbursement under the provisions of 38 U.S.C. § 1728. 38 U.S.C. § 1725; 38 C.F.R. §§ 17.1000-1008. Pursuant to 38 U.S.C. § 1725, under certain circumstances, VA shall reimburse a veteran for the reasonable value of emergency treatment furnished the veteran in a non-Department facility. VA regulations at 38 C.F.R. §§ 17.1000 through 17.1008 constitute the requirements under 38 U.S.C. § 1725 that govern VA payment or reimbursement for non-VA emergency services furnished to a veteran for nonservice-connected conditions. 38 C.F.R. § 17.1000. To obtain payment or reimbursement for emergency treatment 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). 38 C.F.R. § 17.1004(b). To receive payment or reimbursement for emergency services under 38 U.S.C. § 1725, a claimant must file a claim within 90 days after the latest of the following: the date that the veteran was discharged from the facility that furnished the emergency treatment; the date of death, if the death occurred during transportation to a facility for emergency treatment or during the stay in the facility that included the provision of the emergency treatment; or the date the veteran finally exhausted, without success, action to obtain payment or reimbursement for the treatment from a third party. 38 C.F.R. § 17.1004(d). The date of filing any claim for payment or reimbursement of the expenses of medical care and services not previously authorized shall be the postmark date of a formal claim, or the date of any preceding telephone call, telegram, or other communication constituting an informal claim. 38 C.F.R. § 17.127. 1. Payment or reimbursement of medical expenses incurred on February 11, 2014, at MHS is denied. 2. Payment or reimbursement of medical expenses incurred on March 11 and 12, 2014, at MHS is denied. The Veteran received treatment at MHS on February 11, 2014, for a swollen, painful knee. He was again treated at MHS on March 11 and 12, 2014, for gastritis/acute abdominal pain. March and April 2014 VA administrative records reflect that another vendor (providing ambulance transport to MHS) filed timely claims for payment of expenses for these treatment episodes, which had been approved. A June 2014 VA administrative note indicates that a claim had not yet been filed for the Veteran’s March 2014 hospital treatment. VA received claims for both of these episodes of treatment at MHS on June 13, 2017. In September 2017 decisions, and in its June 2019 statement of the case, the AOJ denied each claim under 38 U.S.C. § 1725 on the basis that neither had been timely filed within the 90-day filing period. March 2019 VA administrative notes reflect that VA spoke with the MHS account department regarding billing for the Veteran’s February and March 2014 treatment. MHS verified that the claims were made in June 2017, so that there was not an issue of delay or system problem. Regarding the February 2014 treatment, it was noted by MHS that, at the time of service, the Veteran requested them not to bill VA and wanted them to bill Safeco, but Safeco denied. MHS acknowledged that it did not bill VA within 90 days of the denial from Safeco, but stated that they were are not allowed to release the date that the Veteran told them to bill VA, and the account went to collection. It was noted that the ambulance records listed VA as insurer, which is why the ambulance claim was received timely. Regarding the March 2014 treatment, it was again noted that VA had timely received a claim from Emergency Medical Specialists on April 25, 2014. MHS stated they were not informed that the Veteran had VA insurance and their claim went to Work Comp, which did not pay. According to MHS, VA was not billed within 90 days of the Work Comp denial because the Veteran did not inform MHS that he had VA coverage, and the account went to collection. There is no indication in the record that the Veteran or MHS filed any earlier claim for the Veteran’s February and March 2014 treatment than the June 2017 claims received by VA. Nor is there any indication that, between the time of the Veteran’s February and March 2014 treatment at MHS and the time of its June 2017 claims, the Veteran attempted action to obtain payment for the treatment from a third party, and he has not asserted that he did. The Board is bound by VA regulations regarding limitations on payment or reimbursement, including time limitations for filing claims. See 38 U.S.C. § 1725(c)(1)(B); 38 C.F.R. § 17.1004(d). The record reflects that the Veteran did not meet the basic filing requirements for his claims under 38 C.F.R. § 17.1004–specifically, regarding the time limitations for filing claims–and the Veteran has identified no evidence to the contrary. Accordingly, payment of medical expenses incurred on February 11, 2017, and March 11 and 12, 2017, from MHS must be denied. See 38 U.S.C. § 5107. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Andrew Mack, 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.