Citation Nr: A22016186 Decision Date: 08/16/22 Archive Date: 08/16/22 DOCKET NO. 201117-216421 DATE: August 16, 2022 REMANDED Payment or reimbursement of medical expenses incurred on October 19, 2019 at Rhea Medical Center in Dayton, Tennessee, is remanded. REASONS FOR REMAND This appeal is before the Board of Veterans' Appeals (Board) from a July 2020 decision that denied payment of medical expenses stemming from treatment administered by Rhea Medical Center (RMC) in Dayton, Tennessee. The appellant, RMC, is a private facility that provided medical treatment for the Veteran. In a November 2020 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the decision on appeal. 38 C.F.R. § 20.301. The appellant seeks payment of medical expenses incurred during the Veteran's emergency room treatment for shortness of breath on October 19, 2019, which the record reflets indeed did occur at RMC on that date. When VA facilities are not capable of furnishing required care or services, VA may contract with non-VA facilities in order to furnish certain care, including hospital care or medical services for the treatment of medical emergencies that pose a serious threat to the life or health of a Veteran receiving medical services in a VA facility, until such time following the furnishing of care in the non-VA facility as the Veteran can be safely transferred to a VA facility. See 38 U.S.C. § 1703(a)(3); 38 C.F.R. § 17.52. Generally, the admission of a Veteran to a non-VA hospital at the expense of VA must be authorized in advance. 38 C.F.R. § 17.54. In the case of an emergency that existed at the time of admission, an authorization may be deemed a prior authorization if an application is made to VA within 72 hours after the hour of admission. Id. As an initial matter, the Veteran's claims file notes that the July 2020 decision on appeal is not locatable due to the fact that the former VA program to reimburse costs, the Fee-Basis Claims Systems (FBCS), sunsetted (i.e., was discontinued) on October 30, 2020. As such, the Board is unable to review the actual reasons and bases for the denial payment that occurred prior to that date. The appellant's VA Form 10182 indicates, however, that the claim was denied as untimely (not within 72 hours). It appears that the appellant's claim, which was received on October 25, 2019, was initially rejected due to an "invalid bill type;" however, the 10182 goes on to note that this "invalid bill type" was corrected by the Appellant in August 2020. As such, the claim was apparently then deemed timely, as a reimbursement payment was then made in the amount of $1,410.70 on December 22, 2021. While the Board might normally dismiss the claim as the evidence reflects that a reimbursement payment was made, for the reasons stated above the evidence is absent the amount initially sought for reimbursement. As such, the Board must remand the matter for further development to ensure that the appellant's claim has been fully satisfied. 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: identification of the issues adjudicated; a summary of the evidence considered by the Secretary; a summary of the applicable laws and regulations; identification of findings favorable to the claimant; in the case of a denial, identification of elements not satisfied leading to the denial; an explanation of how to obtain or access evidence used in making the decision; and, if applicable, identification of the criteria that must be satisfied to grant service connection or the next higher level of compensation. 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). Decisions of the Board must be based on a de novo review of the evidence of record at the time of the 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 the present case, there remains a paid bill for $1,410.70, and it is unclear how the determination of that amount was made. Although the Board recognizes that the FBCS program sunsetted on October 30, 2020, and the original decision was not accessible, the fact remains that notice must be provided to the appellant. Thus, the Board 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 as it is unaware of the original amount claimed for reimbursement and denied in July 2020. The Board shall remand for any pre-decisional error on the part of the AOJ to satisfy its duties under 38 U.S.C. § 5103A and may remand for correction of any other 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. 38 C.F.R. § 20.802(a). Here, the Board finds that due process requires that the AOJ ensures that a copy of the record before them is made available for the Board's review in connection with the appeal. See 38 U.S.C. §§ 5103 (requiring notice to claimants of required information and evidence), 5104 (requiring specific information in the notice of a decision), 5107 (requiring the Secretary to consider all information and lay and medical evidence of record in a case). In light of the above, the Board finds that remand is warranted for the AOJ to associate with the electronic claims file the evidence to determine whether the appellant's claim was fully paid and issue a decision which adheres to the requirements of 38 U.S.C. § 5104. The matter is therefore REMANDED for the following actions: 1. Associate with the electronic claims file the evidence to determine whether the appellant's claim for reimbursement of medical expenses was fully paid (contract or additional correspondence detailing the payment distribution process). 2. Readjudicate the claim and issue the appellant a decision and notice of decision on this matter which adheres to the content requirements of 38 U.S.C. § 5104 for the reimbursement claim at issue, including but not limited to a summary of the applicable laws and regulations, identification of findings favorable to the claimant. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Scarduzio, 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.