Citation Nr: A25035478
Decision Date: 04/17/25	Archive Date: 04/17/25

DOCKET NO. 201231-224915
DATE: April 17, 2025

ORDER

Entitlement to payment of the cost of non-Department of Veterans Affairs (VA) medical services provided by appellant from August 28, 2020, to August 29, 2020, is dismissed.

FINDING OF FACT

The Veteran received emergency care through the Veterans Community Care Program by an authorized in-network provider; the authorization process and rates of payment are governed by statutory and contractual authority that does not allow for review by the Board.

CONCLUSION OF LAW

The criteria for dismissal of the appeal for entitlement to payment of the cost of non-VA medical services provided by appellant from August 28, 2020, to August 29, 2020, have been met.  38 U.S.C. §§ 1703, 1703D, 7105; 38 C.F.R. §§ 17.4030, 17.4035.

REASONS AND BASES FOR FINDING AND CONCLUSION

The appellant, Steward Health Care System, is a non-VA healthcare provider who rendered services to the Veteran from August 28, 2020, to August 29, 2020, as an in-network provider of the Veterans Community Care Program.  See generally 38 U.S.C. § 1703(c), (h).

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a determination made by a December 2020 Department of Veterans Affairs (VA) Veterans Community Care Network (VCCN).

In the December 2020 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the appellant elected the Evidence Submission docket.  Therefore, the Board may only consider the evidence of record at the time of the December 2020 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the appellant with, or within 90 days from receipt of, the VA Form 10182.  38 C.F.R. § 20.303.

In the December 2020 decision on appeal, the AOJ denied the claim for lack of authorization.  In its December 2020 appeal, the appellant asserts that Optum, a VA third-party administrator, did not properly bill the services.

VA was directed to enter contracts to establish this network of non-VA healthcare providers to provide sufficient access to medical services.  38 U.S.C. § 1703(h).  This included contracting with a third-party administrator to process claims for compensation for the medical services provided by the in-network non-VA healthcare providers.  38 U.S.C. § 1703D(g)(1).  The process for billing for the medical services, including correction of those claims and the rates paid by VA for such services, are governed by the contractual agreements that this appellant entered into with VA to be a Community Care Network provider.  38 U.S.C. § 1703D(a)-(g), (i); 38 C.F.R. §§ 17.4030, 17.4035.

Therefore, the governing statute and implementing regulations have established a process for billing medical services furnished through the Veterans Community Care Program that does not contemplate Board review.  38 U.S.C. §§ 1703(h), 1703D; 38 C.F.R. § 17.4030.  Moreover, the payment rates paid by VA for the services furnished by a healthcare provider within the Community Care Network are set forth in the terms within the contract the appellant signed to enter into the VCCP.  38 CFR § 17.4035.

In sum, the applicable statutes and regulations governing the Veterans Community Care Program do not contemplate Board review of a question on whether payment is warranted for VCCP in-network medical services provided by the appellant.  Consequently, the instant appeal seeking payment must be dismissed.  38 U.S.C. §§ 1703(h), 1703D; 38 C.F.R. §§ 17.4030, 17.4035. 

 

STEVEN D. REISS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Castillo, Joshua

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.