**§17.1002 Substantive conditions for payment or reimbursement.**

Payment or reimbursement under 38 U.S.C. 1725 for emergency services may
be made only if all of the following conditions are met:

\(a\) The emergency services were provided in a hospital emergency
department or a similar facility held out as providing emergency care to
the public;

\(b\) The claim for payment or reimbursement for the initial evaluation
and treatment is for a condition of such a nature that a prudent
layperson would have reasonably expected that delay in seeking immediate
medical attention would have been hazardous to life or health (this
standard would be met if there were an emergency medical condition
manifesting itself by acute symptoms of sufficient severity (including
severe pain) that a prudent layperson who possesses an average knowledge
of health and medicine could reasonably expect the absence of immediate
medical attention to result in placing the health of the individual in
serious jeopardy, serious impairment to bodily functions, or serious
dysfunction of any bodily organ or part);

\(c\) A VA or other Federal facility/provider was not feasibly available
and an attempt to use them beforehand would not have been considered
reasonable by a prudent layperson (as an example, these conditions would
be met by evidence establishing that a veteran was brought to a hospital
in an ambulance and the ambulance personnel determined that the nearest
available appropriate level of care was at a non-VA medical center);

\(d\) The claim for payment or reimbursement for any medical care beyond
the initial emergency evaluation and treatment is for a continued
medical emergency of such a nature that the veteran could not have been
safely discharged or transferred to a VA or other Federal facility (the
medical emergency lasts only until the time the veteran becomes
stabilized);

\(e\) At the time the emergency treatment was furnished, the veteran was
enrolled in the VA health care system and had received medical services
under authority of 38 U.S.C. chapter 17 within the 24-month period
preceding the furnishing of such emergency treatment;

\(f\) The veteran is financially liable to the provider of emergency
treatment for that treatment;

\(g\) The veteran has no coverage under a health-plan contract for
payment or reimbursement, in whole or in part, for the emergency
treatment (this condition cannot be met if the veteran has coverage
under a health-plan contract but payment is barred because of a failure
by the veteran or the provider to comply with the provisions of that
health-plan contract, e.g., failure to submit a bill or medical records
within specified time limits, or failure to exhaust appeals of the
denial of payment);

\(h\) If the condition for which the emergency treatment was furnished
was caused by an accident or work-related injury, the claimant has
exhausted without success all claims and remedies reasonably available
to the veteran or provider against a third party for payment of such
treatment; and the veteran has no contractual or legal recourse against
a third party that could reasonably be pursued for the purpose of
extinguishing, in whole or in part, the veteran's liability to the
provider; and

\(i\) The veteran is not eligible for reimbursement under 38 U.S.C. 1728
for the emergency treatment provided (38 U.S.C. 1728 authorizes VA
payment or reimbursement for emergency treatment to a limited group of
veterans, primarily those who receive emergency treatment for a
service-connected disability). (Authority: 38 U.S.C. 1725)

\[66 FR 36470, July 12, 2001, as amended at 68 FR 3404, Jan. 24, 2003\]

**Supplement *Highlights* reference**: 14(1)