Court Opinion

ID: 5130514
Source: CourtListenerOpinion
Date Created: 2021-12-01 18:00:34.521489+00
Date Added: 2024-06-11T08:23:18.026738
License: Public Domain

Citation Nr: AXXXXXXXX
Decision Date: 10/29/21	Archive Date: 10/29/21

DOCKET NO. 210401-182676
DATE: October 29, 2021

ORDER

The claim of entitlement to payment or reimbursement of emergency medical expenses incurred at Southern Regional Medical Center on March 6, 2020, is dismissed.

FINDING OF FACT

Subsequent to the denial of payment or reimbursement of expenses related to one line item in the amount of $492.56 based on a billing issue, the episode of care was approved for payment, subject to corrective action on the part of the appellant.

CONCLUSION OF LAW

The criteria for dismissal of the claim of entitlement to payment or reimbursement of emergency medical expenses incurred at Southern Regional Medical Center on March 6, 2020, have been met.  38 U.S.C. § 7105; 38 C.F.R. § 20.205.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty in the United States Army from September 1961 to June 1964.  He died in November 2020.  The appellant in this case is the non Department of Veterans Affairs (VA) hospital that provided the services in question on March 6, 2020.

This appeal before the Board of Veterans' Appeals (Board) arose from a January 2021 determination by the VA Veterans Health Administration (VHA) in which the appellant's claim for payment or reimbursement of emergency medical expenses for services provided to the Veteran on March 6, 2020, was approved only in the amount of $388.83.  

On April 1, 2021, VA received the appellant's VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement (NOD)) in which the appellant disagreed only with the denial of payment of one line item based on an invalid combination of Healthcare Common Procedure Coding System (HCPCS) modifier.  Other line items were not paid for the reason that the benefit for that service is included in the payment/allowance for another service/procedure that has already been adjudicated; the appellant did not disagree with the non-payment of those line times and any issue regarding non-payment of those line items is therefore not before the Board.  Further, as the appellant elected the Evidence Submission docket, the Board may only consider the evidence of record at the time of the 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.

A review of the record shows that the Veteran presented to Southern Regional Medical Center on March 6, 2020, complaining of no drainage from his Foley catheter, for which he received emergency treatment at that facility.  A review of the January 2021 Explanation of Benefits (EOB) shows that billed charges related to service code 96375 in the amount of $492.56 were not paid due to a billing issue.  Specifically, it was indicated that the procedure code was inconsistent with the modifier used or a required modifier was missing.

(Continued on the next page)

 

After filing an NOD as to the non-payment of one line item based on an invalid combination of HCPCS modifiers, the VHA Office of Community Care, Payment Operations and Management (POM) Appeals Section, undertook a review of the appellant's claim in March 2021.  Thereafter, a letter was sent to the appellant notifying the appellant that the episode of care at issue in this appeal had been approved.  It was stated, however, that the original claim could not be reprocessed due to a modifier issue.  The appellant was instructed to resubmit the claim and was advised that once the resubmitted claim had been received, it would be processed according the VA policy.  A report of contact is also of record, which report notes that a member of the POM Appeals Section spoke with a member of Southern Regional Medical Center's Billing Department on August 26, 2021, and advised that individual to resubmit the claim with corrected modifier for the line item that was not paid.  Again, it was stated that once a corrected claim was received, payment would be processed according to VA policy.

Under 38 U.S.C. § 7105, the Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed.  Here, the requested payment or reimbursement has been approved.  Although further action is necessary on the part of the appellant before the claim can be paid, it remains that the payment for the episode of care at issue in this case has been approved.  As such, there remains no adverse action for the Board to adjudicate.  Accordingly, the Board is without jurisdiction to review the appeal with respect to this issue, and the appeal is therefore dismissed.  See 38 U.S.C. § 7105.  Should the bill not be fully paid or reimbursed once the appellant has resubmitted the claim with the corrected modifier for the line item that was not paid, the appellant may submit a new appeal or request reopening of this appeal

 

 

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.