Citation Nr: A22025942
Decision Date: 12/21/22	Archive Date: 12/21/22

DOCKET NO. 200930-164108
DATE: December 21, 2022

REMANDED

Entitlement to payment or reimbursement for medical treatment provided by the appellant on February 19, 2020, is remanded.

REASONS FOR REMAND

The Veteran served on active duty from December 1967 to December 1969.  The appellant is the medical service provider who treated the Veteran on the date of episode of care, February 19, 2020.

In September 2020, the appellant submitted a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), electing the direct review docket and appealing a July 2020 denial issued by the Agency of Original Jurisdiction (AOJ).

The Board of Veterans' Appeals (Board) must remand the appellant's claim to correct a pre-decisional error as the evidentiary record is incomplete.  While the record contains a BVA-AMA Requests Check List stating that the denial was overturned and that documentation showing the claim was sent for payment in the expected payment amount, this documentation is missing.  The Board notes that the claims file also contains a VA Form 10-7080 Approved Referral for Medical Care, demonstrating that the Veteran's treatment was pre-authorized by VA and notice was given that any claims should be submitted to Optum, the third party administrator (TPA).  The claims file also contains a Health Insurance Claim Form from Optum to VA.  On remand, the AOJ should associate the missing documentation of the proof of reversal with the record, and it should additionally attempt to confirm whether Optum has indeed reimburse the appellant for the submitted claim.

The matters are REMANDED for the following action:

Undertake all reasonable efforts, including contacting the appellant, if appropriate, to determine whether Optum has indeed reimbursed the appellant for the submitted claim regarding the episode of care incurred on February 19, 2020.

Then, if after undertaking all reasonable efforts, the status of the appellant's submitted claim cannot be determined, or if it is determined that the appellant's submitted claim has been denied, associate with the record all outstanding records related to any decisions rendered by VA.

 

 

L. M. BARNARD

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	J. Lee

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 This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.