[Federal Register Volume 62, Number 189 (Tuesday, September 30, 1997)]
[Rules and Regulations]
[Pages 51281-51286]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-25664]
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 17
RIN 2900-AI65
Provision of Health Care to Vietnam Veterans' Children With Spina
Bifida
AGENCY: Department of Veterans Affairs.
ACTION: Final rule.
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SUMMARY: This document establishes regulations regarding Vietnam
veterans' children with spina bifida. The regulations concern the
provision of health care needed for the spina bifida or any disability
that is associated with such condition. This action is necessary to
establish a mechanism for providing health care to such children in
accordance with recently enacted legislation.
DATES: Effective Date: October 1, 1997.
FOR FURTHER INFORMATION CONTACT: Robert De Vesty, Health Systems
Specialist, Office of Public Health and Environmental Hazards (13),
Department of Veterans Affairs, 810 Vermont Avenue, NW, Washington DC,
20420, telephone (202) 273-8575.
SUPPLEMENTARY INFORMATION: In a document published in the Federal
Register on May 1, 1997 (62 FR 23731), we proposed to amend the
``Medical'' regulations (38 CFR part 17) by setting forth new
Secs. 17.900-17.905 regarding the provision of health care to Vietnam
veterans' children with spina bifida. Spina bifida is a congenital
birth defect, characterized by defective closure of the bones
surrounding the spinal cord. The spinal cord and its covering (the
meninges) may protrude through the defect.
The provisions of 38 U.S.C. Chapter 18 (Pub. L. 104-204, section
421, September 26, 1996) provide for three separate types of benefits
for Vietnam veterans' children who suffer from spina bifida: (1)
Monthly monetary allowances, (2) provision of health care needed for
the spina bifida or any disability that is associated with such
condition, and (3) provision of vocational training and rehabilitation.
This document establishes a final rule to set forth a mechanism
regarding provision of health care to Vietnam veterans' children with
spina bifida.
We requested that comments to the proposed rule be submitted on or
before June 30, 1997. We received 33 comments. Based on the rationale
set forth in the proposed rule and this document, the proposed rule is
adopted as a final rule with changes explained below.
[[Page 51282]]
Comments regarding issues concerning monthly monetary allowances
for Vietnam veterans' children who suffer from spina bifida and the
provision of vocational training and rehabilitation for such children
will be addressed in separate final rules that specifically concern
these issues.
Some of the suggested changes cannot be made because they would be
inconsistent with statutory authorities. There is no authority for VA
to pay for services provided before October 1, 1997, or to pay for
services prior to the date of receipt of application. There is no
authority to provide comprehensive health care coverage or insurance
(health care is limited to care for spina bifida or disabilities
associated with such condition). There is no authority to provide such
health care unless the child is a child of a Vietnam veteran who was
not dishonorably discharged (see Pub. L. 104-204, 38 U.S.C. 101, 1801-
1806).
Commenters asserted that the final rule should state specifically
that the provision of health care would cover durable medical equipment
and medical supplies, including catheters, diapers, pads, etc. Because
this appeared to be a concern from many of the commenters, the final
rule is clarified, consistent with the intent of the proposed rule, to
state specifically that these types of equipment and supplies are
covered when provided by VA or authorized by an approved health care
provider (see Sec. 17.900(b) and the definition of ``health care'' in
Sec. 17.901).
One commenter questioned what standard would apply for replacing
durable medical equipment, particularly when a child has outgrown
medical equipment. In this regard, the provisions of Sec. 17.902
provide that medical equipment will be covered based on a demonstrated
medical need.
Commenters questioned whether the final rule would cover adaptive
housing and vehicles. VA is authorized to provide health care
determined to be medically necessary. In our view, coverage for
adaptive housing and vehicles is outside the scope of this
authorization.
One commenter questioned whether treatment of behavioral problems
such as attention deficit disorder would be covered under the final
rule. This would have to be determined on a case-by-case basis. Any
health care determined to be needed for the spina bifida or any
disability that is associated with such condition would be covered.
One commenter questioned whether payment would be made for services
if the child suffering from spina bifida has died. Covered services
provided for an eligible child prior to death would be paid even if the
child died after the services were provided.
One commenter questioned whether complications during pregnancy of
a Vietnam veterans' child who suffer from spina bifida would be
covered. Another commenter questioned whether hydrocephalus and Arnold-
Chiari malformation would be covered for such children. Another
questioned whether other abnormalities would be covered. These
conditions would be covered insofar as they constitute a disability
associated with spina bifida.
One commenter questioned whether care at the Department of Defense
(DOD) facilities would be paid by VA. Costs for care provided by DOD is
the responsibility of DOD.
One commenter asserted that preventive care should be listed
specifically as a covered benefit. No changes are made based on this
comment. The definition of ``health care'' in Sec. 17.901 specifically
states that ``preventive care'' is covered.
One commenter asserted that payment should be made for experimental
or investigative care. No changes are made based on this comment. We
have no way to determine whether such care would be effective and not
harmful.
Commenters asserted that payment for respite care and home care
(including attendant care) and case management services should not be
limited to approved health care providers and should include health
care providers that are not certified or licensed. The terms ``health
care provider'' and ``approved health care provider'' are defined in
Sec. 17.901. No changes are made based on these comments. This final
rule does not preclude services from individuals who do not qualify as
``approved health care providers.'' However, VA will pay only for
services rendered by ``approved health care providers.'' We believe
that the utilization of approved health care providers as defined in
Sec. 17.901 is necessary to ensure appropriate quality standards for
services paid by VA.
A number of commenters expressed concern that their ability to
utilize Medicaid, Medicare, or other health insurance would be limited
by the spina bifida program. In this regard, the spina bifida
regulations provide for VA to be the exclusive payer only for services
paid under the spina bifida regulations. Also, by statute monetary
benefits are not considered income or resources in determining
eligibility for or the amount of benefits under any Federal or
Federally-assisted program, including Medicaid and Medicare. Consistent
with these concepts, we added language to the final rule to state that
in the usual case claims for health care for other than covered
services for spina bifida and disabilities associated with spina bifida
would be submitted to an insurer, Medicare, Medicaid, health plan, or
other program providing health care coverage.
One commenter expressed concern that charges could exceed the
amount reimbursed by VA and that providers would charge patients for
the excess. In this regard, the regulations state that VA is the
exclusive payer for services paid under the spina bifida regulations.
Accordingly, the amount paid by VA would constitute payment in full.
Several commenters questioned whether they could have a choice
regarding their provider. Recipients will be able to choose any
provider meeting the criteria in Sec. 17.901.
One commenter suggested that the preauthorization procedures are
unnecessarily restrictive and burdensome, and that there should be an
emergency exception for preauthorization. The preauthorization
procedures apply to that type of care most likely to cause disagreement
with respect to medical need. These procedures will help avoid
unexpected liabilities for noncovered services. Further, it would be
rare that an emergency would arise for the types of care requiring
preauthorization. Even so, we have added provisions stating that
preauthorization would not be required for a condition for which
failure to receive immediate treatment poses a serious threat to life
or health. A provision also is added stating that such emergency care
should be reported by telephone within 72 hours of the emergency. These
provisions would ensure that preauthorization procedures would not
impede the provisions of emergent health care and would help ensure
that recipients understand in a timely manner what health care is
covered under this final rule.
The preauthorization provisions state that care will be authorized
only in those cases where there is a demonstrated medical need. One
commenter asserted that the burden of proof should rest on VA regarding
whether care is medically necessary. No changes are made based on this
comment. The statutory provisions of 38 U.S.C. 1803(a) state that the
Secretary shall provide ``such health care as the Secretary determines
is needed for the child for the spina bifida or any disability
associated with such condition.'' Even so, VA will consider any
evidence from providers or others that might support a claim.
[[Page 51283]]
One commenter asserted that Vietnam veterans' children who suffer
from spina bifida should have the same appeal rights as other VA
claimants. In this regard, Sec. 17.904 sets forth an appeal process and
the note to this section states that there are further appellate rights
for an appeal to the Board of Veterans' Appeals. This is equivalent to
the appellate process afforded veterans for other matters.
The proposed regulations provided that ``if a health care provider,
Vietnam veteran's child or representative disagrees with a
determination concerning provision of health care or a health care
provider disagrees with a determination concerning payment, the person
or entity may request reconsideration.'' The proposed regulations
further provided that ``such request must be submitted in writing
within one year of the date of the initial determination to the Chief,
Administrative Division, Health Administration Center, P.O. Box 65025,
Denver, CO 80206-9025.'' Moreover, the proposed regulations provided
that ``if the person or entity seeking reconsideration is still
dissatisfied, within 30 days of the date of the decision he or she may
make a written request for review by the Director, Health
Administration Center, P.O. Box 65025, Denver, CO 80206-9025.''
Commenters asserted that the 30-day period for further reconsideration
should be extended to 90 or 180 days. In this regard, they argued that
30 days might not be enough time for individuals on travel or who get
their mail irregularly. The final rule extends the time period from 30
days to 90 days. This should be adequate to allow sufficient time for
the preparation of an appeal.
One commenter asserted that the date for satisfying the period for
filing an appeal be the date the appeal is postmarked. The provisions
of Sec. 17.904 are amended to state that an appeal would be filed at
the time it was delivered to VA or the time it was released for
submission to VA (postmark would constitute evidence of release for
submission to VA).
One commenter asserted that the review appeal decisions should be
required to include a statement of findings and reasons. The
regulations are clarified to specifically require inclusion of findings
and reasons.
One commenter asserted that ID cards should be issued so that
children suffering from spina bifida could more easily identify
themselves to health care providers as eligible for benefits under the
VA's spina bifida regulations. It is anticipated that ID cards will be
issued.
One commenter requested that the comment period for this rule
making proceeding be extended until the end of the comment period for
the proposed rule regarding vocational training and rehabilitation for
Vietnam veterans' children who suffer from spina bifida. Such an
extension is unwarranted. An understanding of the issues in the rule
making proceeding regarding vocational training and rehabilitation is
not necessary to make informed comments regarding this rule making
proceeding.
Additional changes are made to the final rule for purposes of
clarification.
Executive Order 12866
This final rule has been reviewed by OMB under Executive Order
12866.
Administrative Procedure Act
There is good cause for making this final rule effective without
regard to a 30 day delay. This final rule does not adversely affect
anyone and the affected children need the benefits from the rule as
soon as possible.
Paperwork Reduction Act
Information collection and recordkeeping requirements associated
with this final rule (38 CFR 17.902, 17.903, 17.904) have been approved
by the Office of Management and Budget (OMB) under the provisions of
the Paperwork Reduction Act (44 U.S.C. 3501-3520) and have been
assigned OMB control number 2900-0577.
The provisions of 38 CFR 17.902 will require individuals to submit
to a preauthorization specialist of the Health Administration Center a
preauthorization application for health care consisting of case
management, durable medical equipment, home care, professional
counseling, mental health services, respite care, training, substance
abuse treatment, dental services, transplantation services or travel
(other than mileage at the General Services Administration rate for
privately owned automobiles). The preauthorization application will
contain the child's name and social security number; the type of
service requested; the medical justification; the estimated cost; and
the name, address, and telephone number of the provider. Such
information is necessary to make preauthorization determinations in
accordance with Sec. 17.902.
The provisions of 38 CFR 17.903 will require that, as a condition
of payment, claims from ``approved health care providers'' for health
care provided under 38 CFR 17.900 must include the following
information, as appropriate: with respect to patient identification
information: the veteran's and patient's full name, social security
numbers, patient's address, and date of birth; with respect to patient
treatment information (inpatient and outpatient services): full name
and address (such as hospital or physician), remittance address,
physical location where services were rendered, individual provider's
professional status (M.D., Ph.D., R.N., etc.), and provider tax
identification number (TIN) or social security number (SSN); with
respect to patient treatment information (inpatient institutional
services): dates of service (specific and inclusive); summary level
itemization (by revenue code); dates of service for all absences from a
hospital or other approved institution during a period for which
inpatient benefits are being claimed; principal diagnosis established,
after study, to be chiefly responsible for causing the patient's
hospitalization; all secondary diagnoses; all procedures performed;
discharge status of the patient; and institution's Medicare provider
number; with respect to patient treatment information for all other
health care providers and ancillary outpatient services: diagnosis,
procedure code for each procedure, service or supply for each date of
service, and individual billed charge for each procedure, service or
supply for each date of service; with respect to prescription drugs and
medicines: name and address of pharmacy where drug was dispensed, name
of drug, National Drug Code (NDC) for drug provided, strength,
quantity, date dispensed, and pharmacy receipt for each drug dispensed.
Such information will be necessary to make payment determinations in
accordance with 38 CFR 17.903.
The provisions of 38 CFR 17.904 will establish a review process
regarding disagreements by a Vietnam veteran's child or representative
with a determination concerning authorization of health care or a
health care provider's disagreement with a determination regarding
payment. The person or entity requesting reconsideration of such
determination will be required to submit such request to the Chief,
Administrative Division, Health Administration Center, in writing
within one year of the date of initial determination. The request must
state why the decision is in error and include any new and relevant
information not previously considered. After reviewing the matter, a
benefits advisor will issue a written determination to the person or
entity seeking reconsideration. If such person or entity remains
dissatisfied with the determination, the person or entity will be
permitted to make a written request for review by the
[[Page 51284]]
Director, Health Administration Center. The information to be collected
under Sec. 17.904 is necessary to make review and appeal
determinations.
Interested parties were invited to submit comments on the
collection of information. However, no comments were received.
OMB assigns a control number for each collection of information it
approves. VA may not conduct or sponsor, and a person is not required
to respond to, a collection of information unless it displays a
currently valid OMB control number. The valid OMB control number
assigned to the collections of information in this final rule is
displayed at the end of each of the affected sections of the
regulations.
Regulatory Flexibility Act
The Secretary hereby certifies that this final rule will not have a
significant impact on a substantial number of small entities as they
are defined in the Regulatory Flexibility Act, 5 U.S.C. 601-612. It is
estimated that there are only between 600 and 2,000 Vietnam veterans'
children who suffer from spina bifida. They are widely geographically
diverse and the health care provided to them would not have a
significant impact on any small businesses. Therefore, pursuant to 5
U.S.C. 605(b), the final rule is exempt from the initial and final
regulatory flexibility analysis requirements of Secs. 603 and 604.
There are no Catalog of Federal Domestic Assistance numbers for
this final rule.
List of Subjects in 38 CFR Part 17
Administrative practice and procedure, Alcohol abuse, Alcoholism,
Claims, Day care, Dental health, Drug abuse, Foreign relations,
Government contracts, Grant programs-health, Grant programs-veterans,
Health care, Health facilities, Health professions, Health records,
Homeless, Medical and dental schools, Medical devices, Medical
research, Mental health programs, Nursing homes, Philippines, Reporting
and recordkeeping requirements, Scholarships and fellowships, Travel
and transportation expenses, Veterans.
Approved: September 11, 1997.
Hershel W. Gober,
Acting Secretary of Veterans Affairs.
For the reasons set forth in the preamble, 38 CFR part 17 is
amended as follows:
PART 17--MEDICAL
1. The authority citation for part 17 continues to read as follows:
Authority: 38 U.S.C. 501(a), 1721, unless otherwise noted.
2. In part 17, an undesignated center heading and new Secs. 17.900
through 17.905 are added to read as follows:
Health Care for a Vietnam Veteran's Child With Spina Bifida
Sec.
17.900 Spina bifida--provision of health care.
17.901 Definitions.
17.902 Preauthorization.
17.903 Payment.
17.904 Review and appeal process.
17.905 Medical records.
Health Care for a Vietnam Veteran's Child With Spina Bifida
Sec. 17.900 Spina bifida--provision of health care.
(a) VA shall provide a Vietnam veteran's child who has been
determined under Sec. 3.814 of this title to suffer from spina bifida
with such health care as the Secretary determines is needed by the
child for the spina bifida or any disability that is associated with
such condition. This is not intended to be a comprehensive insurance
plan and does not cover health care unrelated to spina bifida.
(b) Health care provided under this section shall be provided
directly by VA, by contract with an approved health care provider, or
by other arrangement with an approved health care provider. VA may
inform spina bifida patients, parents, or guardians that health care
may be available at not-for-profit charitable entities.
(Authority: 38 U.S.C. 101(2), 1801-1806)
Note to Sec. 17.900: VA provides payment under this section only
for health care relating to spina bifida or a disability that is
associated with such condition. VA is the exclusive payer for
services paid under this section regardless of any third party
insurer, Medicare, Medicaid, health plan, or any other plan or
program providing health care coverage. Any third-party insurer,
Medicare, Medicaid, health plan, or any other plan or program
providing health care coverage would be responsible according to its
provisions for payment for health care not relating to spina bifida
and not constituting a disability that is associated with such
condition (accordingly, in the usual case claims for health care for
other than covered services for spina bifida and disabilities
associated with spinal bifida would be submitted to an insurer,
Medicare, Medicaid, health plan, or other program providing health
care coverage).
Sec. 17.901 Definitions.
For purposes of Secs. 17.900 through 17.905--
Approved health care provider means a health care provider approved
by the Health Care Financing Administration (HCFA), Department of
Defense Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS), Civilian Health and Medical Program of the Department of
Veterans Affairs (CHAMPVA), Joint Commission on Accreditation of Health
Care Organizations (JCAHO), or any health care provider approved for
providing health care pursuant to a state license or certificate. An
entity or individual shall be deemed to be an approved health care
provider only when acting within the scope of the approval, license, or
certificate.
Child means the same as defined at Sec. 3.814(c) of this title.
Habilitative and rehabilitative care means such professional
counseling, guidance services and treatment programs (other than
vocational training under 38 U.S.C. 1804) as are necessary to develop,
maintain, or restore, to the maximum extent practicable, the
functioning of a disabled person.
Health care means home care, hospital care, nursing home care,
outpatient care, preventive care, habilitative and rehabilitative care,
case management, and respite care; and includes the training of
appropriate members of a child's family or household in the care of the
child; and the provision of such pharmaceuticals, supplies (including
continence-related supplies such as catheters, pads, and diapers),
equipment (including durable medical equipment), devices, appliances,
assistive technology, direct transportation costs to and from approved
health care providers (including any necessary costs for meals and
lodging en route, and accompaniment by an attendant or attendants), and
other materials as the Secretary determines necessary.
Health care provider means any entity or individual who furnishes
health care, including specialized spina bifida clinics, health care
plans, insurers, organizations, and institutions.
Home care means medical care, habilitative and rehabilitative care,
preventive health services, and health-related services furnished to an
individual in the individual's home or other place of residence.
Hospital care means care and treatment furnished to an individual
who has been admitted to a hospital as a patient.
Nursing home care means care and treatment furnished to an
individual who has been admitted to a nursing home as a resident.
Outpatient care means care and treatment, including preventive
health services, furnished to an individual other than hospital care or
nursing home care.
[[Page 51285]]
Preventive care means care and treatment furnished to prevent
disability or illness, including periodic examinations, immunizations,
patient health education, and such other services as the Secretary
determines necessary to provide effective and economical preventive
health care.
Respite care means care furnished on an intermittent basis for a
limited period to an individual who resides primarily in a private
residence when such care will help the individual continue residing in
such private residence.
Spina bifida means all forms and manifestations of spina bifida
except spina bifida occulta (this includes complications or associated
medical conditions which are adjunct to spina bifida according to the
scientific literature).
Vietnam veteran means the same as defined at Sec. 3.814(c) of this
title.
(Authority: 38 U.S.C. 101(2), 1801-1806)
Sec. 17.902 Preauthorization.
(a) Preauthorization from a preauthorization specialist of the
Health Administration Center is required for health care consisting of
case management, durable medical equipment, home care, professional
counseling, mental health services, respite care, training, substance
abuse treatment, dental services, transplantation services, or travel
(other than mileage at the General Services Administration rate for
privately owned automobiles). This care will be authorized only in
those cases where there is a demonstrated medical need. Applications
for provision of health care requiring preauthorization shall either be
made by telephone at (800) 733-8387, or in writing to Health
Administration Center, P.O. Box 65025, Denver, CO 80206-9025. The
application shall contain the following:
(1) Name of child,
(2) Child's social security number,
(3) Name of veteran,
(4) Veteran's social security number,
(5) Type of service requested,
(6) Medical justification,
(7) Estimated cost, and
(8) Name, address, and telephone number of provider.
(b) Notwithstanding the provisions of paragraph (a) of this
section, preauthorization shall not be required for a condition for
which failure to receive immediate treatment poses a serious threat to
life or health. Such emergency care should be reported by telephone at
(800) 733-8387 to the Health Administration Center, Denver, CO within
72 hours of the emergency.
(Paperwork requirements were approved by the Office of Management
and Budget under control number 2900-0577.)
(Authority: 38 U.S.C. 101(2), 1801-1806)
Sec. 17.903 Payment.
(a)(1) Payment under this section will be determined utilizing the
same payment methodologies as provided for under the Civilian Health
and Medical Program of the Department of Veterans Affairs (CHAMPVA)
(see 38 CFR 17.84).
(2) As a condition of payment, the services must have occurred on
or after October 1, 1997, and must have occurred on or after the date
the child was determined eligible for benefits under Sec. 3.814 of this
title. Also, as a condition of payment, claims from approved health
care providers for health care provided under this section must be
filed with the Health Administration Center, P.O. Box 65025, Denver, CO
80206-9025, no later than:
(i) One year after the date of service; or
(ii) In the case of inpatient care, one year after the date of
discharge; or
(iii) In the case of retroactive approval for health care, 180 days
following beneficiary notification of authorization.
(3) Claims for health care provided under the provisions of
Secs. 17.900 through 17.905 shall contain, as appropriate, the
information set forth in paragraphs (a)(3)(i) through (a)(3)(v) of this
section.
(i) Patient identification information:
(A) Full name,
(B) Address,
(C) Date of birth, and
(D) Social Security number.
(ii) Provider identification information (inpatient and outpatient
services):
(A) Full name and address (such as hospital or physician),
(B) Remittance address,
(C) Address where services were rendered,
(D) Individual provider's professional status (M.D., Ph.D., R.N.,
etc.), and
(E) Provider tax identification number (TIN) or Social Security
number.
(iii) Patient treatment information (long-term care or
institutional services):
(A) Dates of service (specific and inclusive),
(B) Summary level itemization (by revenue code),
(C) Dates of service for all absences from a hospital or other
approved institution during a period for which inpatient benefits are
being claimed,
(D) Principal diagnosis established, after study, to be chiefly
responsible for causing the patient's hospitalization,
(E) All secondary diagnoses,
(F) All procedures performed,
(G) Discharge status of the patient, and
(H) Institution's Medicare provider number.
(iv) Patient treatment information for all other health care
providers and ancillary outpatient services such as durable medical
equipment, medical requisites and independent laboratories:
(A) Diagnosis,
(B) Procedure code for each procedure, service or supply for each
date of service, and
(C) Individual billed charge for each procedure, service or supply
for each date of service.
(v) Prescription drugs and medicines and pharmacy supplies:
(A) Name and address of pharmacy where drug was dispensed,
(B) Name of drug,
(C) Drug Code for drug provided,
(D) Strength,
(E) Quantity,
(F) Date dispensed,
(G) Pharmacy receipt for each drug dispensed (including billed
charge), and
(H) Diagnosis.
(b) Health care payment shall be provided in accordance with the
provisions of Secs. 17.900 through 17.905. However, the following are
specifically excluded from payment:
(1) Care as part of a grant study or research program,
(2) Care considered experimental or investigational,
(3) Drugs not approved by the U.S. Food and Drug Administration for
commercial marketing,
(4) Services, procedures or supplies for which the beneficiary has
no legal obligation to pay, such as services obtained at a health fair,
(5) Services provided outside the scope of the provider's license
or certification, and
(6) Services rendered by providers suspended or sanctioned by a
Federal agency.
(c) Payments made in accordance with the provisions of Secs. 17.900
through 17.905 shall constitute payment in full. Accordingly, the
health care provider or agent for the health care provider may not
impose any additional charge for any services for which payment is made
by VA.
(d) Explanation of benefits (EOB). When a claim under the
provisions of Secs. 17.900 through 17.905 is adjudicated, an EOB will
be sent to the beneficiary or guardian and the provider. The EOB
provides at a minimum, the following information:
(1) Name and address of recipient,
(2) Description of services and/or supplies provided,
(3) Dates of services or supplies provided,
[[Page 51286]]
(4) Amount billed,
(5) Determined allowable amount,
(6) To whom payment, if any, was made, and
(7) Reasons for denial (if applicable).
(Paperwork requirements were approved by the Office of Management
and Budget under control number 2900-0577.)
(Authority: 38 U.S.C. 101(2), 1801-1806)
Sec. 17.904 Review and appeal process.
If a health care provider, Vietnam veteran's child or
representative disagrees with a determination concerning provision of
health care or a health care provider disagrees with a determination
concerning payment, the person or entity may request reconsideration.
Such request must be submitted in writing within one year of the date
of the initial determination to the Chief, Administrative Division,
Health Administration Center, P.O. Box 65025, Denver, CO 80206-9025.
The request must state why it is concluded that the decision is in
error and must include any new and relevant information not previously
considered. Any request for reconsideration that does not identify the
reason for dispute will be returned to the sender without further
consideration. After reviewing the matter, including any relevant
supporting documentation, a benefits advisor will issue a written
determination (with a statement of findings and reasons) to the person
or entity seeking reconsideration that affirms, reverses or modifies
the previous decision. If the person or entity seeking reconsideration
is still dissatisfied, within 90 days of the date of the decision he or
she may make a written request for review by the Director, Health
Administration Center, P.O. Box 65025, Denver, CO 80206-9025. The
Director will review the claim and any relevant supporting
documentation and issue a decision in writing (with a statement of
findings and reasons) that affirms, reverses or modifies the previous
decision. An appeal under this section would be considered as filed the
time it was delivered to the VA or at the time it was released for
submission to the VA (for example, this could be evidenced by the
postmark, if mailed).
Note to Sec. 17.904: The final decision of the Director will
inform the claimant of further appellate rights for an appeal to the
Board of Veterans Appeals.
(Paperwork requirements were approved by the Office of Management
and Budget under control number 2900-0577.)
(Authority: 38 U.S.C. 101(2), 1801-1806)
Sec. 17.905 Medical records.
Copies of medical records generated outside VA that relate to
activities for which VA is asked to provide payment, and that VA
determines are necessary to adjudicate claims under Secs. 17.900
through 17.905, must be provided to VA at no cost.
(Authority: 38 U.S.C. 101(2), 1801-1806)
[FR Doc. 97-25664 Filed 9-29-97; 8:45 am]
BILLING CODE 8320-01-P
