38 CFR 17.1005 - Payment limitations.

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§ 17.1005 Payment limitations.
(a) Payment or reimbursement for emergency treatment under 38 U.S.C. 1725 shall be the lesser of the amount for which the veteran is personally liable or 70 percent of the amount under the applicable Medicare fee schedule for such treatment.
(b) Except as provided in paragraph (c) of this section, VA will not approve claims for payment or reimbursement of the costs of emergency treatment not previously authorized for any period beyond the date on which the medical emergency ended. For this purpose, VA considers that an emergency ends when the designated VA clinician at the VA facility has determined that, based on sound medical judgment, a veteran who received emergency treatment:
(1) Could have been transferred from the non-VA facility to a VA medical center (or other Federal facility that VA has an agreement with to furnish health care services for veterans) for continuation of treatment, or
(2) Could have reported to a VA medical center (or other Federal facility that VA has an agreement with to furnish health care services for veterans) for continuation of treatment.
(c) Claims for payment or reimbursement of the costs of emergency treatment not previously authorized may be approved for continued, non-emergency treatment, only if:
(1) The non-VA facility notified VA at the time the veteran could be safely transferred to a VA facility (or other Federal facility that VA has an agreement with to furnish health care services for veterans) and the transfer of the veteran was not accepted, and
(2) The non-VA facility made and documented reasonable attempts to request transfer of the veteran to VA (or to another Federal facility that VA has an agreement with to furnish health care services for veterans), which means the non-VA facility contacted either the VA Transfer Coordinator, Administrative Officer of the Day, or designated staff responsible for accepting transfer of patients at a local VA (or other Federal facility) and documented such contact in the veteran's progress/physicians' notes, discharge summary, or other applicable medical record.
(d) If a stabilized veteran who requires continued non-emergency treatment refuses to be transferred to an available VA facility (or other Federal facility that VA has an agreement with to furnish health care services for veterans), VA will make payment or reimbursement only for the expenses related to the initial evaluation and the emergency treatment furnished to the veteran up to the point of refusal of transfer by the veteran.
(e) If an eligible veteran under § 17.1002 has contractual or legal recourse against a third party that would only partially extinguish the veteran's liability to the provider of emergency treatment, then:
(1) VA will be the secondary payer;
(2) Subject to the limitations of this section, VA will pay the difference between the amount VA would have paid under this section for the cost of the emergency treatment and the amount paid (or payable) by the third party; and
(3) The provider will consider the combined payment under paragraph (e)(2) of this section as payment in full and extinguish the veteran's liability to the provider.
(f) VA will not reimburse a claimant under this section for any deductible, copayment or similar payment that the veteran owes the third party.
(Authority: 38 U.S.C. 1725)
[66 FR 36470, July 12, 2001, as amended at 68 FR 3404, Jan. 24, 2003; 76 FR 79071, Dec. 21, 2011; 77 FR 23618, Apr. 20, 2012; 78 FR 36093, June 17, 2013]

Title 38 published on 2013-07-01

The following are only the Rules published in the Federal Register after the published date of Title 38.

For a complete list of all Rules, Proposed Rules, and Notices view the Rulemaking tab.

  • 2014-01-08; vol. 79 # 5 - Wednesday, January 8, 2014
    1. 79 FR 1330 - Community Residential Care
      GPO FDSys XML | Text
      DEPARTMENT OF VETERANS AFFAIRS
      Final rule.
      Effective Date: This final rule is effective January 8, 2014.
      38 CFR Part 17

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United States Code
U.S. Code: Title 38 - VETERANS’ BENEFITS

Title 38 published on 2013-07-01

The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 38 CFR 17 after this date.

  • 2014-01-08; vol. 79 # 5 - Wednesday, January 8, 2014
    1. 79 FR 1330 - Community Residential Care
      GPO FDSys XML | Text
      DEPARTMENT OF VETERANS AFFAIRS
      Final rule.
      Effective Date: This final rule is effective January 8, 2014.
      38 CFR Part 17