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Non-VA Emergency Care for NSC Veterans

Post Date:10/27/2017 9:00 am

Payment for Emergency Non-VA Care for non-service connected conditions may be made when all of the following administrative and clinical criteria are met:

ADMINISTRATIVE CRITERIA

  • A claim is not payable under 38 U.S.C. ยง1728 (for Service Connection related care).
  • A claim is filed, in accordance with 38 CFR 17.1004(d), within 90 days of the following:
    • date of service (DOS),
    • date of death, but only if the death occurred during transportation to a facility for emergency treatment or if the death occurred during the stay in the facility that included the provision of the emergency treatment, or
    • supporting documentation of the date that third party liability benefits have been exhausted

And, the Veteran meets each and every one of the following criteria:

  • Is enrolled in the VHA Health Care System,
  • Has received care under 38 U.S.C. Chapter 17 within the 24-month period preceding the date of treatment for the episode of non-VA emergency care,
  • Is financially liable to the provider of emergency treatment,
  • Has no entitlement or coverage under a health plan, * this is subject to change when the Staab v. McDonald appeal case is published, until that time, VA is suspending claims that meet all Mill Bill criteria except for other health coverage.
  • Has no other contractual or legal recourse against a third party that would in whole extinguish their liability to the provider.
  • The Veteran (or someone) notifies the VA within 72 hours of the emergency care excluding weekends and holidays.

CLINICAL CRITERIA

  • Treatment was rendered in a hospital emergency department or a similar facility providing emergency care to the public.
  • Care was emergent in nature and rendered in a situation where a prudent layperson reasonably expects that delay in seeking immediate medical attention would be hazardous to life or health.
  • VA or other Federal facility was not feasibly available to provide the needed care.

NOTE: All emergency care must be reviewed and adjudicated after the fact. VA does not authorize emergency care over the phone and will always direct Veterans to the nearest emergency room if the care required is emergent.

Nurse Advice Line: 1-866-687-7200
NOTE: The Nurse Advice Line can be contacted to document an admission to an emergency facility or hospital. However, the Nurse Advice Line should never take the place of contacting 911 in an emergent situation.

For questions or for more information, call (701) 239-3700 extension 9-3454.