Getting emergency health care in a non-VA health care facility paid for by the Veterans Administration is allowed but often difficult for veterans to succeed at. There are very strict guidelines to this benefit. A veteran trying to get their non-VA emergency room visit paid for must meet ALL the requirements.
The first requirement is the ER visit must meet the definition of an emergency. The definition of an emergency is based on the “prudent layperson” standard that a delay in care would be hazardous to life or health. This is often a difficult test for a veteran to argue with a VA administrator.
Veterans must use the VA for healthcare and be registered as a VA patient. It is not an exclusive requirement that the veteran receive all their health care at the VA but the veteran must have accessed health care at a VA facility within 24 months prior to the emergency room visit.
The veteran cannot have any other insurance nor can a third-party have any liability for the illness or injury which the veteran is seeking care. This could include workman comp and other situations when a third-party caused the illness or injury.
There can be no VA health care facility reasonably accessible when treatment for the condition is received.
The VA also wants to be notified in advance. This is not always reasonably possible but usually expected. Veterans are advised to contact the VA as soon as possible after receiving emergency care. A recommended way to meet this requirement is to have the ER physician contact the closest VA facility to consult with the VA ER physician on a treatment plan. The VA may want to transfer the veteran to the VA facility for further treatment and/or assessment.
Once the VA receives the bills for care, they will either pay the bills or notify the veteran of a denial. The denial can be appealed. The appeal must be made with one year of the denial letter. Get legal assistance as soon as possible in the event of a denial. Experienced attorneys can help process this important appeal increasing your chances of an approved payment for your emergency care.