Common use of RECONSIDERATION AND APPEAL Clause in Contracts

RECONSIDERATION AND APPEAL. A. VA may only deny a claim or a portion of a claim for services for the AI/AN Veteran when: 1. Ineligible for VA services, or 2. The care or services provided are not Direct Care Services, or 3. The care or services provided are not reimbursable services such as those described in Section VI, or 4. The claim was not submitted on a nationally recognized standard format, such as the CMS (Center for Medicare Services) Form 1500 (which replaced the HCFA (Health Care Financing Administration) Form 1500), or the UB-04 (Universal Billing, which replaced the UB-92), the ANSI (American National Standards Institute) Form X12 837, or the NCPDP (National Council for Prescription Drug Programs), or 5. The information needed to adjudicate the claim, consistent with the information contained on the electronic HCFA and UB forms, is not provided. B. If VA denies reimbursement for a claim listed above, VA shall notify the Service Unit of the denial in writing together with a statement of the reason for the denial. The notice shall advise that the Service Unit may obtain a reconsideration of the denial by submitting a request for reconsideration or appeal in writing, within one year of the notice, setting forth the grounds supporting the request or appeal, including any documentation requested by VA for reconsideration. C. VA shall review and respond to a request for reconsideration or appeal within 30 days of receipt. If the original decision is affirmed on reconsideration, the Service Unit shall be so notified in writing and advised that a notice of disagreement (NOD) may be submitted to VA within one year of the notice of the reconsidered decision. The NOD shall be in writing and shall set forth the grounds supporting the appeal. If the claimant continues to disagree after VA review of the NOD, VA will inform the claimant of further appellate rights for an appeal to the Board of Veterans Appeals (38 CFR §§17.132 & 17.133).