Provision of Health Care to Vietnam Veterans' Children With Spina Bifida

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.

-----------------------------------------------------------------------

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