NVLSP Intake Form for Veterans Who May Be Entitled to Reimbursement of Emergency Medical Care Expenses At Non-VA Facilities 

On October 25, 2022, a federal appeals court ordered the VA to reimburse veterans for some costs associated with emergency medical care they received at non-VA facilities.  When a veteran’s health insurance does not cover all of the veteran’s emergency medical expenses, the VA is required to reimburse the veteran for “coinsurance,” but not for copayments or deductibles.  The order may impact veterans who incurred coinsurance costs in the past, including class members in the Wolfe v. Wilkie case. 

Lawyers at National Veterans Legal Services Program (NVLSP) represented the class in the Wolfe v. Wilkie case, and if you were a Wolfe class member whose claim is still unresolved, we may be able to assist you. Please fill out the form below if the VA still has not reimbursed you or sent you a letter saying whether VA granted or denied your reimbursement claim for emergencies that occurred between 2016 and 2020. Depending on the facts of your case, we may also be able to assist even if you are not a Wolfe class member. 

To help us determine whether VA owes you reimbursement for coinsurance costs, please fill out and return this form to NVLSP. It is common that veterans are not aware of whether the money they owed for an emergency is for a copayment, deductible, or coinsurance.  However, we may be able to help determine what type of costs you were charged if you have bills, “explanations of benefits”, or related documents prepared by your health care providers or your insurance company that describe the costs of your emergency care treatment.  Please keep copies of them because we may need copies to evaluate your case.

Because of the high volume of inquiries we are receiving, it may take us up to one week to review your completed form and respond to you.

If you have questions about a reimbursement claim you filed with the VA, you can call the following telephone number established by the VA for answering questions about reimbursement claims: 1-877-466-7124.

 Please fill out only one form, even if you have multiple claims.

Sign in to Google to save your progress. Learn more
Name (Last, First) *
Best phone number *
Email Address (If you do not have an email address, please write "none") *
If you do not have an email address, please provide a mailing address where you can be reached. 

 

1. When did you receive emergency medical care at a non-VA facility for which you are seeking reimbursement?  This is known as the episode of care date. An approximate date is OK. 

 *

2. If you are seeking reimbursement for more than one time you received emergency care at a non-VA facility, please list the approximate dates of those other episodes of care.

3. Did you have a non-VA health insurer when you received the emergency medical care? For example, you might have had Medicare, Medicaid, or  private insurance through your employer. 

 *
Required

4. How much were you billed for your date(s) of care, after insurance coverage? An approximate amount is OK.

 *

5. How much money were you charged for coinsurance payments?  This is typically a percentage of the total cost of the care, rather than a flat fee like a co-payment or a deductible.  An approximate amount is OK.  If you do not know, please write “I don’t know.”

6.  Do you have a copy of the Explanation of Benefits or Medicare Summary Notice for your episode of care date(s)? 

 *
7.  Have you or your health care provider submitted one or more claims for reimbursement to the VA?  
Clear selection

8. Sometimes the emergency health care provider will submit a reimbursement claim for you.  But if you remember submitting a reimbursement claim to the VA, when did you submit a claim for reimbursement?  An approximate date is OK. If you submitted more than one claim, please list the oldest claim you believe the VA has not paid yet. If you don't know, please proceed to question #10. 

MM
/
DD
/
YYYY

9. If you submitted more than one claim for reimbursement to the VA, please list the approximate dates you submitted them.

10. Have you received any correspondence from VA about your reimbursement claims for emergency care? VA correspondence could be, but is not limited to, a letter from VA stating you will receive payment in 4 to 6 weeks or a letter from VA requesting an explanation of benefits.

 *

11. If you have received correspondence from the VA about your reimbursement claims, please briefly describe it.

12. How much do you believe the VA still owes you for coinsurance payments and for what episode of care date(s)? If you do not know, please write “I don’t know.”

 *

13. Do you believe you have received any money from the VA or the U.S. Department of the Treasury for your reimbursement claims for emergency care? A check from the Department of Treasury or a direct deposit might not be accompanied with an explanation that it is a payment for your reimbursement claim. 

 *

14. If yes, approximately how much money have you received and, if you know, for what dates of care?

15.  Please let us know any additional comments or questions you have: 

Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms