Code of Federal Regulations · Section
§ 17.277 — Appeals
38 C.F.R. § 17.277
(a) This section applies only to legacy claims.
(b) Notice of the initial determination regarding payment of CHAMPVA benefits will be provided to the CHAMPVA beneficiary on a CHAMPVA Explanation of Benefits (EOB) form. The EOB form is generated by the CHAMPVA automated payment processing system. If a CHAMPVA beneficiary or provider disagrees with the determination concerning CHAMPVA-covered services and supplies or calculation of benefits, he or she may request reconsideration. Such requests must be submitted to VA in writing within one year of the date of the initial determination. The request must state why the CHAMPVA claimant believes 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 claimant without further consideration. After reviewing the claim and any relevant supporting documentation, VA will issue a written determination to the claimant that affirms, reverses, or modifies the previous decision. If the claimant is still dissatisfied, within 90 days of the date of the decision he or she may make a written request for review by VA. After reviewing the claim and any relevant supporting documentation, VA will issue a written determination to the claimant that affirms, reverses, or modifies the previous decision. The decision of VA with respect to benefit coverage and computation of benefits is final. When a CHAMPVA beneficiary has other health insurance (OHI), an appeal must first be filed with the OHI, and a determination made, before submitting the appeal to CHAMPVA with limited exceptions such as if the OHI deems the issue non-appealable. Denial of CHAMPVA benefits based on legal eligibility requirements may be appealed to the Board of Veterans' Appeals in accordance with 38 CFR part 20. Medical determinations are not appealable to the Board. 38 CFR 20.101.
Authorizing Statute
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Rules and regulations38 U.S.C. § 501
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Medical care for survivors and dependents of certain veterans38 U.S.C. § 1781
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Definitions38 U.S.C. § 1701
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Definitions38 U.S.C. § 101
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Assistance for providing automobile and adaptive equipment38 U.S.C. § 3902
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Clothing allowance38 U.S.C. § 1162
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Eligibility for hospital, nursing home, and domiciliary care38 U.S.C. § 1710
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Community residential care38 U.S.C. § 1730
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Agreements with eligible entities or providers; certification processes38 U.S.C. § 1703A
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Contracts and personal services38 U.S.C. § 513
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Definitions38 U.S.C. § 3901
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Establishment38 U.S.C. § 7691
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Care and services during certain disasters and emergencies38 U.S.C. § 1785
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Benefits for discharged members of allied forces38 U.S.C. § 109
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Emergent suicide care38 U.S.C. § 1720J
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Recovery by United States42 U.S.C. § 2651
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Transplant procedures with live donors and related services38 U.S.C. § 1788
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Access to walk-in care38 U.S.C. § 1725A
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Assistance and support services for caregivers38 U.S.C. § 1720G
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Functions of Veterans Health Administration: in general38 U.S.C. § 7301
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Medicaid and CHIP Payment and Access Commission42 U.S.C. § 1396
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Regulations38 U.S.C. § 7304
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Requirement for program38 U.S.C. § 7698
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Hospital care, medical services, and nursing home care abroad38 U.S.C. § 1724
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Veterans Community Care Program38 U.S.C. § 1703
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Center for Innovation for Care and Payment38 U.S.C. § 1703E