DEPARTMENT 0F VETERANS AF AIRS
Minneapelis Care Department
Dee Veterans Drive ITAZ
Minneapelis, MN 554] 
till 2325-3003

 


CMS Claim 
Fee Pregrarn: 

KRALTSE BENJAMIN LEE

Previder.? HEALTH CAMPUS
Episede ef llC'are Beginning: Gilli-Em 

The abeve listed claim has been administratively and clinically reviewed te determine ifit
meets eligibility requirements payment fer service cennceted emergency unautheriaed
medical care. We regret te infen-n yea that year claim dees net meet the requirements ef
38 HES.

ln erdcr fer ?v?A te reimburse the nee-VA previder mt yeur behalf fer the service cenneeted
services previded. the t'ellewing eligibility criteria must be met: 'l'reatment was emergent
aceerding te the prudent laypersen standard; VA facilities were net feasibly available and
attempt te use them hefnrehand weuld have been Iraeerdeus te life er health by prudent laypersen
standard. Furthermere. the emergency treatment must have been her at least ene ef the fellewing:
An adjudicated scri-?ice eenneeted disability: A nee-service disability asseciated
with and aggravating an adjudicated service disability; Any disability efa veteran
whe has a tetal disability permanent in nature resulting frem a service eenneeted disability: 
Any illness. injury er dental cenditien efa veteran participating in a rehabilitatien pregram under

33 Ch. 
This claim fer VA reimbursement has been disappreved fer the tbllewing reasents]:
Claim Denied - The treatment previded dees net meet the Prudent Laypersen de?nitien ef

an emergency. 33 CFR 11120 

lfyeu de net agree with this decisien, yeu have the right te appeal. VA Femt 4] UTVHA. ?feur
Rights te Appeal Our Decisien. Please read the infermatien previded carefully se that yeu will
clearly understand yeur precedureal and appeal rights in cenneetien with any denied services.

Ifyeu have any questiens er ceneerns, please centact us at the abeve address or call (612)