Instructions for Claiming Past Out-Of-Pocket Medical Expenses

As part of the economic loss component of your claim, you can request reimbursement for past out-of-pocket medical expenses you have paid as a result of your eligible condition(s). Your claim for reimbursement of past out-of-pocket medical expenses will only be considered if the criteria below are met:

• The expenses were paid prior to the date the WTC Health Program certified the applicable condition as eligible for treatment (“applicable condition” refers to the specific condition for which the expenses were incurred).  Because you are eligible for treatment and medications once your condition is certified, the VCF will not reimburse for expenses you incur after your condition is certified if you decide to be treated by a non-WTC Health Program physician, or to have your prescriptions filled by an unaffiliated pharmacy.
• The expenses are related to an eligible condition that was verified through the VCF Private Physician Process.  Expenses related to these conditions may be eligible for reimbursement before and after the date the VCF verified the condition as eligible, since the treatment of the conditions is not covered by the WTC Health Program.   
• The total amount of the claimed medical expenses incurred due to eligible conditions exceeds $5,000, and the VCF is able to verify at least $5,000 of the claimed out-of-pocket expenses based on the submitted documentation.
• The expenses are acceptable expenses as outlined in Acceptable Medical Expenses Claims below. 
• The claim is submitted with the required documentation and in the required format, as explained in Documentation Required to Support a Medical Expenses Claim below.

The Special Master may exercise discretion to waive one or more of these requirements as appropriate based on individual claimant circumstances.  If you wish to seek a waiver, please contact the VCF Helpline.

Because claims for reimbursement of out-of-pocket medical expenses require the submission and review of significant documentation establishing that the claimed medical expense was related to your eligible condition, that you personally paid for the expense out of pocket, and that the expense was incurred prior to your WTC Health Program certification for the applicable condition, processing these claims takes time and can delay your award. As a result, the VCF has established specific criteria about when and how you should submit your claim for medical expenses.  Please review the details below specific to personal injury and deceased claims. 

I. When To File A Medical Expenses Claim.

1. Personal Injury Claims:  Claims for medical expenses must be submitted as a compensation amendment to your claim only after you have received your initial award determination. This allows the VCF to issue your initial award determination more quickly, since we are not spending time during our initial review to verify each claimed medical expense. You may also amend your claim to seek reimbursement for medical expenses after receiving a revised award decision.  Instructions for how to amend your claim can be found under “Forms and Resources” on the VCF website.
   
   The amendment may be filed at any time following receipt of your initial award determination, but no later than October 1, 2090.
    
2. Deceased Claims: Claims for medical expenses may be submitted as part of your initial claim or on amendment. NOTE:  If you choose to submit documentation on amendment and the VCF changes your award, your may need to return to the court to have them lift any limitations in the Letters of Administration, Letters Testamentary, or other Court Order.
    
3. Pending Claims and Amendments.
   
   Personal Injury Claims:  If you have already filed a claim for medical expenses as part of your personal injury claim form submission, the VCF will not review the expenses as part of our initial review of your claim.
   
   Once you receive your award determination, you will need to determine if the out-of-pocket medical expenses you incurred meet the $5,000 minimum threshold and other criteria noted above and are acceptable expenses as described in Section II below. You are not required to amend your claim if you decide you no longer want to seek reimbursement for medical expenses.  If the paid medical expenses incurred meet the VCF criteria and you want to seek reimbursement of the expenses, you must submit an amendment to reactivate your request. You do not need to resubmit documents in support of your medical expenses claim if you already submitted them with your claim form, although you may submit additional documentation.  You must be certain any documentation you provide meets the requirements outlined in Section III below.
   
   If you have already filed an amendment to seek medical expenses reimbursement, the VCF will review the expenses as part of our review of your amendment, provided the expenses meet the established criteria. You do not need to resubmit documents you have already submitted in support of your amendment, but you must be certain the documentation you provided meets the requirements outlined in Section III below.
   
   Deceased Claims: If you already filed an amendment for medical expenses on a deceased claim, we will review your amendment. 

II. Acceptable Medical Expenses Claims.

1. Types of Expenses Covered.  By statute, the VCF does not compensate for potential or anticipated future medical expenses.
   
   Compensable expenses include costs you have paid out-of-pocket for prescription medication, prescribed medical equipment, doctor visits, diagnostic tests, surgeries, or other medical procedures relating to your eligible condition(s).  The VCF will not compensate for any travel expenses you incurred while seeking medical treatment, including the cost of gas, public transportation, hotels, and meals, except in extraordinary circumstances. Other expenses that are not eligible for reimbursement include insurance premiums; investigational and holistic treatment; wigs; household items such as vacuum cleaners, air filters, and water filters; or home modifications.
   
   Compensable expenses do not include any costs for which you have been, or will be, reimbursed by your insurance company, a secondary payer (like Medicaid, Medicare, or a second insurance provider), or any other collateral source. 

• If you have insurance, the VCF will not compensate for any expenses that have not yet been evaluated by your insurance company or any applicable secondary payer.
• If the service or medication is provided to you by the WTC Health Program, it is not eligible for reimbursement from the VCF, and you should not include it with your claim.
• Treatment expenses covered by private health insurance, Workers’ Compensation, or other programs will not be reimbursed.  If you receive a benefit intended to cover medical expenses from a workers’ compensation program or any other collateral source, please include information regarding that payment, so that it can be appropriately offset from your medical expenses award.
• Treatment expenses billed to you as a co-payment, after denial of insurance coverage, or that you pay because they fall within your insurance deductible, may be reimbursed if appropriate documentation is submitted.
   

2. Timing of Reimbursable Expenses. By statute, the VCF does not compensate for potential or anticipated future medical expenses.  The VCF will consider reimbursement of out-of-pocket medical expenses that you incurred up until the date of WTC Health Program certification of the applicable condition(s).  Expenses you incurred after the date of certification are not eligible for reimbursement. If you are claiming medical expenses relating to conditions with different certification dates, you can claim reimbursement for applicable expenses up to the certification date for each individual condition.  If you have already filed a claim for reimbursement of expenses that you incurred after your certification date for the applicable condition, the VCF will not reimburse for these expenses.  We will still review your claim to see if it includes reimbursable expenses that you incurred before the applicable condition was certified.
   
   If you are claiming reimbursement for expenses related to conditions that are verified as eligible through the VCF Private Physician Process, we will consider reimbursement for expenses you incurred at any time before you filed your medical expenses claim, subject to the specific circumstances of your individual claim.  This means you may file multiple claims for medical expense reimbursement over time as you incur additional out-of-pocket costs, as long as each claim meets the $5,000 threshold and all other criteria for reimbursement are met.
    
3. The Minimum Monetary Threshold. The VCF will consider claims for medical expenses only if the total amount legitimately claimed in your amendment exceeds $5,000. The “total amount legitimately claimed” means that the claimed expenses are reasonably related to your eligible conditions (as identified in your most recent eligibility determination letter) and that you have documentation demonstrating that you paid the expense out-of-pocket. The VCF will only reimburse the expenses, however, if a minimum of $5,000 can be verified as valid expenses.  This means even if you claim $5,000 or more in expenses, we will only reimburse the expenses if we can validate at least $5,000 of the claimed expenses. 

III. Documentation Required to Support a Medical Expenses Claim.

If your medical expenses claim does not meet the documentation requirements described in this section, the VCF reserves the right to deny the claim. For the VCF to consider your claim for medical expenses, you must submit the following documents in support of your claim:

1. VCF Medical Expense Worksheet (available under “Forms and Resources” on the VCF website) The worksheet must be completed following the specific instructions provided with the Worksheet; and
2. A Medical Expense Supporting Documentation Packet that verifies: (a) the relationship of each claimed expense to one of your eligible conditions; and (b) the amount of each claimed expense that you have paid out-of-pocket.

The requirements for each of these items are described in greater detail below.

• The Medical Expense Worksheet.  The Medical Expense Worksheet is used to identify each discrete medical expense for which you are seeking reimbursement.  The worksheet must be completed following the instructions below (the instructions are also included in the worksheet.  The VCF will not review your amendment if the worksheet is not properly completed.  If you are unable to complete the worksheet in Excel format, please contact the VCF Helpline for assistance. 

Instructions for Completing the Worksheet.  The numbers below correspond to the numbers for each field or column in the worksheet. 

1. Claim Number: enter your 7-digit VCF claim number including any leading zeros.
2. Victim Name: enter your full name (or the victim’s name if you are not the victim).
3. Medical Insurance (Primary and Secondary if applicable): Enter the name of your insurance carrier (if you had one) at the time the expense was incurred and the name of any applicable secondary payer, such as Medicaid, Medicare, or a second insurance provider. 

Each expense you are claiming must be entered in a separate row in the Worksheet following the guidelines below.  Do not group expenses together – each unique expense must be entered as a separate line item.  You should sort the Worksheet chronologically by column A, the date of service.

4. Date of Service: Enter the date that you received the medical service.  The field will automatically format the date to MM/DD/YYYY.  For doctor visits, diagnostic tests, surgeries, or other procedures, this is the date you went to the doctor or had the test or procedure performed.  For prescriptions or equipment, this is the date you filled the prescription or purchased the equipment.  It is very helpful if you list the dates in chronological order (starting with the oldest date of service and ending with the most recent date of service).
5. Name of Doctor, Facility, or Pharmacy: Enter the name of the doctor, facility, or pharmacy as shown on the invoice, receipt, or medical records.
6. Short description of Procedure, Treatment, or related Expense: Enter a brief description of the treatment, procedure, or test.  Some examples are: office visit; surgery; prescription - [name of prescription drug]; MRI; blood test.
7. Related Eligible Condition: Enter the name of the eligible condition to which the specific expense relates.  The condition name MUST match the name of one of the conditions listed on your most recent eligibility determination letter.
8. Amount Paid by Victim/Claimant: Enter the amount you paid out-of-pocket for the medical service or treatment.  This is the amount for which you are personally responsible; it should not include any portion covered by insurance or any other source.  Do not include any amounts that have not yet been evaluated by your insurance company or any applicable secondary payer.  The field will automatically format the entry in $0.00 format.
9. Page within Supporting Documentation Packet that shows relationship to Eligible Condition: Unless the expense claimed is on the list of Presumptively Compensable Expenses (see Table 1 below), enter the page number (or numbers) from the Supporting Documentation Packet that shows that the expense is related to one of your eligible conditions.
   
   If the expense claimed is on the list of Presumptively Compensable Expenses, this cell may be left blank.
10. Specific Page within Supporting Documentation Packet that shows Proof of Payment: Enter the page number (or numbers) from the Supporting Documentation Packet that show that you personally paid for the claimed expense.  Note that there must be specific documentation supporting the payment of the claimed expense.  A credit card statement or cancelled check will not be sufficient if it identifies only that an amount was paid to a pharmacy such as CVS or Duane Reade, but is not accompanied by a receipt that demonstrates that the amount paid for was for the specific claimed prescription cost. 

Submitting the Worksheet: You must upload the Worksheet to your claim in Excel format. If you do not upload the Worksheet, or if you upload the file in any format other than Excel, the VCF reserves the right to deny your medical expenses claim. 

When uploading the Worksheet to your online claim, select “Medical Expense Worksheet” as the document type. 

• Medical Expense Supporting Documentation Packet.  For each discrete medical expense entered on the Medical Expense Worksheet, the Supporting Documentation Packet must include:
  
  (1) A document that demonstrates that the expense is related to one of your eligible conditions as explained below, unless the expense is on the list of Presumptively Compensable Expenses (see Table 1 below); and
  
  (2) A document that demonstrates the amount of the expense that you have paid out-of-pocket, as explained below. 

When uploading the Supporting Documentation Packet to your claim, select the document type “Medical Expense Supporting Documentation Packet.”  If you fail to include the required supporting documentation, your claim for medical expenses will be denied.

1. Demonstrating the Relationship between the Claimed Expense and your Eligible Condition. 
   • Presumptively Compensable Expenses:  If your eligible conditions fall within one of the categories in Table 1, the VCF will presume that any expense for the medications and procedures listed in Table 1 is related to your eligible condition and you do not need to provide any further proof of the relationship.  You still must complete the Medical Expense Worksheet to list the specific expense, but you may leave Column F blank for the specific entry. 
   • Non-Presumptively Compensable Expenses: If your eligible condition or your medical expense is not listed in Table 1, then you must submit medical records that demonstrate the relationship between each claimed expense and one (or more) of your eligible conditions.  The medical records must include your name, date of birth or other identifying information, and date of service, and must state the condition for which you were treated.  If medical records are not available, you may instead submit a letter from your doctor explaining how the expense is related to your eligible condition.
2. Demonstrating the Amount of the Expense you Paid.  For all claimed medical expenses (without regard to whether they are Presumptively Compensable Expenses), you must submit documentation showing the amount you were billed, the date of service, the service provider, and proof that you paid the expense.  The documentation must also include your name or other identifying information. 

Documents that are sufficient to demonstrate the amount of the expense you paid include receipts from providers or pharmacies, provider billing statements, cancelled checks or credit card statements if they contain the necessary detail, pharmacy prescription histories, or an explanation of benefits statements from your insurance provider if you do not have a secondary payer. 

If you have insurance or a secondary payer, do not submit any bill or invoice for expenses that have not yet been evaluated by your insurance company, or an explanation of benefits statement that does not reflect the contribution of the secondary payer.

3. General organization of Supporting Documentation Packet.  It is extremely helpful to the VCF, and will minimize delay in processing your medical expense claim once it is in substantive review, if you organize the Supporting Documentation Packet in the following way:
   1. Label all submitted documentation with the line number from the Medical Expense Worksheet that corresponds to the specific expense.  This helps the VCF to easily match the documentation to the associated entry on the worksheet.
   2. Sort the submitted documentation chronologically by the date of service. This should match the “Date of Service” as entered on the worksheet for the specific item.
   3. Organize the documents in the packet so that the documentation demonstrating that the expense is related to an eligible condition (when required) is immediately followed by the documentation demonstrating the amount of the expense and your proof of payment. 

If the VCF, with reasonable effort, cannot clearly identify the required documentation necessary to support each claimed medical expense, the VCF reserves the right to deny your medical expenses claim.