M21-1, Part III, Subpart i, Chapter 3, Section D – Processing Decision Ready Claims (DRCs)

In This Section

Introduction

Change Date

III.i.3.D.1.a.  Declaration of Representation 

• establishment of power of attorney through SEP, see M21-1, Part III, Subpart i, 4.B.1.c
• disclosure of records protected by 38 U.S.C. 7332, see M21-1, Part I, 3.B.2.d-f
• 38 U.S.C. 7332 authorization and relationship to the representative’s system access, see M21-1, Part I, 3.B.2.g, and
• notification requirement where a representative appointment form lacks a38 U.S.C. 7332 election, see M21-1, Part I, 3.B.2.h.

III.i.3.D.1.b.  Communication of an ITF

• claimant or his/her accredited representative has previously submitted an ITF whose status remains active, or
• representative is submitting the DRC on the same day that the ITF would have otherwise been submitted.

III.i.3.D.1.c.  Digitization of Paper Claims Folders

• DRC process is being initiated, and
• paper claims folder must be converted to an electronic format to support the submission.

• the requirement for conversion of existing paper claims folder, see M21-1, Part III, Subpart ii, 3.B.1.e
• situations in which a DRC contract examination will not be requested, seeM21-1, Part III, Subpart i, 3.D.1.g, and
• excluding claims from DRC processing, see M21-1, Part III, Subpart i, 3.D.3.b.

III.i.3.D.1.d.  Pre-Claim Evidence Gathering

• gather all relevant records and evidence needed to render a decision, including all pertinent private and Federal treatment records, and
• determine and identify which method of examination discussed in M21-1, Part III, Subpart i, 3.D.1.e will be pursued.

• If a contract examination is being sought in support of the DRC, all relevant medical evidence must be obtained and submitted to the Department of Veterans Affairs (VA) prior to requesting the contract examination.
• All evidence and contract examination requests submitted in support of the DRC Initiative should include the appropriate DRC documents coversheet(s) pictured in M21-1, Part III, Subpart i, 3.C.4.
• As discussed in M21-1, Part III, Subpart i, 3.C.1.c, copies of service treatment records (STRs) for all periods of military service must be submitted at such time as an ITF is communicated for a pre-discharge DRC.

III.i.3.D.1.e.  Methods of DRC Examination

• gather and submit DBQs prepared by a claimant’s private treating physician, or
• request performance of one or more contract examinations.

• As discussed in M21-1, Part III, Subpart i, 3.D.1.d, neither private DBQ submission nor contract examination performance is required if medical evidence submitted in support of the DRC is otherwise independently sufficient for rating purposes.
• Contract examinations will not be warranted or authorized for claims for Dependency and Indemnity Compensation (DIC).

III.i.3.D.1.f.  Handling DRC Contract Examination Requests

Step	Who Is Responsible?	Action
1	RO intake activity	Establishes an end product (EP) 400 – DRC Exam Request, and assigns a date of claim reflecting the date of the VA Form 21-4138’s receipt.
2	RO intake activity	Enters DRC Exam Conditions in the Veterans Benefits Management System (VBMS) Contention field selects Administrative Issue from the Classification drop-down menu, and appends the Decision Ready Claim special issue indicator. Example:
3	National Work Queue	Routes the EP 400 for assignment to the DRC Examination Request Hub.
4	DRC Examination Request Hub	Reviews the DRC contract examination contention(s) to ensure that none of the conditions outlined in M21-1, Part III, Subpart i, 3.D.1.g are applicable determines the appropriate DBQ(s) bookmarks/annotates all relevant medical evidence for the examiner’s review, and enters a corresponding contract examination request. References:  For more information on entering examination requests, see M21-1, Part III, Subpart iv, 3.A, and bookmarking/annotating documents for the examiner’s review, see M21-1, Part III, Subpart iv, 3.A.8.

• If the contract examination request is returned for clarification or correction, correct and resubmit it within two business days.
• If contract examination results are not available for viewing in the VBMS eFolder within 10 calendar days of the last examination’s completion, follow the instructions found inM21-1, Part III, Subpart iv, 3.C.1.b.
• If a representative’s request for a contract examination results in the need to clarify the terms of the request with him/her, seek such clarification, and allow two days for a response.  If no response is received,
  • clear the pending EP 400, and
  • notify the representative that
    • no additional action will be taken, and
    • he/she may resubmit the contract examination request for further action in the future.
• For eligible pre-discharge DRCs, request
  • the General Medical DBQ, and
  • any implicated specialist examination(s) identified in M21-1, Part III, Subpart iv, 3.A.6.

III.i.3.D.1.g.  Situations in Which a DRC Contract Examination Will Not Be Requested

• The claimant previously rejected examination by a DRC contract examination vendor.
• The type of examination needed conflicts with contract examination exclusion bases referenced in M21-1, Part III, Subpart iv, 3.A.1.j.
• No ITF is of record.
• The requesting representative is not recognized or reflected as the claimant’s accredited representative in VA systems.
• The claimant previously failed to report for a DRC contract examination targeted at assessing the contention(s) at issue, regardless of whether good cause was or was not demonstrated.
• The relevant evidence listed or identified by the representative is not a matter of record.
• An examination for the contended disability has been conducted within the previous year, but no claim for said disability has since been filed and decided.

• It is permissible to request a new DRC contract examination if at least one year has elapsed since the claimant’s previous failure to report for examination.
• If one or more conditions associated with the DRC submission are noteligible for a DRC contract examination, but others are,
  • request contract examinations for the eligible DRC contentions, and
  • notify the representative that contract examinations will not be requested for the DRC-ineligible conditions, as well as the justification for that determination.

Introduction

Change Date

III.i.3.D.2.a.  Submission of Compensation DRCs

• submit to the DRC Direct Upload portal a complete DRC package, including
  • VA Form 21-22 (or 21-22a), if one is not already a matter of record
  • VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits
  • any medical evidence pertinent to consideration of the contention(s) at issue, and
  • privately prepared DBQ(s), if available medical evidence is not otherwise sufficient for rating purposes, or
• progressively submit DRC-related materials in the following order:
  • communication of an ITF (with copies of STRs for all periods of military service, in pre-discharge cases)
  • relevant medical evidence
  • contract examination request, and
  • completed VA Form 21-526EZ (with a certified copy of DD Form 214, Certificate of Release or Discharge from Active Duty, for all periods of military service, in pre-discharge cases).

• The VA Form 21-526EZ must be signed by the Veteran or service member.  If only the accredited representative has signed the application, exclude the claim from the DRC Initiative by following the instructions inM21-1, Part III, Subpart i, 3.D.3.b.
• In pre-discharge cases, the formal DRC must not be submitted until afterthe service member has been discharged from active duty service.

• submit to the DRC Direct Upload portal a complete DRC package, including a
  • VA Form 21-22 (or 21-22a), if one is not already a matter of record
  • VA Form 21P-534EZ, Application for DIC, Death Pension, and/or Accrued Benefits, and
  • death certificate, or
• progressively submit DRC-related materials in the following order:
  • communication of an ITF
  • a death certificate, and
  • a completed VA Form 21P-534EZ.

III.i.3.D.2.c.  Vendor Review of DRCs

Introduction

Change Date

III.i.3.D.3.a.  Establishing and Readying a DRC for Decision

III.i.3.D.3.b.  Excluding Claims From DRC Processing

• One or more of the exclusion parameters described in M21-1, Part III, Subpart i, 3.C.1.d apply.
• A DBQ or contract examination provided in support of the DRC is insufficient or requires clarification that cannot be expeditiously obtained.
• Medical evidence or additional records necessary to render a decision were not submitted concurrently with the DRC.
• Additional evidence or subsequent claims were received after the DRC was submitted.
• The claim results in deferral (complete or partial) by the rating activity.

Introduction

Change Date

III.i.3.D.4.a.  Issuing a Decision on a DRC

• pre-rating review of claims by the rating activity, see M21-1, Part III, Subpart iv, 2.A, and
• partial rating decisions and deferred issues, see M21-1, Part III, Subpart iv, 6.A.

III.i.3.D.4.b.  Resolving Examination Insufficiencies in DRCs

• telephonic or e-mail communication with the certifying provider, as discussed in M21-1, Part III, Subpart iv, 3.D.2.e, and
• reliance on local RO
  • resident clinicians to resolve questions or simple needs for clarification, as discussed in M21-1, Part III, Subpart iv, 3.D.3.e, or
  • contract examination coordinators/liaisons to utilize expedited means of inquiry discussed in the Contract Examination Inquiry Protocol Job Aid.

• take any rating action supported by the existing evidence, as discussed inM21-1, Part III, Subpart i, 3.D.4.a
• request any necessary contract examination(s) (or return existing contract examination results as inadequate, if applicable), and
• route the claim for additional processing and exclusion in accordance withM21-1, Part III, Subpart i, 3.D.3.b.