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

Overview


In This Section

This section contains the following topics:
Topic
Topic Name
1
2
3
4 Rating Review of DRCs

1.  Pre-Claim Process for DRCs


Introduction


Change Date

April 19, 2018

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

In order to successfully initiate processing under the Decision Ready Claim (DRC) Initiative, a claimant must be represented by an accredited representative.
If no representative relationship has been previously established, a 38 U.S.C 7332-compliant version of VA Form 21-22, Appointment of Veterans Service Organization as Claimant’s Representative, or VA Form 21-22a, Appointment of Individual as Claimant’s Representative, must accompany the DRC package submission.
Important:  Accredited representatives and Veterans may also utilize existing Stakeholder Enterprise Portal (SEP) and eBenefits functionality to establish representation in lieu of submitting VA Form 21-22 (or 21-22a) through the Direct Upload portal.
References:  For more information on

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

Prior to submitting a claim under the DRC Initiative, a claimant or his/her accredited representative may communicate an intent to file (ITF) via any of the acceptable means identified in M21-1, Part III, Subpart ii, 2.C.2.a in order to preserve the earliest possible effective date for any benefits subsequently awarded.
Communication of an ITF may not be warranted if the
  • 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.
However, an active ITF must be of record if a representative requests performance of one or more contract examinations, as provided in M21-1, Part III, Subpart i, 3.D.1.f.
Reference:  For more information on situations in which DRC contract examinations will not be requested, see M21-1, Part III, Subpart i, 3.D.1.g.

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

If a DRC is being considered or initiated on the behalf of a claimant for whom a paper claims folder exists, the representative must notify the regional office (RO) that the
  • DRC process is being initiated, and
  • paper claims folder must be converted to an electronic format to support the submission.
Important:  DRC contract examinations, if elected, cannot be requested until the Veteran’s claims folder has been converted into electronic format.
Note:  Whenever possible, utilize the local RO Intake Processing Center (IPC) Coach to facilitate the paper claims folder conversion process.
Reference:  For more information on

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

Prior to formal DRC submission, representatives must
  • 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.
Exception:  If non-disability benefits questionnaire (DBQ) medical evidence submitted in support of the DRC is deemed independently sufficient for rating purposes, no contract examination request or privately-prepared DBQ submission is necessary.
Important:
  • 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

Representatives have two options for ensuring that appropriate DBQs are completed in support of DRCs for compensation.  They may either
  • gather and submit DBQs prepared by a claimant’s private treating physician, or
  • request performance of one or more contract examinations.
Notes:
  • 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).
Use the table below to determine how examinations are secured in conjunction with either method.
If the preferred method of examination is via …
Then the representative must …
privately prepared DBQ
submit all necessary DBQs simultaneously with associated DRC materials.
Reference:  For a complete list of DBQs available for completion by private providers, see the List by DBQ Form Name page.
contract examination
 
Important:  All evidence and contract examination requests submitted in support of the DRC Initiative must include the appropriate DRC documents coversheet(s) pictured in M21-1, Part III, Subpart i, 3.C.4.

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

Follow the steps in the table below upon receipt of a VA Form 21-4138 identifying DRC contentions in need of contract examinations.
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:
Image of the contentions list in VBMS.
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
 
Notes:
  • 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

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

Do not request a DRC contract examination if any of the following conditions are applicable:
  • 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.
Use the table below to determine the next action if a DRC contract examination is incompatible with one or more of the criteria outlined in this block.
If the contract examination cannot be requested because the …
Then …
  • Veteran previously
    • rejected examination by a contract vendor, or
    • failed to report for a DRC contract examination targeted at assessing the contention(s) at issue
  • type of examination needed conflicts with M21-1, Part III, Subpart iv, 3.A.1.j, and/or
  • contended disability has been examined within the previous year, but not subsequently claimed or decided
  • e-mail the representative in order to notify him/her that
    • no new DRC contract examination will be requested, and why, and
    • the Veteran must
      • provide a privately-prepared DBQ (or other medical evidence sufficient for rating purposes) for the contended disability(ies), or
      • submit his/her claim via traditional means or the Fully Developed Claim (FDC) Program
  • upload a copy of the e-mail to the claims folder, and
  • clear the pending EP 400.
  • corporate record does not reflect the presence of an active ITF,
  • submitting individual is not recognized as the Veteran’s accredited representative, and/or
  • relevant evidence listed or identified by the representative is not a matter of record
  • e-mail the representative in order to notify him/her
    • of the nature of the submission’s deficiency
    • that no new DRC contract examination may currently be requested
    • that he/she may submit a new request for contract examination once the deficiency has been resolved, and
    • that the Veteran may alternatively
      • provide a privately-prepared DBQ (or other medical evidence sufficient for rating purposes) for the contended disability(ies), or
      • submit his/her claim via traditional means or the FDC Program
  • upload a copy of the e-mail to the claims folder, and
  • clear the pending EP 400.
   
Exceptions:
  • 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.
Notes:
  • If the claimant’s records include a paper claims folder that has not yet been digitized,
    • follow the instructions in M21-1, Part III, Subpart ii, 3.B, to initiate the paper claims folder’s conversion
    • notify the appointed representative that the examination request will not be processed until the claims folder has been successfully converted to an electronic format, and
    • hold the case until the paper record’s conversion is complete.
  • Once the paper claims folder has been converted and its contents uploaded to the eFolder, notify the representative, and proceed with requesting any necessary contract examinations using procedures inM21-1, Part III, Subpart i, 3.D.1.f.

2.  Intake Process for DRCs


Introduction

This topic contains information on the intake process for DRCs, including

Change Date

April 19, 2018

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

Compensation DRCs must be submitted by an accredited representative on behalf of the Veteran or service member.  Accredited representatives will use the DRC Direct Upload portal to submit a DRC electronically.
In order to initiate a DRC, the representative may
  • submit to the DRC Direct Upload portal a complete DRC package, including
  • 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).
Exception:  In pre-discharge cases, if the representative is unable to upload STRs to the Direct Upload portal due to size or volume, he/she should attach both the general DRC Documents coversheet and the pre-discharge DRC Documents coversheet to the hard-copy STRs or STR compact disc (whichever is provided) and submit them to the Centralized Mail (CM) vendor.  All other DRC documents, including the ITF and the formal claim application, must be submitted through the Direct Upload portal.
Important:
  • 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.
Reference:  For more information on DRC Documents coversheets, see M21-1, Part III, Subpart i, 3.C.2.b.

III.i.3.D.2.b.Submission of DIC DRCs
DIC DRCs must be submitted by an accredited representative on behalf of the surviving spouse.  Accredited representatives will use the DRC Direct Upload portal to submit a DRC electronically.
In order to initiate a DRC, the representative may
Important:  The VA Form 21-534EZ must be signed by the surviving spouse.  If only the accredited representative has signed the application, exclude the claim from the DRC Initiative by following the instructions in M21-1, Part III, Subpart i, 3.D.3.b.

III.i.3.D.2.c.  Vendor Review of DRCs

Upon receipt of a DRC through the DRC Direct Upload portal, the scanning vendor conducts a preliminary review to ensure that all required documents and evidence are included with the submission and substantially complete.
Based upon its review of the DRC submission, the scanning vendor takes action as outlined in the table below.
If the DRC submission appears …
Then the scanning vendor uses the Direct Upload portal to …
complete
route the DRC mail packet to the DRC Compensation Queue or DRC Pension Queue, depending on the claim type, with a status ofAvailable in Mail Portal.
incomplete
  • notify the representative that the DRC package is incomplete, and
  • provide an explanation or description of what elements are missing or incomplete.
Notes:
  • If the representative resubmits the DRC package within 72 hours of return, the scanning vendor will review the submission materials anew.
  • The claim will be routed to the non-DRC (or regular) CM queue for traditional claim processing if the representative
    • does not resubmit the DRC package within 72 hours, or
    • resubmits a DRC package that continues to lack required components.
  • The DRC’s date of claim remains the date of initial submission through the Direct Upload portal, even if materials are returned and subsequently resubmitted.
 
Reference:  For more information on the DRC Direct Upload portal, see the VSO Direct Upload/DRC User Guide.

3.  Taking Initial Action on DRCs


Introduction

This topic contains information on initial actions to take on DRCs, including


Change Date

April 19, 2018

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

Upon assignment of an eligible DRC mail package from an IPC Super User, follow the steps in the table below to review the submission’s eligibility, establish EP control, and ready the claim for decision, as warranted.
Step
Action
1
Does the DRC involve an exclusion reason identified in M21-1, Part III, Subpart i, 3.C.1.d?
2
Establish the appropriate EP (i.e. 110, 010, 020, or 140) with an appropriate claim label.
Reference:  For more information on
3
  • Enter the associated eligible contentions, and
  • append the Decision Ready Claim special issue indicator to at least one of them.
4
Create and close, as of the date of entry, a custom tracked item labeledDRC in order to advance the claim into Ready for Decision status.
Note:  The tracked item above should be established with a one-day suspense.
Reference:  For more information on creation of tracked items, see M21-1, Part III, Subpart iii, 1.F.3.b.
5
For compensation (including pre-discharge) claims, clear any concurrent EP 400 previously used to control a contract examination request in connection with the current DRC.

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

Follow the steps in the table below to exclude a claim from DRC processing if, at the time of submission or at any point thereafter, any of the following are found to be true:
  • 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.

Step

Action

1

Use the Letter Creator tool to send the claimant an appropriate version of the DRC Exclusion Letter, specifying the reason(s) for exclusion.

2

Remove the Decision Ready Claim special issue indicator from any contention(s) with which it may be associated.

3

Continue processing the claim in accordance with standard procedures.
 
Reference:  For more information on the Letter Creator tool, see the Letter Creator User Guide.

 4.  Rating Review of DRCs


Introduction

This topic contains information on the rating activity’s review of DRCs, including


Change Date

April 19, 2018

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

Upon assignment of a DRC in Ready for Decision status, the rating activity must review the claim submission and all associated evidence to ensure that preparation of a rating decision, to include a partial rating decision, is possible and appropriate.
Use the table below to determine the proper rating action to take on a DRC.
If the DRC submission …
Then …
contains sufficient evidence to render decisions on all contended issues
  • prepare a rating decision addressing all contended issues, and
  • route the claim to the authorization activity.
contains sufficient evidence to render decisions on some, but not all contended issues
  • prepare a partial rating decision in accordance with standard procedures
  • append the Decision Ready Claim – Partial Deferred special issue indicator to all contentions subject to deferral, and
  • route the claim to the authorization activity for additional processing and exclusion in accordance with M21-1, Part III, Subpart i, 3.D.3.b.
does not contain sufficient evidence to render decisions on any of the contended issues.
  • prepare a deferral in accordance with standard procedures
  • append the Decision Ready Claim – Deferred special issue indicator to at least one contention, and
  • route the claim to the development activity for additional processing and exclusion in accordance with M21-1, Part III, Subpart i, 3.D.3.b.
 

Important:  If review of the claim reveals that it should have been excluded from DRC processing, but the existing evidence supports completion of a full or partial rating decision, prepare the appropriate decision in accordance with the instructions provided in the table above.

 
References:  For more information on

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

The general standards for examination report sufficiency, as discussed in M21-1, Part III, Subpart iv, 3.D, are equally applicable to DRCs.  Because the timely processing of DRCs is of critical importance, the rating activity must, to the extent possible, utilize available methods of recourse to mitigate DBQs or examination reports that are insufficient for rating purposes or require additional clarification.  Such methods include
If, however, efforts to expeditiously resolve DBQ or contract examination insufficiencies are unsuccessful or impractical,
  • 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.
Reference:  For more information on returning examination reports, see M21-1, Part III, Subpart iv, 3.D.3.
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