Overview
In This Section |
This section contains the following topics:
|
Introduction |
This topic contains general information on requesting PMRs, including
|
Change Date |
September 14, 2018
|
III.iii.1.D.1.a. Authorization Required by PHPs |
Treatment received from private healthcare providers (PHPs) is often identified as relevant to a claim. The PHP who holds these records will not release the treatment records without a Health Insurance Portability and Accountability Act (HIPAA) compliant authorization statement signed by the individual who is the subject of the information.
When the Department of Veterans Affairs (VA) is attempting to secure the private medical records (PMR) on the claimant’s behalf, the claimant should provide an authorization form that is acceptable to the records holder by using the following
Note: If VA Forms 21-4142 and 21-4142a or other required PHP authorization forms are not of record, send a request to the claimant, fiduciary, or next of kin, as appropriate.
References: For more information on
|
III.iii.1.D.1.b. VA Forms 21-4142 and 21-4142a |
VA Forms 21-4142 and 21-4142a are used in conjunction with each other and both forms must be completed in order to obtain a claimant’s PMRs from the identified PHP or Vet Center. The differences between these two forms are
If the claimant submits a version of VA Form 21-4142 dated before June 2014, the form will be accepted and used to develop for the claimant’s PMRs. In these cases, VA will not require development for current versions of VA Forms 21-4142and 21-4142a.
Notes:
References: For more information on
|
III.iii.1.D.1.c. Expiration of Signed and Dated VA Forms 21-4142 |
The privacy rule requires an authorization form to contain an expiration date or an expiration event that relates to the individual or the purpose of the disclosure. The completed VA Form 21-4142 will expire
Important:
|
III.iii.1.D.1.d. Development Actions Related to VA Forms 21-4142 and 21-4142a |
Follow the instructions in the table below to determine what development actions to take when requesting authorization to obtain treatment records from a PHP or a Vet Center.
Notes:
References: For more information on
|
III.iii.1.D.1.e. Procedure for Requesting Medical Records for Non-PMR Program ROs |
Follow the steps in the table below to request medical records from sources other than VA.
Important: These procedures apply only to regional offices (ROs) not participating in the PMR Program.
|
III.iii.1.D.1.f.Rejected Requests for Non-PMR Program ROs |
Follow the instructions in the table below if a records custodian refuses to give VA a copy of a claimant’s medical records because
Important: These procedures apply only to ROs not participating in the PMR Program.
|
III.iii.1.D.1.g. Claimant Notification When PMRs Are Unavailable |
As noted in M21-1, Part I, 1.C.5.a, VA must notify the claimant of its inability to obtain relevant PMRs the claimant identified. This requirement is met by the rating activity when it enters the following text in the Evidence section of the rating decision: Private medical records requested from [name of provider], but not received. (Claimants receive a copy of the rating decision with the corresponding decision notice.)
Important: The rating activity must enter the referenced text in the rating decision regardless of whether the records were requested by the PMR Program contractor or an RO.
References: For more information on
|
III.iii.1.D.1.h. General Information About HIPAA |
The HIPAA Privacy Rule protects all “individually identifiable health information”held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. The Privacy Rule calls this information protected health information (PHI).
PHI includes the
The Privacy Rule limits the circumstances in which an individual’s PHI may be used or disclosed by covered entities. A covered entity may not use or disclose PHI, except when the individual who is the subject of the information (or the individual’s personal representative) authorizes in writing the release of the PHI.
Note: Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security numbers).
|
III.iii.1.D.1.i. HIPAA’s Impact on VBA |
In Advisory Opinion ADV 3-2003, the Office of General Council determined that records in compensation and pension claims folders are not subject to HIPAA privacy rules. Its conclusion is based on the fact that the Veterans Benefits Administration (VBA) does not meet the definition of a “covered entity,” as described in 45 CFR 160.103.
However, the HIPAA privacy rules do affect VA Forms 21-4142 and 21-4142a.
References: For more information on
|
III.iii.1.D.1.j. Covered Entities Under HIPAA |
The entities listed below are covered entities under HIPAA.
|
Introduction |
This topic contains information on the PMR retrieval program, including
|
Change Date |
September 14, 2018
|
III.iii.1.D.2.a. Purpose of PMR Program |
The purpose of this program is to have a PMR contractor obtain PMRs by contacting PHPs and requesting the treatment records identified on the medical release form(s).
Obtaining PMRs on behalf of a claimant begins when the claimant, fiduciary, or next of kin provides VA with
Note: For purposes of this section, DOMA Technologies (DOMA) is operating as a PMR Retrieval Center in support of the PMR Program.
Reference: For more information on the PMR Program, see the
|
III.iii.1.D.2.b. PMR Contractor Responsibilities |
The PMR Program was deployed nationally in November 2014, and was designed to work in collaboration with ROs to improve the receipt of medical records in support of Veterans’ or dependents of Veterans’ claims.
The PMR contractor will process the medical release regardless of the benefit types from
Incoming medical release requests received through the Centralized Mail (CM) program will be automatically routed to the PMR contractor for processing. Upon receipt, the PMR contractor will review the medical release forms to determine if the forms meet the processing requirements.
The PMR contractor will develop any PMR release forms with sufficient information. The PMR contractor will also develop the PMR release form, if they can augment the form by pulling the missing information from Share.
Notes:
Exception: The San Juan and Manila ROs are outside the scope of the PMR Program, so the PMR contractor will not obtain any PMRs on their behalf.
References: For more information on
|
III.iii.1.D.2.c. Medical Releases Not Processed by PMR Contractor |
There are several circumstances when the PMR contractor will not process the medical release. The contractor will create a Reject Notice which will be transmitted to the claims folder through the CM program.
Most commonly, this will occur when
Important: The RO employees who develop claims are required to review the rejected medical releases to ensure the medical release is truly incomplete and does not provide sufficient information that allows the PMR contractor the ability to process the form.
References: For more information on how to handle medical release forms that are
|
III.iii.1.D.2.d. RO Leadership Responsibilities |
RO leadership is responsible for ensuring designated PMR Super Users complete the required training prior to accessing the PMR contractor’s online portal application. The RO reserves the right to designate or replace assigned PMR Super Users.
The RO must provide the PMR contractor and the PMR Program Management Office (PMO) staff with the contact information listed below for its designated PMR Super User and back-up Super User
Important: The PMR Super Users’ contact information must be current at all times and should be reported to the contractor’s help desk atsupport@domaonline.com. This includes a change to update the RO’s Super User, as necessary.
The PMR contractor will provide PMR Super Users with the PMR Portal internet address, user name, and temporary password via e-mail once the PMR training is completed in TMS.
Note: The PMR contractor will respond within 24 hours of reported changes made through the contractor’s help desk e-mail.
Reference: For more information on the PMR Program, see the document on thePMR Retrieval Program home page titled PMR Program SOP.
|
III.iii.1.D.2.e. PMR Super Users |
The ROs will identify PMR Super Users who will support the PMR contractor processing activity by
References: For more information on the
|
III.iii.1.D.2.f. Uploading VA Forms 21-4142 and 21-4142a to the PMR Vault |
There are instances in which the PMR requests will not be received through the CM program. These include VA Forms 21-4142 and 21-4142a received through Veterans On-Line Application Direct Connect and eBenefits uploads.
In these instances, the ROs will be responsible for uploading the forms to the PMR Vault for processing by the PMR contractor.
The PMR Vault is a secure online website that
Note: Access to the PMR Vault is gained by using a unique RO passcode provided to each RO individually from the PMR PMO.
References: For more information on
|
III.iii.1.D.2.g. PMR VBMS Tracked Item |
To ensure adequate tracking of development actions completed by the contractor under the PMR Program, RO employees must manually create a tracked item in VBMS when a PMR request is pending.
RO employees must follow the steps in the table below
Reference: For more information on creating a tracked item in VBMS, see theVBMS User Guide.
|
III.iii.1.D.2.h.Rejected Request From a PHP |
A PHP who provides a service in a private setting may impose various protections with respect to their health information, including important controls over how their health information is released to requesting parties.
If the PMR contractor creates a Reject Notice because the PHP declines to give VA a copy of the claimant’s PMRs, follow the instructions in the table shown below.
|
10-27-17_Key-Changes_M21-1III_iii_1_SecD.docx | May 12, 2019 | 537 KB |
9-12-17_Key-Changes_M21-1III_iii_1_SecD.doc | May 12, 2019 | 218 KB |
9-12-17_Key-Changes_M21-1III_iii_1_SecD-1.doc | May 12, 2019 | 218 KB |
7-14-16_Key-Changes_M21-1III_iii_1_SecD.docx | May 12, 2019 | 117 KB |
4-4-16_Key-Changes_M21-1III_iii_1_SecD.docx | May 12, 2019 | 118 KB |
1-26-16_Key_Changes_M21-1III_iii_1_SecD.docx | May 12, 2019 | 113 KB |
in Chapter 1 Rules and Process, Part III General Claims Process, Subpart iii General Development and Dependency Issues
Related Articles