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M21-1, Part III, Subpart iii, Chapter 1, Section D – Requesting Evidence From Private Healthcare Providers (PHPs)

Overview

In This Section
  
This section contains the following topics:
Topic
Topic Name
1
2
1.  Requesting PMRs

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
  • VA Form 21-4142 gives authorization to PHP’s/Vet Centers to disclose information to VA, and
  • VA Form 21-4142a provides the PHP’s/Vet Center’s contact information.
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:
  • A VA Form 21-4142a is generally for VA internal use only.  However, Vet Centers or PHPs will occasionally request a copy of VA Form 21-4142a to identify treatment dates and other information not contained on VA Form 21-4142.
  • Releasing information about other PHPs is prohibited under HIPAA privacy rules; therefore, a VA Form 21-4142a with information about multiple PHPs must be redacted before it is sent to the treatment facility to obtain records.
  • Some PHPs may require the completion of a specialized authorization form before they will release the claimant’s PMRs.
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
  • one year from the date the claimant signs it, or
  • 180 days from the date the claimant signs it for versions of the form datedbefore June 2014.
Important:
  • VA Form 21-4142 must be signed and dated to be considered complete. Request a completed form from the claimant if the signature or date is missing.
  • If VA Form 21-4142 expires before VA can obtain the PHP’s/Vet Center records, request the Veteran provide VA with an updated VA Form 21-4142.  Do not request the Veteran complete an additional VA Form 21-4142a.

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.
If …
Then …
a complete VA Form 21-4142 is of record but a complete VA Form 21-4142a is not
  • develop to the claimant by telephone and record any PHP/Vet Center source information provided by the claimant on VA Form 21-4142a, or
  • if unable to reach the claimant via telephone, generate a development letter to the claimant requesting the return of a completed VA Form 21-4142a.
Important:  If developing for a release for Vet Center records, users must alter the generated text to inform the claimant the form is needed for Vet Center records.
a complete VA Form 21-4142a is of record but a complete VA Form 21-4142 is not
generate a development letter to the claimant requesting the return of a completed VA Form 21-4142.
Important:  If developing for a release for Vet Center records, users must alter the generated text to inform the claimant the form is needed for Vet Center records.
follow the instructions in M21-1, Part III, Subpart iii, 1.D.2.f for development of the claimant’s PMRs.
Exception:  Claims filed with the San Juan and Manila ROs should be processed as noted in the instructions in M21-1, Part III, Subpart iii, 1.D.1.e.
both VA Forms 21-4142and 21-4142a are either incomplete or not of record
generate a development letter to the claimant to complete, sign, date and return both forms.
Important:  If developing for a release for Vet Center records, users must alter the generated text to inform the claimant of the form needed for Vet Center records.
Notes:
  • If PHP source information is obtained from the claimant by telephone and recorded on VA Form 21-4142a, follow the instructions in M21-1, Part III, Subpart iii, 1.D.2.f for development of the claimant’s PMRs.
  • If the claimant fails to respond to the request for additional information, no further action to request the claimant’s PMRs is required.
  • The PMR Program is utilizing a contractor to provide development assistance by attempting to retrieve all PMRs that Veterans and their dependents have identified on the VA Form 21-4142a.
  • The PMR contractor will not request Vet Center records.
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.
Step
Action
1
  • Prepare and send a request for any medical records that
    • the claimant has identified, and
    • are relevant to his/her claim.
  • Attach to the original letter
    • VA Form 21-4142, signed by the claimant, and
    • an extra copy of the letter.
  • Advise the custodian of the records that VA cannot pay for records it requests.
Note:  When creating the letter in
  • Modern Awards Processing- Development (MAP-D), select the Private Treatment Records 15-Day Notification – Providerparagraph, or
  • the Veterans Benefits Management System (VBMS), select the Notice – VA Is Contacting Provider for Med Rcds letter.
2
Notify the claimant that
  • VA made the request, and
  • he/she is ultimately responsible for ensuring VA receives the records.
3
Establish a suspense date that expires 15 days from the current date.
4
Did VA receive the records it requested within 15 days?
  • If yes,
    • route the claim to the rating activity after all other development is complete, and
    • proceed no further.
  • If no, make one attempt to request the records from their custodian by telephone.
5
Was telephone contact made with the custodian of the records?
  • If yes,
    • document the telephone call on VA Form 27-0820, Report of General Information, including the
      • name of the individual contacted
      • date and time of the call
      • reason for the call, and
      • substance of the conversation, and
    • allow the individual 15 days to respond, unlesshe/she indicates the records
      • are unavailable
      • do not exist, or
      • cannot be obtained without a fee.
  • If no,
    • document the attempt to contact the custodian as a note in either MAP-D or VBMS (whichever application is being used to process the claim), including the
      • date and time of the call, and
      • reason for the call
    • send a follow-up letter to the custodian, and
    • allow 15 days for a response.
Note:  Whenever appropriate, ask the custodian to fax the requested records to VA.  (Ensure the fax machine is in a secure location, since the faxed documents may contain personally identifiable information.)
References:  For more information about using
6
After the 15-day response period ends, route the claim to the rating activity (if all other development is complete), regardless of whether or not the custodian of the records responded.
Exceptions:
  • Return to Step 1 if a negative response from a records custodian suggests VA could obtain the records it is seeking by submitting another request to the same custodian or to a different one.
  • Follow the instructions in M21-1, Part III, Subpart iii, 1.D.1.fif a records custodian rejects VA’s request because one of the following is required:

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
  • the VA Form 21-4142 VA included in its initial request did not have an original signature, or
  • the records custodian requires the claimant to complete a special authorization form (other than VA Form 21-4142).
Important:  These procedures apply only to ROs not participating in the PMR Program.
If …
Then …
the records custodian requires the claimant to complete a special authorization form
  • prepare a letter containing the paragraphs labeled Private provider requires spec. release
  • change the time limit for responding to the letter to 30 days
  • send the letter to the claimant, along with the special authorization form (if available), and
  • allow 30 days for a response.
Notes:
  • If the claimant fails to respond to the request for medical records within 30 days, route his/her claim to the rating activity after all other development is complete.
  • If the claimant returns the special authorization form to VA instead of obtaining the records him/herself, follow the instructions in M21-1, Part III, Subpart iii, 1.D.1.e.
  • If the medical care provider requires an original signature on the form, and VA is processing the corresponding claim in a paperless environment, the claimant must
    • send the form directly to the medical care provider, or
    • obtain the records and submit them to VA.
  • the medical care provider requires a VA Form 21-4142with an original signature, and
  • the VA Form 21-4142 in the claims folder has an original signature
  • make a photocopy of the VA Form 21-4142 (with the original signature) and retain it in the claims folder
  • send the medical care provider a letter containing the
    • paragraphs labeled
      • in MAP-D: Private treatment records – 15-day notification – Provider, or
      • in VBMS: Initial Private 3rd Party Letter, and
    • VA Form 21-4142(with the original signature)
  • notify the claimant of the action taken, and
  • allow 15 days for a response.

Note:  After the response period ends and all other development is complete, route the claim to the rating activity, regardless of whether or not the medical care provider responded.
the medical care provider requires a VA Form 21-4142 with an original signature, and
  • the VA Form 21-4142 in the claims folder does not have an original signature, or
  • the claimant has an electronic claims folder (eFolder) instead of a claims folder
  • prepare a letter containing the paragraphs labeled Private treatment records – 15-day notification – Claimant
  • change the time limit for responding to the letter to 30 days
  • send the letter to the claimant, and
  • allow 30 days for a response.
Notes:
  • If the claimant fails to respond to the request for medical records within 30 days, route his/her claim to the rating activity after all other development is complete.
  • If the claimant returns VA Form 21-4142 to VA with an original signature instead of obtaining the records him/herself, follow the instructions in M21-1, Part III, Subpart iii, 1.D.1.e.
  • If VA is processing the corresponding claim in a paperless environment, theclaimant must
    • send the form directly to the medical care provider, or
    • obtain the records and submit them to VA.

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
  • individual’s past and present physical or mental health condition(s), and
  • health care provided to the individual.
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.
Covered Entity
Definition
Health Plan
Provides or pays the cost of medical care.
Health Care Clearinghouse
A public or private entity that translates health information from one format to another.
Health Care Provider
  • A provider of services as defined in 42 U.S.C.1395x(u). This includes hospitals, critical access hospitals, skilled nursing facilities, comprehensive outpatient rehabilitation facilities, home health agencies, and hospice programs.
  • A provider of medical or health services as defined in 42 U.S.C. 1395x(s). This includes physicians’ services, office-type services, and supplies furnished incident to a physician’s professional service, such as diagnostic tests, therapy, dressings, casts, durable medical equipment, ambulance service, prosthetic devices, vaccines, nurse anesthetist service, mammography, and other types of screening. This also includes anyone else who furnishes, bills, or is paid for health care in the normal course of business.

2.  PMR Retrieval Program

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
  • ROs
  • pension management centers, and
  • decision review operations centers.
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:
  • If the PMR contractor sends a third-party notice to an incorrect address for the PHP, the PMR Super User should open a help desk ticket to advise the PMR contractor of the error.
  • The PMR contractor will not notify the Veteran on negative responses received from PHPs.  Consequently, ROs must follow the notification procedures outlined in M21-1, Part III, Subpart iii, 1.D.1.g.
  • If the PMR contractor receives an undeliverable notice from the address of record, they will close out the medical release request unless they have a forwarding address provided by the U.S. Postal Service.
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
  • the medical release is
    • illegible
    • a duplicate medical release (previously submitted)
    • identifying treatment at a
      • VA medical center
      • Vet Center
      • military treatment facility, or
      • Federal facility
    • improperly signed
    • missing PHP information that cannot be obtained by PMR contractor
    • missing a signature and/or signature date
    • identifying a foreign provider
    • for a non-medical record request
    • expired, or
    • displaying claimant with a foreign address
  • PHP declines request for PMRs
  • a request is cancelled, or
  • a death certificate is needed.
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
  • name
  • phone number
  • e-mail address
  • date of completion of PMR training in VA’s Talent Management System (TMS), and
  • RO name and number.
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
  • serving as their RO’s point of contact
  • monitoring the PMR workflow process locally
  • uploading medical release requests which have not been previously submitted to the PMR contractor
  • regularly logging into the PMR Program portal and completing the PMR Portal Checklist, which is found on the PMR Retrieval Program home page)
  • reviewing PMR metrics available in the PMR Portal
  • communicating the provisions of the PMR Program to employees who are designated to develop claims
  • communicating any challenges to the PMR PMO staff, and
  • attending PMR conference calls.
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
  • receives incoming medical release requests from the ROs which did not go through the CM automated process, and
  • serves as an electronic method for PHPs to upload PMR requests to the PMR contractor for processing.
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
  • prior to placing a case in ready for decision (RFD) status, or
  • before making a decision on any case placed in RFD status automatically.
Step
Action
1
Review the VBMS electronic contents to verify a medical release request is pending in the PMR Program.  In these cases, the eFolder will contain the
  • third party notice sent to the claimant by the PMR contractor, and
  • medical release request forms bearing the watermark PMR Program Referred.
Example:
Bottom of 21-4142a PMR program referred
Top of 21-4142
Note:  If it is determined that medical release requests were sent and they are now rejected or returned to VA, then follow the steps noted in M21-1, Part III, Subpart iii, 1.D.2.h.
2
If a request is still pending in the PMR Program, add a tracked item to VBMS.
  • On the CLAIM DETAILS screen, click the
    • TRACKED ITEMS tab, and then
    • ADD TRACKED ITEM button.
  • From the ADD TRACKED ITEMS screen
    • choose Custom Tracked Item from the CHOOSE A CATEGORY drop-down men
    • select the Custom Tracked Item development action, and
    • click the ADD TO LIST button.
3
Click the ADD button to finalize the tracked item after entering the following data:
  • enter DOMA pending – [provider name] in the ITEM REQUESTED field, and
  • enter the amount of days remaining from the 35-day suspense period following the initial PMR request.
Example:  If establishing the tracked item 10 days after the PMR request, input 25 in the TRACKED ITEM SUSPENSE field.
Note:  In the event the PHP does not respond, the PMR contractor will start the close-out process 31 days after the initial request by completingVA Form 27-0820, documenting attempts made to receive the records.  Creating a suspense date 35 days after the initial PMR request will enable the PMR contractor to route VA Form 27-0820 through internal quality controls and then for electronic ingestion/transfer to VBMS.
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.
If …
Then …
the PHP requires a VA Form 21-4142 with an original signature
  • prepare a letter in MAP-D or VBMS informing the claimant that he/she must
    • send the completed form with an original signature to the PHP, or
    • obtain the PMRs and submit them to VA
  • change the time limit for responding to the letter to 30 days
  • send the letter to the claimant, and
  • allow 30 days for a response.
the PHP requires the claimant to complete a special authorization form
  • prepare a letter in MAP-D or VBMS containing the development action labeled Private provider requires spec. release
  • change the time limit for responding to the letter to 30 days
  • send the letter to the claimant, along with the special authorization form (if available), and
  • allow 30 days for a response.
Note:  If the claimant returns the special authorization form to VA instead of obtaining the records him/herself, follow the instructions inM21-1, Part III, Subpart iii, 1.D.2.f.
Important:
  • If the claimant fails to respond to the request for PMRs within 30 days, route his/her claim to the rating activity when all other development is complete.
  • VA processes claims in an electronic environment, which requires a VA Form 21-4142 with an original signature to be scanned into the claims folder through CM. A VA Form 21-4142 with an original signature will notbe returned to the ROs.
Reference:  For more information on Reject Notices created by the PMR contractor, see M21-1, Part III, Subpart iii, 1.D.2.c.
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in Chapter 1 Rules and Process, Part III General Claims Process, Subpart iii General Development and Dependency Issues
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