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M21-1, Part III, Subpart iv, Chapter 3, Section A – Examination Requests Overview

Overview


In This Section

This section contains the following topics:
Topic
Topic Name
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1.  General Information on Examination Requests


Introduction

This topic contains general information about examination requests, including

Change Date

February 19, 2019

III.iv.3.A.1.a.  Who May Request an Examination

Development activity personnel have the primary responsibility for requesting examinations.
The rating activity may provide guidance as necessary and also has authority to request examinations.
In addition, a Veterans Service Center Manager (VSCM), Pension Management Center Manager (PMCM), or designee may authorize an examination in any case in which he/she believes it is warranted.

III.iv.3.A.1.b.  Definition: Appropriate Examination Facility

An appropriate examination facility is a Department of Veterans Affairs (VA) examination facility or contract examination provider that can complete the examination(s) required by the specific claim.
Regional offices (ROs) have the flexibility to request an examination from the VA medical center (VAMC) or designated contract provider closest to where the claimant lives or receives regular medical treatment.
References:  For more information on

III.iv.3.A.1.c.  Jurisdiction Over Examination Requests for Foreign Resident Claimants or Beneficiaries

Use the table below to determine which specific office or center has processing jurisdiction over an examination request involving a claim initiated by a foreign resident claimant or beneficiary.
If the claim at issue …
And the claimant or beneficiary …
Then the station of jurisdiction is the …
  • is for
    • compensation, or
    • both compensation and pension, and/or
  • involves a legacy appeal
resides in a foreign country or region
Pittsburgh RO.
  • is for
    • compensation
    • pension, or
    • both compensation and pension, and/or
  • involves a legacy appeal
is a VA-employee Veteran working in an office located in a foreign country or region
San Diego RO.
is for pension
resides in
  • Mexico
  • Central or South America, or
  • the Caribbean
St. Paul Pension Management Center (PMC).
resides in any foreign country or region other than those specified in the cell above
Philadelphia PMC.
Manila RO.
Note:  Once requested, field examinations for foreign resident beneficiaries become the ultimate responsibilities of the Indianapolis and Lincoln Fiduciary Hubs.
References:  For more information on the

III.iv.3.A.1.d.  Mandatory Use of the ERRA Tool

Claims processors must use the ERRA tool when requesting examinations in support of claims for service-connected (SC) compensation.  Although the ERRA tool has an option for pension, PMC use of the ERRA tool is optional to determine the closest VAMC to conduct an examination.  VA resources will be utilized to the fullest extent possible in performing examinations, but the use of contract/vendor resources is authorized whenever a VA examination facility has reached or exceeded maximum capacity.  When queried, the ERRA tool will identify the
  • 10 VA examination facilities nearest the ZIP code entered, and/or
  • contract examiner associated with the ZIP code entered, if applicable.
Compensation claims processors are required to associate the ERRA tool’s inquiry results with the claims folder.  When uploading the results to the Veterans Benefits Management System (VBMS), users should identify the document by entering the following information:
SUBJECT:  ERRA Results
CATEGORY – TYPE:  Medical Records- VAX & AMIE – Request Worksheets: VA Exam Worksheet
SOURCE:  VBMS
ASSOCIATE TO:  [End product for which examination is being requested].
Note:  Requests for non-Veterans Health Administration (VHA) examinations scheduled through a designated contractor are limited to the geographic area specified by the contractual agreement.
Exceptions:
  • The ERRA tool’s use is not required at Integrated Disability Evaluation System (IDES) or Benefits Delivery at Discharge (BDD) intake sites where existing agreements specify the provider(s) responsible for local IDES or BDD examinations.
  • The ERRA tool’s use is not required for requests involving
    • examination clarification
    • examination addenda
    • corrections to insufficient/inadequate examinations, or
    • acceptable clinical evidence (ACE) examinations completed by a VHA practitioner assigned to serve the RO.
References:  For more information on

III.iv.3.A.1.e.  When an Examination or Opinion Is Necessary

For more information on when a medical examination or opinion is necessary, see

III.iv.3.A.1.f.  Definition: General Medical Examination

The main purpose of a general medical examination is to screen all body systems and either
  • document normal findings, or
  • identify disabilities that are found or suspected.
Note:  The examiner must fully evaluate any disability that is found or suspected according to the applicable disability benefit questionnaires (DBQs).  Opinions addressing etiology and relationship to service are not typically provided by general medical examinations.
References:  For more information on

III.iv.3.A.1.g.Definition:  Specialty Examination

specialty examination focuses on the disabilities that are specifically at issue in the Veteran’s claim.  For example, if a Veteran claims that SC hypertension has worsened, an examination using the Hypertension Disability Benefits Questionnaireshould be requested.
Notes:
  • Specialty examinations generally do not address disorders that are not at issue in the claim, even if the disorders are found or suspected during the examination.
  • Specialty examinations may be (and usually are) performed by non-specialist clinicians, but in unusual cases, or as requested by a Board of Veterans’ Appeals (BVA) remand, it may be necessary for the specialty examination to be performed by a specialist.

III.iv.3.A.1.h.DefinitionSpecialistExamination

specialist examination is any examination that is conducted by a clinician who specializes in a particular field.
Notes:
  • All vision, hearing, dental, and psychiatric examinations must be conducted by a specialist.
  • In unusual cases, or as requested by a BVA remand, it may be necessary to request a specialist examination for other types of disabilities.
References:  For more information on

III.iv.3.A.1.i.  Veteran’s Legal Rights at an Examination

A Veteran has no legal right to
  • be accompanied by counsel during an examination, or
  • record an examination.

III.iv.3.A.1.j.  Contract Examination Exclusions

Examinations must not be requested from contract examiners under the circumstances specified in the Contract Exam Exclusions List.  Use discretion based on RO expertise and consultation with VA Central Office (CO) when determining whether a contract examination is warranted.
Important:  Annotate in the Compensation and Pension Record Interchange (CAPRI) REMARKS section when an examination cannot be performed by a contract examiner.
Example of required annotation:  Veteran has filed a claim for [excluded condition] – cannot submit to VBA contract exam provider.

2.  Examination Request Tools


Introduction

This topic contains information about tools used for requesting exams, including

Change Date

February 19, 2019

III.iv.3.A.2.a.Tools Used for Requesting Examinations

The examination request tools listed in this topic allow users to
  • identify the examining facility location closest to the Veteran
  • identify the DBQs for the claimed disabilities
  • build the examination request, and
  • enter the examination request to the VA or VA contract examination facility.

III.iv.3.A.2.b.ERRA Tool
Examination facilities designated to conduct exams are found in the ERRA tool.
The ERRA tool’s search results include information about the
  • application to use for submitting the examination request
  • facility routing location
  • the routing location and exam list comments
  • exam type details, and
  • approximate distance (from the ZIP code entered, including driving distance and estimated time).
Important:  This tool is designed as a guide to assist in the routing of C&P examination requests.  Its usage in the development of SC compensation claims is mandatory.  When routing an examination request, take into account any
  • claimant preferences, or
  • topography/driving concerns.
Notes:
  • The ERRA tool identifies whether a VA facility has capacity to complete examinations timely and suggests a contract provider/vendor be used if necessary.
  • Any justifiable deviation from the ERRA tool’s recommendations must be explained as a remark in the examination request’s body.
Important:  The ERRA tool’s data are refreshed daily.  Therefore, it is imperative to check ZIP codes daily, as the suitability of a claimant’s direction to a VA or contract examination facility may vary in response to demand and facility availability.  Routing location and exam type comments may also be subject to daily updates.
References:  For more information on the

III.iv.3.A.2.c.  Interpreting the ERRA Tool’s Results

Use the table below to interpret the ERRA tool’s results and determine the appropriate examination facility to which an examination request should be routed.
If …
Then route the examination request to the identified …
  • the ERRA tool’s results direct, Please route examination requests to the appropriate VA facility
  • the ERRA tool recommends sending all DBQs required to adjudicate the claim toVA
  • the claim involves one or more of the contract examination exclusions referenced in M21-1, Part III, Subpart iv, 3.A.1.j, or
  • the Veteran has expressed a preference that his/her examination be conducted at a VHA facility
VHA facility.
  • the claim does not involve one or more of the contract examination exclusions referenced in M21-1, Part III, Subpart iv, 3.A.1.j, and
  • the ERRA tool recommends sending at least one required DBQ to Vendor
contract examination vendor.
Note:  If, after reviewing the ERRA tool’s results, the proper VHA routing location is not clear, VA clinics may be contacted to request clarification.  Identify points of contact (POCs) by using the C&P Clinic POC List.
Reference:  For more information on the ERRA tool’s functionality, see the Disability Examination Program Management page.

III.iv.3.A.2.d.Index of DBQ/Exams by Disability Tool

The Index of DBQ/Exams by Disability tool allows users to search by a particular word, phrase, or diagnostic code (DC).  Input information in the SEARCH CRITERIA text box, and the tool will generate suggested DBQs, DCs, and relevant legacy examination worksheets.

III.iv.3.A.2.e.  ERB Tool

The primary purpose of the Exam Request Builder (ERB) tool is to standardize the format for exam requests.
Important:
  • Use of the ERB tool is mandatory when creating a(n) examination or medical opinion request in CAPRI for a compensation claim.
  • As with all automated tools, users should ensure the suggested language and examinations are adequate before inputting the exam requests.  This includes ensuring that the ADDITIONAL EXAM REMARKS field of the ERB is completed to include information needed by the examiner but not automatically generated by the tool.
Note:  Report any corrected information needed by e-mail toVAVBAWAS/CO/CAPRI.
Reference:  For more information on ERB functionality and training, see the ERB Training Guide.

III.iv.3.A.2.f.ERB-S Tool

The Simplified ERB (ERB-S) tool is a streamlined, less functionally comprehensive companion to the traditional ERB tool.  Like the latter, it is designed to promote the standardization of the language and formatting used to compose examination requests.
The use of the ERB-S tool in connection with the VBMS examination scheduling requests discussed in M21-1, Part III, Subpart iv, 3.A.10.b, is mandatory.
Reference:  For more information on the ERB-S tool, see the ERB Training Guide.

III.iv.3.A.2.g.Selecting the Appropriate Application for Entering Examination Requests

Use the table below to determine which application to use in preparing and submitting an examination
  • request, or
  • scheduling request.
If the necessary examination must be conducted by a …
Then submit the request using …
VHA facility
CAPRI.
contract examination provider/vendor
VBMS.
References:  For more information on

III.iv.3.A.2.h.  MandatoryEntry of Requestor’s Contact Information

Examination requests submitted through CAPRI must include the primary requestor’s contact information, to include, at a minimum, his/her
  • first and last name
  • e-mail address, and
  • 10-digit telephone number.
Notes:
  • The telephone number provided must be one that is accessible during any authorized periods of telework the requestor may perform.
  • Examination scheduling requests prepared and submitted through VBMSdo not require inclusion of the primary requestor’s contact information, as any subsequent clarification the contract examination provider/vendor deems necessary will be requested electronically.
Reference:  For more information on entering contact information in the ERB tool, see the ERB Training Guide.

3.  DBQs


Introduction

This topic contains information about DBQs, including

Change Date

April 24, 2017

III.iv.3.A.3.a.  Definition:  DBQs

Disability benefit questionnaires (DBQs) are documents used to
  • elicit medical information needed to make decisions on claims, and
  • provide a standardized report format for medical examinations and opinions.
DBQs are designed for internal use by both VHA and contract examiners.  The majority of DBQs are also approved for public use by private providers.
References:  For more information on

III.iv.3.A.3.b.  Use and Acceptance of DBQs for VA Examinations and Opinions

Use of DBQs to record the results of VA examinations and medical opinions is required.
However, if there is not a DBQ appropriate for a particular type of examination, or examination results or an opinion are submitted in another format, do not return the report as insufficient for rating purposes on that basis alone.
In lieu of a DBQ completed by a VA examiner or contract examiner, decision makers can accept
  • a DBQ, other medical report, or medical opinion completed by a VA or private health care provider, or
  • examination results not reported using a DBQ if the DBQ, examination, medical report, or opinion includes the findings and conclusions necessary to make the needed regulatory determinations on the issues, as described in 38 CFR 3.326 and 38 CFR 4.2.

References:  For more information on


4.  ACE Examinations


Introduction

This topic contains information on ACE examinations, including

Change Date

February 19, 2019

III.iv.3.A.4.a.Examinations Based on ACE

In lieu of scheduling an in-person examination, VHA and contract examiners generally (subject to some limitations) have the option to complete a DBQ based on review of existing paper and/or electronic medical evidence.  They may also conduct a telephone interview with the claimant.  Examinations based upon medical records and history without an in-person clinical examination or testing are known as ACE examinations or the ACE process.
Reference:  For more information on categories of examinations where the ACE process is prohibited, see M21-1, Part III, Subpart iv, 3.A.4.b.

III.iv.3.A.4.b.Categories of Examinations for Which the ACE Process Is Prohibited

The ACE process is not available in the following categories of examinations:
  • exams when necessary electronic medical records are not available for examiner review
  • IDES or the BDD pre-discharge program
  • exams required by BVA remands
  • general medical examinations
  • female sexual arousal disorder (FSAD) exams, and
  • mental disorder examinations, including medical opinions for claimed conditions secondary to an SC mental disorder.  This specifically applies tophysical secondary conditions related to SC mental disorders, such as bruxism.
Example:  A claimant who is SC for posttraumatic stress disorder (PTSD) due to military sexual trauma (MST) files a claim for FSAD secondary to PTSD.  Both the gynecological DBQ and PTSD medical opinions will require in-person examinations.
VBA may also specifically require an in-person examination, but in the interest of expediting the claims process, RO employees should not routinely exclude the use of the ACE process absent a compelling reason, particularly for
  • homeless Veterans, and/or
  • the following conditions:
    • hearing loss
    • tinnitus
    • cardiac conditions
    • amyotrophic lateral sclerosis (ALS), and
    • any terminal condition.
Reference:  For more information on the requirement to identify evidence for the examiner’s review, see M21-1, Part III, Subpart iv, 3.A.8.d.

III.iv.3.A.4.c.Examination Requests and ACE

When entering an examination request in CAPRI, ensure that the examination request
  • specifies that the ACE process is permitted, or
  • clearly states that the ACE process may not be used, and an in-person examination is required to complete the DBQ.
Notes:
  • VBA has updated the DBQ templates in CAPRI to include the ACE check boxes that contain the rationale for the use of ACE, requiring the clinician to identify the materials relied on when using ACE to prepare the DBQ.
  • The ERB contains the appropriate ACE language to include in the CAPRI examination request.
Reference:  For more information on requirements of ACE examinations, see M21-1, Part III, Subpart iv, 3.D.2.m.

5.  General Medical Examinations


Introduction

This topic contains information about general medical examinations, including

Change Date

August 4, 2017

III.iv.3.A.5.a.  When to Request a General Medical Examination

A general medical examination containing a full report of complaints and functional impairments is the preferred type of examination in cases concerning original compensation claims.
Request a general medical examination if
  • an original claim is received within one year of discharge, or
  • an intent to file (ITF) is received within one year of discharge, and a substantially complete application is received within one year of the ITF.
It may also be appropriate to request a general medical examination to obtain evidence in claims for
  • individual unemployability (IU)
  • service connection (SC) under 38 CFR 3.317, or
  • Veterans Pension.
Important:  When requesting a general medical examination to evaluate an original compensation claim received within one year of discharge, do not specify that the examiner also complete specialty examinations for each claimed disability.  However, consider whether specialist examinations are required by virtue of the specific claims.  This policy applies to examinations requested from VHA, as well as from private providers under VA contract.

Notes:

  • A fully sufficient general medical examination is usually of greater value than a number of uncorrelated specialty examinations.
  • If a subsequent claim is received within the initial year following discharge, but after a general medical examination has been conducted, do not order an additional general medical examination to evaluate the disability(ies) contended.
  • Request a general medical examination for Veterans Pension claims that require a permanent and total (P&T) disability determination when there is insufficient medical evidence to decide the claim.
References:  For more information on

III.iv.3.A.5.b.  When a General Medical Examination Is Not Necessary

It is not necessary to request a general medical examination if
  • an original claim for compensation is being rated many years after separation from service, or
  • a Veterans Pension claim that requires a P&T disability determination contains sufficient medical evidence to decide the claim.
Exception:  In claims for IU, SC under 38 CFR 3.317, or Veterans Pension filed more than one year after service, a general medical examination may be appropriate.  General medical DBQs exist for compensation, Veterans Pension, and Gulf War claims.
Reference:  For more information on acceptable medical evidence for pension rating purposes, M21-1, Part V, Subpart i, 2.2.f.

III.iv.3.A.5.c.  Conducting a General Medical Examination

When the medical examiner conducts the examination, he/she should confirm the existence of and evaluate
  • all disabilities listed in the examination request, and
  • any other disabilities the Veteran identifies during the examination.
Note:  Opinions addressing etiology and relationship to service are not typically provided by general medical examinations.
Reference:  For more information on DBQs used for general medical examinations, see the DBQ Switchboard.

III.iv.3.A.5.d.  Citing Medical Conditions to Be Examined

The examination request for a general medical examination should clearly cite the conditions or particular diagnoses that require attention.

6.  Specialist Examinations


Introduction

This topic contains information about specialist examinations, including

Change Date

March 12, 2018

III.iv.3.A.6.a.  Examinations Routinely Performed by Specialists

Some examinations are routinely performed by specialists.  These examinations include
  • hearing
  • vision
  • dental, and
  • psychiatric.

III.iv.3.A.6.b.  Who May Request Other Types of Specialist Examinations

In certain circumstances, specialist examinations for other conditions can be requested by
  • the development or rating activity
  • the medical examiner, or
  • BVA.

III.iv.3.A.6.c.  When to Request a Specialist Examination

Request a specialist examination only if it is considered essential for rating purposes.
Example:  A specialist examination may be requested
  • if an issue is unusually complex
  • if there are conflicting opinions or diagnoses that must be reconciled, or
  • based on a BVA remand.

III.iv.3.A.6.d.  Who Determines the Choice of Examiner

The choice of examiners is up to the VA medical facility conducting the examination, unless the BVA remand specifies that the examination must be conducted by a
  • Board-certified specialist in …, or
  • specialist who is Board qualified.
Some DBQs require a specialist to complete the examination.  The DBQ will identify specialist requirements in one of the first paragraphs on the form.
Note:  In the absence of a BVA remand, ROs may not designate qualification requirements for a specialist examination.

7.  Medical Opinions


Introduction

This topic contains information about medical opinions, including

Change Date

February 19, 2019

III.iv.3.A.7.a.  Who May Request a Medical Opinion

Development activity personnel and Military Services Coordinators (MSCs) who have completed training specified by CO are authorized to prepare basic or straightforward medical opinion requests without rating activity review.
The VSCM or PMCM will designate categories of opinions that are sufficiently basic or straightforward for preparation by the development activity.  However, medical opinion requests of a complex nature, including the following types, must be prepared by the rating activity:
  • compensation under 38 U.S.C. 1151
  • aggravation (including Allen aggravation)
  • diagnostic variation or conflicting medical evidence
  • questions of credibility of evidence presented to the examiner, or
  • any other matters specified by the VSCM or PMCM, such as
    • rare disorders/rare etiologies, or
    • sensitive or high priority claims.
Exception:  M21-1, Part III, Subpart i, 2.D.6.e, authorizes MSCs to independently prepare medical opinion requests regarding in-service aggravation of pre-service disabilities as they pertain to IDES claims.  If, however, MSCs recognize the need for other “complex” medical opinion types described above, they must refer them for review in accordance with guidance found in M21-1, Part III, Subpart i, 2.D.6.f.
Notes:
  • A VSCM or PMCM may authorize a medical opinion in any case in which he/she believes it is warranted.
  • Generally, any development activity employee or MSC may order an examination using the Hearing Loss and Tinnitus Disability Benefits Questionnaire, which includes certain routine etiology opinions.  However, in cases where (1) a separate medical opinion DBQ is required to solicit an opinion not included on the audiological DBQ, or (2) the type of opinion needed is consistent with one of the “complex” exceptions identified above, the opinion request should be prepared by the rating activity.
  • Most medical opinions regarding secondary causation are considered of sufficient simplicity to be requested by the development activity without rating oversight.  When, however, a Veteran contends entitlement on the basis of Allen aggravation, or a secondary claim is accompanied by competent medical evidence of the contended disability, such that aggravation may be implicated, follow the procedures in M21-1, Part III, Subpart iv, 3.A.7.b, to refer the claim for complex medical opinion review.
References:  For more information on

III.iv.3.A.7.b. Referring Claims for Complex Medical Opinion Review

The table below describes the responsibilities of the development and rating activities in ensuring that complex medical opinions are appropriately routed for preparation and entry.
Stage
Who Is Responsible
Description
1
Development Activity
  • Reviews the claim and all associated evidence.
  • Determines that a complex medical opinion, as discussed in M21-1, Part III, Subpart iv, 3.A.7.a, is warranted to resolve one or more contended issues.
2
Development Activity
Prevents the claim’s recall by the National Work Queue (NWQ) and routes it for the rating activity’s review by performing the following actions within the timelines established in the NWQ Phase 1 & 2 Playbook section entitled Disability Examination Requests:  RVSR Review for Examination:
  • appends the RVSR Examination special issue to at least one contention requiring complex medical opinion review
  • adds the Review Complex Exam tracked item, and
  • follows local procedures to ensure the claim’s assignment to the rating activity for review.
3
Rating Activity
  • Reviews the claim and all associated evidence to confirm that a medical opinion is warranted.
  • Reflects the medical opinion review’s completion by performing the following actions within the timelines established in the NWQ Phase 1 & 2 Playbooksection entitled Disability Examination Requests:  RVSR Review for Examination:
    • marks the Review Complex Exam tracked item as received, and
    • removes the RVSR Examination special issue indicator(s).
4
Rating Activity
Prepares and enters in the appropriate examination-requesting application a request for any medical opinion deemed necessary by the review.
Note:  The rating activity must also add appropriate VBMS tracked items for all examination and medical opinion requests submitted through CAPRI.
References:  For more information on

III.iv.3.A.7.c.  Completing Medical Opinion Requests Using the ERB Tool

As stated in M21-1, Part III, Subpart iv, 3.A.2.e, use of the ERB tool is mandatory in all CAPRI exam/medical opinion requests for compensation claims.
When requesting a medical opinion using the ERB tool, follow the steps in the table below.
Step
Action
1
Determine the appropriate examination facility.
Reference:  For assistance with locating the appropriate exam facility, see the ERRA tool.
2
  • Select the appropriate medical opinion template, and
  • populate all required fields in the ERB tool.
Reference:  For more information on appropriate selections and required fields, see the ERB User Guide.
3
Edit the generated medical opinion language to ensure it is case-specific and will result in an adequate opinion.
4
Create all required tracked items in the appropriate claims-processing system.
Reference:  For more information on creating a tracked item, see
5
Open CAPRI.
6
Select all required exams and medical opinion DBQs.
7
Paste the ERB exam request language into the REMARKS field.
References:  For more information on inputting a(n)

III.iv.3.A.7.d.Procedure for Identifying the Evidence in a Medical Opinion Request in the ERB Tool

Identify all pertinent evidence for the examiner to review in the ERB tool by completing the TAB screen.  For each tabbed item of evidence, populate the following fields:
  • ASSOCIATED EXAM
  • EVIDENCE
  • TAB NAME
  • DATE
  • DESCRIPTION, and
  • LOCATION.
ERB will generate language in the exam request based on the completion of these fields.
References:  For more information on

III.iv.3.A.7.e.Maintaining Objectivity in Medical Opinion Requests

When requesting medical opinions, RO employees should identify all relevant evidence for the examiner’s review, both favorable and unfavorable.  However, maintain objectivity when preparing medical opinion requests.
  • Use a neutral and unbiased tone.
  • Do not slant the facts.
  • Do not communicate that VA prefers one answer or outcome over another.
References:  For more information on
  • requesting a medical opinion in an impartial manner, see Douglas v. Shinseki, 23 Vet.App. 19, 24, 25-26 (2009), and
  • the attitude of rating officers, see 38 CFR 4.23.

III.iv.3.A.7.f.Medical Opinions Required For Remands

When requesting an opinion in compliance with BVA remand instructions,  specifically explain what information is needed.
Quoting the instructions from BVA on the medical opinion request may be helpful, but try to avoid legal jargon.
Important:  Do not simply refer the examiner to the claims folder containing the remand instructions.

III.iv.3.A.7.g. Instructions for Providing Medical Opinions – Claims Under 38 U.S.C. 1151

When requesting a medical opinion for a claim involving benefits under 38 U.S.C. 1151, use the ERB tool to generate the appropriate language.  Ensure the generated request asks the provider only the specific opinion(s) required by the facts of the case.
Medical opinions for conditions claimed under 38 U.S.C. 1151 may be completed at the same facility where the alleged incident happened, as long as there is no conflict of interest.
In general, VHA facilities will determine whether a conflict of interest exists once the request is received from the RO.  If applicable, the VHA facility will work with the RO to transfer the medical opinion request to another facility.
Note:  The medical opinion for a 38 U.S.C. 1151 claim does not have to be provided by a C&P certified clinician.  Any qualified clinician may be designated by the Chief of Staff of the medical facility to render the opinion.
Reference:  For more information on disability examinations involving claims under38 U.S.C. 1151, see the C&P Disability Examinations Procedure Guide.

III.iv.3.A.7.h.  Medical Opinions in the Hearing Loss and Tinnitus DBQ

The DBQ for hearing loss and tinnitus contains specific sections for etiology opinions.  However, examiners generally are not expected to provide unsolicited medical opinions, and in some types of hearing loss and tinnitus claims (such as claims for an increased evaluation), an opinion may not be routinely required.
In any case involving SC for hearing loss or tinnitus where an etiology opinion is required, follow the medical opinion procedures outlined in M21-1, Part III, Subpart iv, 3.A.7.d.
Exception:  If tinnitus is not claimed, but reported during the course of the exam, examiners will provide this etiology opinion even when not solicited.
Important:
  • Do not request a separate medical opinion DBQ unless a medical opinion that is not included on the Hearing Loss and Tinnitus Disability Benefits Questionnaire is needed.
  • The claims folder should be sent when an etiology opinion or other opinion is required.
References:  For more information on

III.iv.3.A.7.i.  Avoiding Asking for Legal Conclusions in Medical Opinion Requests

Do not request that a medical authority make conclusions of law, as this is a responsibility inherent to the rating activity.  To prevent confusion, avoid using the word “opinion” when asking the examiner a question about any issue that does not require a formal medical opinion.
Examples:
  • Do not request the medical authority to determine if there is loss of use of an extremity.  Instead, ask for a description of the remaining function of the extremity.
  • Do not ask the medical authority to determine if a particular disability is “service-connected” or “SC.”  Instead, identify the in-service injury, event, or illness, as well as current disability, and ask the examiner to provide an opinion as to whether or not the current disability was caused by or the result of the identified in-service injury, event, or illness.
  • Do not ask the medical authority to provide an opinion as to whether a Veteran is “unemployable” or “entitled to individual unemployability.”  Instead, in the Remarks section of the examination request, ask the examiner to comment on the Veteran’s ability to function in an occupational environment and to describe functional limitations.
Note:  The language generated upon selection of either of the following is legally sufficient to elicit the information necessary to adjudicate the issue of IU:
  • the IU block in the ERB tool, or
  • the EMPLOYMENT IMPACT ASSESSMENT REQUESTED? field in VBMS.
Reference:  For additional information on requesting examinations in IU claims, see M21-1, Part IV, Subpart ii, 2.F.2.d.

8.  Examiner Review of the Claims Folder


Introduction

This topic contains information about inputting examination requests, including

Change Date

February 19, 2019

III.iv.3.A.8.a.  Importance of Claims Folder Review

Folder review helps VA ensure that the examiner is given the fullest evidentiary picture possible.  The claims folder often contains a history of treatment of the disability at issue.  In order to provide an adequate basis for the findings and conclusions of an examination, the examiner needs access to that history.

References:  For more information on


III.iv.3.A.8.b.  Examinations Requiring Claims Folder Review

The examiner must review the claims folder for the following DBQs or claim types:
  • SC under 38 CFR 3.317
  • cold injury residuals
  • former prisoner of war (FPOW) protocol
  • Gulf War general medical
  • medical opinions, including etiology opinions in hearing loss and tinnitus claims
  • mental health exams
  • traumatic brain injury
  • BVA remands
  • 1151 Claims
  • ACE
  • environmental hazards in Iraq, Afghanistan, and other military installations, and
  • IDES claims.
Note:  For pension claims, sending the claims folder for review is not required.  However, medical records received with the claim relevant to the issue of whether the claimant is currently permanently and totally disabled due to non-service-connected causes must be uploaded into the eFolder.
References:  For more information on

III.iv.3.A.8.c.Requesting Examiner Review of the Claims Folder

To ensure VHA examination requests clearly indicate claims folder review is required, use the ERB tool’s
  • INTRODUCTION screen and C-FILE TYPE drop-down menu to indicate the format(s) of the claims folder, and
  • EXAM REQUEST ENTRY screen to select the REVIEW E-FOLDER/REVIEW CLAIMS FOLDER box.
Note:  Examination scheduling requests prepared using VBMS examination management functionality will generate the necessary language indicative of the need for folder review without further user intervention.
Important:  When requesting a VHA examination for a sensitive-level case, check the SENSITIVE box on the INTRODUCTION screen in the ERB tool.
Reference:  For more information on using the ERB tool, see the ERB User Guide.

III.iv.3.A.8.d. Requirement to Identify Relevant Evidence for the Examiner’s Review

RO employees must ensure that each piece of relevant evidence in the
Important:  All pertinent evidence (to include service treatment records (STRs) when their review is relevant to the underlying request), must be scanned into the eFolder prior to requesting any examination.  This includes any case for which a VHA examiner may complete an ACE examination.
Note:  Contract examiners do not have access to CAPRI.  Any VHA treatment report that needs to be reviewed must be uploaded to the eFolder or, if applicable, printed and filed in the paper claims folder.
References:  For more information on

III.iv.3.A.8.e.  Bookmarking Documents for Examiner Review

ROs must follow the standardized steps in the table below to bookmark documents in the claims folder for the examiner’s review.
Important:  While there are multiple bookmark types available in VBMS, when bookmarking evidence for an examiner’s review, ROs must use the Medical bookmark.
Step
Action
1
Locate the document in which you want to add a bookmark.
2
Click on the bookmark icon in the TOOLS column.  The BOOKMARKS prompt box appears.
Example:
screenshot of bookmark icon in the TOOLS column 
3
For each document in the eFolder that contains information to be reviewed by a VA examiner, select the Medical bookmark (heart-shaped icon).
Example:  The Veteran has claimed a right knee and left shoulder condition. A review of the STRs shows treatment for chondromalacia patella of the right knee and a rotator cuff tear of the left shoulder. An examiner will need to review the records.
4
In the expanded prompt box that appears, type the
  • tab name, and
  • contention(s) name.
Example:
In the contention box, type tab name and contention name
5
  • Click the Working Notes bookmark (note paper icon).
  • In the expanded prompt box list
    • the condition treated, and
    • the pages where treatment for the relevant conditionscan be found.
Example:
in the expanded prompt box, condition treated and pages

III.iv.3.A.8.f.  Annotating Documents for Examiner Review

ROs must follow the standardized steps in the table below to annotate documents in the claims folder for the examiner’s review.
Important:  There are many available styles of annotations.  For the purpose of promoting consistency, use only the Note annotation when tabbing evidence for the examiner’s review.
Step
Action
1
Locate the document you want to annotate.
2
Click on the annotator view icon next to the document name.
Example:
annotator view icon next to the document name
3
The document will open with an additional toolbar located at the top.  Click on the ADD AN ANNOTATION button.
Example:
add an annotation button
4
Hold down the left mouse button and drag the cursor over a small area where you want the annotation to appear. This action will bring up the text box that allows you to type out notes or details for consideration.
5
  • In the ANNOTATION text box, select Note.
  • In the text field, list the
    • tab name
    • relevant contentions, and
    • page numbers where treatment can be found in the document.
Example:
annotation text box, select note
6
Click the SAVE button in the toolbar.
Example:
image of SAVE button in the toolbar

9.  Inputting Examination Requests in CAPRI


Introduction

This topic contains information about inputting examination requests, including

Change Date

February 19, 2019

III.iv.3.A.9.a. Steps to Requesting an Examination in CAPRI

Follow the steps below when inputting an examination request in CAPRI.
Step
Action
1
Prior to requesting an examination, ensure all development actions sufficient to warrant the scheduling of an examination, as discussed inM21-1, Part I, 1.C.3.k, have been completed.
2
Ensure the evidence which substantiates the examination request meets the requirements under 38 CFR 3.159(c)(4), as discussed in M21-1, Part I, 1.C.3.
3
Identify the appropriate examination facility using the ERRA tool.
Reference:  For more information on
4
Identify all appropriate DBQs and/or medical opinions for all claimed contentions when an examination is warranted.
Reference:  For more information on DBQs, see the Index of DBQ/Exams by Disability tool.
5
Identify the exams which require a claims folder review by the examiner.
Reference:  For more information on claims folder review, see M21-1 Part III, Subpart iv, 3.A.8.
6
If folder review is required, ensure all necessary records are
  • uploaded into VBMS or in the paper claims folder, and
  • either
    • annotated or bookmarked in the eFolder, or
    • tabbed in the paper claims folder.
Reference:  For more information on bookmarking and annotating records, see M21-1, Part III, Subpart iv, 3.A.8.e and f.
7
Use the ERB tool to generate standardized text for the exam request.
Reference:  For more information on when use of the ERB tool is required, see M21-1, Part III, Subpart iv, 3.A.2.e.
8
Paste the ERB-generated text (to include entries to the ERB ADDITIONAL EXAM REMARKS field) into the COMMENTS field in CAPRI.
9
Complete all other required entries in CAPRI.
10
Is there an eFolder?
  • If yes,
    • upload the exam request into the eFolder, and
    • in the CATEGORY-TYPE field enter Medical Records – VAX & AMIE- Request Worksheets: VA 21-2507a Request for Physical Examination.
  • If no,
    • print the examination request, and
    • reverse file it in the center portion of the paper claims folder pending receipt of the completed examination report.
11
Create a tracked item for each examination requested.
Reference:  For more information on tracked items, see

III.iv.3.A.9.b.Completing a CAPRI Examination Request

After utilizing the ERB tool to create the exam request, fully complete all fields on the examination request screen in CAPRI, ensuring that those discussed below are appropriately populated.
  • The examination location selected should be the appropriate facility identified using the guidance in M21-1, Part III, Subpart iv, 3.A.2.ac.
  • Under LIST OF EXAMS, select all appropriate DBQs.  Do not check DBQs for specific body systems if requesting a general medical examination unless the claim also requires the performance of one or more specialist examination(s) discussed in M21-1, Part III, Subpart iv, 3.A.6.a.
  • Under the CLAIM TYPE field, select the relevant claim type.  Only one selection can be made.
  • Under the SPECIAL CONSIDERATIONS field, select any priority processing reason(s) that applies, including
    • AGE OF CLAIM
    • FDC
    • HOMELESS
    • NOT APPLICABLE
    • POW, and/or
    • TERMINAL.
  • For the LAST RATING EXAM DATE field, the default entry is N/A.  However, where there was a prior examination pertinent to the examination being entered, delete N/A and enter the date of the pertinent prior examination.
  • In REMARKS
    • transfer all text generated by the ERB tool (to include, as applicable, the date of receipt of an ITF and/or other information manually entered in the ADDITIONAL EXAM REMARKS field of the ERB)
    • do not use manual, regulation, or code citations
    • avoid using acronyms or VBA jargon
    • if the examinee is not the Veteran, indicate the examinee’s relationship to the Veteran along with the Veteran’s name and VA claim number, and
    • if the examinee is rated incompetent, note that fact.
Important:  Entering the ITF date is key to correct examination of claims pending at the time of a rating schedule change.  This will alert the examiner as to the need to provide historical DBQ information.
Reference:  For more information on completing a CAPRI examination request, see the CAPRI User’s Guide.

10.  Examination Scheduling Requests in VBMS


Introduction

Change Date
April 1, 2019

III.iv.3.A.10.a.  Entering an Examination Scheduling Request

As discussed in M21-1, Part III, Subpart iv, 3.A.2.g, and subject to the ERRA tool’s recommendations, requests for contract examinations must be prepared and submitted via VBMS.
Follow the steps outlined in the VMBS User Guide to prepare an examination scheduling request in VBMS.
Important:
  • Requests for VHA examinations must still be entered in CAPRI.
  • As is required with all automated tools, users must ensure that all VBMS system-generated language is legally and procedurally adequate before finalizing an examination scheduling request.  This includes ensuring that the SPECIAL INSTRUCTIONS field is completed so as to include information needed by the examiner, but not automatically generated.
  • Report any

Note:  VBMS examination scheduling request submission and acceptance will automate the creation of one tracked item for each contention identified in the request.  Manual entry of tracked items, as is directed in M21-1, Part III, Subpart iv, 3.A.9.a, for examination requests submitted through CAPRI, is not required for scheduling requests submitted through VBMS.

References:  For more information on

III.iv.3.A.10.b. Types of Requests Requiring Supplemental Language from the ERB-S Tool

Examination scheduling requests involving the components or claim attributes identified in the ERB-S Usage Matrix require supplementation with language generated using the ERB-S tool.
References:  For more information on

III.iv.3.A.10.c.  Definition:  Request for Clarification

In the context of VBMS examination management, a request for clarification is a communication from the examining facility, indicating that additional information about an examination request or individual contention is needed.  The request generates an Exam Request – Request for Clarification tracked item, which triggers a NWQ event and electronic routing for review and subsequent action by claims processing personnel.
When an examining facility generates a request for clarification, its receipt is reflected by a graphic indicator that appears next to the request in the Exam Scheduling Request Summary table view.
Example:
Image of the graphic indicator that appears next to the request in the Exam Scheduling Requuest Summary table view.
Reference:  For more information on responding to requests for clarification, see

III.iv.3.A.10.d. Responding to a Request for Clarification

The response to an examining provider’s request for clarification can be provided with a full edit to the previously-submitted examination scheduling request, or with a claim- or contention-specific narrative response that addresses specific questions posed, depending upon the nature of the information elicited and the processing stage at which the request is received.
Follow the steps in the table below to respond to a request for clarification initiated by an examining facility.
Step
Action
1
In the Exam Scheduling Request Summary table view, click the request for clarification indicator pictured in M21-1, Part III, Subpart iv, 3.A.10.c.  Doing so will produce a dialog box containing the body of the clarification request and a description of the information needed to resolve it.
2
  • From the message dialog box, click the RESPOND button, or
  • in the Exam Scheduling Request Summary table view, select Edit Clarification Response from the Actions drop-down menu.
3
Use the table below to determine how to satisfy the request for clarification.
If the request for clarification arises at the …
And the examination appointment(s) has/have …
Then …
scheduling request level
been scheduled
  • select the CLAIM INFORMATION tab, and
  • enter the information necessary to satisfy the clarification request in the CLARIFICATION REQUEST RESPONSE field.
Note:  Entry of separate clarification request responses on the CONTENTION INFORMATION tab is optional in this instance.
not been scheduled
determine whether the examination scheduling request requires edits or corrections to previous VBMS selections and examination request attributes.
  • If yes,
    • select the FULL EDIT button from the CLAIM INFORMATION tab
    • enter the information necessary to satisfy the clarification request in the CLARIFICATION REQUEST RESPONSE field on the CLAIM INFORMATION tab, and
    • use the
      • remainder of the CLAIM INFORMATION tab to make any and all necessary corrections to claim-level system entries and attributes, and
      • CONTENTION INFORMATION tab to make any and all necessary corrections to system entries associated with affected contentions.
  • If no,
    • select the NARRATIVE RESPONSE button from the CLAIM INFORMATION tab
    • enter the information necessary to satisfy the clarification request in the CLARIFICATION REQUEST RESPONSE field on the CLAIM INFORMATION tab, and
    • use the CONTENTION INFORMATION tab to add contention-specific clarification request responses if desired or appropriate.
contention level
been scheduled
  • select the CONTENTION INFORMATION tab, and
  • enter the information necessary to satisfy the clarification request in the CLARIFICATION REQUEST RESPONSE field associated with each affected contention.
Note:  Entry of a clarification request response on the CLAIM INFORMATION tab is optional in this instance.
not been scheduled
determine whether the examination scheduling request requires edits or corrections to previous VBMS selections and examination request attributes.
  • If yes,
    • select the FULL EDIT button from the CLAIM INFORMATION tab
    • enter the information necessary to satisfy the clarification request in the CLARIFICATION REQUEST RESPONSE field on the CLAIM INFORMATION tab, and
    • use the
      • CLAIM INFORMATION tab to make any and all necessary corrections to claim-level system entries and attributes, and
      • CONTENTION INFORMATION tab to make any and all necessary corrections to system entries associated with affected contentions.
  • If no,
    • select the NARRATIVE RESPONSE button from the CONTENTION INFORMATION tab, and
    • enter the information necessary to satisfy the clarification request in the CLARIFICATION REQUEST RESPONSE field associated with each affected contention.
4
Click the PREVIEW tab to preview the response to the request for clarification and proofread it for accuracy and completeness prior to submission.
5
Click the SUBMIT REQUEST button to finalize and transmit the response.
Reference:  For more information on requests for clarification, see
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