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M21-1, Part III, Subpart v, Chapter 2, Section A – Decision Authorization

Overview


In This Section

This section contains the following topics:
Topic
Topic Name
1
2
3
4
5

 

1.  General Claim Considerations


Introduction

This topic contains general information about awards and denials of claims, including

Change Date

February 19, 2019

III.v.2.A.1.a.  Final Stage in Adjudicating a Claim

The final stage in adjudicating a claim, after all relevant evidence (to include Federal tax information (FTI)) has been collected and reviewed, and a rating decision prepared (if necessary), is to
  • award benefits when entitlement exists, and/or
  • deny benefits when entitlement does not exist.

Reference:  For more information about FTI, see M21-1, Part X, 9.


III.v.2.A.1.b.  Responsibility for Awarding or Denying Benefits

A single claim typically involves multiple issues the Department of Veterans Affairs (VA) must resolve.  The authorization activity is responsible for ensuring VA makes a decision to award or deny entitlement to benefits for each issue a claimant raises.
The authorization activity must
  • address all issues based on
    • eligibility criteria, and
    • any rating decision, and
  • inform the claimant of the decision on each issue.

Notes:

  • Many adjudication actions will be a combination of awarding and denying entitlement.
  • The end product (EP) controlling the claim must remain pending until VA resolves each of the issues the claimant raised in that claim.

III.v.2.A.1.c.  Requirement to Reduce or Withhold Payments

Even if VA determines a claimant is eligible for monetary benefits, to include disability compensation for one or more service-connected (SC) disability(ies), VA may have to reduce or withhold payments if
  • the claimant is a Veteran who
    • received separation benefits, or
    • is receiving military retired pay (MRP), or
  • VA has proposed to rate the claimant incompetent.
References:  For more information about reducing or withholding payments based on

III.v.2.A.1.d.  Reviewing a Supplemental Claim

For a supplemental claim, the process for requesting information from a claimant and other sources is the same as it is for an initial claim.
If basic eligibility criteria (such as Veteran status, or wartime and minimum active duty service requirements for pension claims) are met, the rating activity must review the following types of supplemental claims:
  • claims for benefits involving (a) specific disability(ies), and/or
  • claims in which benefits were previously discontinued due to a change in special eligibility, such as no longer being
    • permanently and totally disabled, or
    • in need of aid and attendance (A&A).
Important:  The rating activity does not need to review pension claims to make a disability determination when income or net worth bar pension entitlement.
Reference:  For more information about supplemental claims, see M21-1, Part III, Subpart ii, 2.D.

 

2.  General Information on Processing Decisions


Introduction

This topic contains general information on processing decisions, including

Change Date

July 13, 2018

III.v.2.A.2.a.  Responsibility for Processing Rating Decisions

Once Veterans service organizations (VSOs) have been given an opportunity to review completed rating decisions for which they hold valid power of attorney, the rating activity must route the rating decisions directly to the authorization activity.
The authorization activity is responsible for processing rating decisions.
Reference:  For more information about VSO review of completed rating decisions, see M21-1, Part I, 3.B.3.

III.v.2.A.2.b.  Effective Date of Payment Under 38 CFR 3.31

It is important to understand the difference between the effective date of paymentand the effective date of entitlement.
Under 38 CFR 3.31, VA may not pay monetary benefits based on an original, supplemental, or increased award of compensation, pension, or Dependency and Indemnity Compensation (DIC) for any period prior to the first day of the calendar month following the month in which the beneficiary became entitled to the benefit.
Example:
Scenario:  The rating activity assigns an increased disability rating to a Veteran’s SC back disorder effective April 21, 2012.  (This represents the effective date of entitlement.)
 Result:  The effective date of the corresponding increase in the Veteran’s compensation is May 1, 2012.  (This represents the effective date of payment.)
Exception:  Effective October 1, 2011, Section 605 of Public Law 111-275amended 38 U.S.C. 5111 to allow VA to pay disability compensation from the date of entitlement to said benefit to any Veteran who retires or separates from active duty due to a catastrophic disability.  For VA purposes, “catastrophic disability” means a permanent, severely disabling injury, disorder, or disease that compromises the ability of the Veteran to carry out the activities of daily living to such a degree that he/she requires
  • personal or mechanical assistance to leave home or bed, or
  • constant supervision to avoid physical harm to self or others.

III.v.2.A.2.c.  Award Processing Responsibilities

The table below describes who is responsible for specific actions during the award process.
Who Is Responsible
Actions
Veterans Service Representative (VSR)
  • Conduct a cursory review of the rating decision, to include the code sheet, in an attempt to identify any obvious errors, such as failure to consider entitlement to Chapter 35 benefits when a total evaluation is granted and no future exam is required.
  • Enter additional data pertaining to the decision into the claims-processing system, as applicable.
  • Generate an award.
  • Ensure, as applicable, that the award document fully reflects all new and/or increased entitlements implemented by the associated rating decision and/or authorization determination(s).
  • Prepare a decision notice for the claimant.
  • For pension and Parents DIC cases only:  Ensure documentation of calculations made to determine the rate of benefits (such as calculations of medical expenses, net worth, and waived overpayments) are included in the eFolder.
  • Route the award to a Senior VSR (SVSR).
Notes:
  • If the decision notice contains FTI, follow the instructions in M21-1, Part III, Subpart v, 2.B.3.
  • The successful generation of adjusted payment rates from the earliest implicated effective date – for awards converted from the Benefits Delivery Network – may require the entry of an appropriate control date in the ONLY GENERATE NEW AWARD LINES FROM field on the claims-processing system’s RECORD DECISIONS screen.
  • VSRs may not make entries on the RATING screen in the claims-processing system. VSRs should
    • access these screens only to validate data contained in individual rating decisions, and
    • notify the rating activity if they identify any inconsistencies.
  • The processing of a decision is commonly referred to as an “award” action, regardless of whether the decision
    • constitutes a grant or denial of benefits, or
    • results in an adjustment of benefits.
References:  For more information on
SVSR
  • Review the award and decision notice for accuracy. (Return the award and decision notice to the VSR for correction if errors exist.)
  • Authorize the award.
  • Date the decision notice with the expected date of mailing.
  • Release the following for mailing to the claimant:
    • decision notice
    • copy of the rating decision (if applicable), and
    • any pertinent enclosures.
  • Return the claims folder to the files activity (if a physical claims folder was used in the award/authorization process).
Note:  If the decision notice contains FTI, see M21-1, Part III, Subpart v, 2.B.3.
Important:
  • In the VBMS awards-processing environment, the returning of an award or decision notice to a VSR for correction is known as a deferral.  TheNational Work Queue (NWQ) Playbook contains instructions (under the heading VBMS Deferrals) that claims processors must follow to properly manage such deferrals.
  • Only awards or decision notices associated with rating EPs are subject to deferral in VBMS at the present time.
  • The Veterans Benefits Administration’s mission is to serve Veterans and their eligible dependents and survivors in the most timely and accurate manner possible.
    • It is only appropriate to extend suspense or diary dates if it is necessary for a specific adjudicative action.  Suspense dates must always correspond with specific actions and should not be arbitrarily extended under any circumstance.
    • When employees handle a claim, they are expected to take the most full and complete action possible on a claim every time – including development, rating, and promulgation actions – to move a claim forward to accurate completion in the claims process.  Every effort should be made to move the claim to the next processing cycle each time it is handled.

III.v.2.A.2.d.  Awards That Require VSCM or PMCM Concurrence 

Some awards require concurrence by a Veterans Service Center Manager (VSCM) or Pension Management Center Manager (PMCM) (or a designee of one of these managers) in addition to authorization by an SVSR.  They include
  • awards having a net effect of a payment of at least $25,000.00, and
  • awards that were generated using the GENERATE AWARD OVERRIDE function in VETSNET or VBMS.
The table below describes the process for obtaining concurrence from a VSCM or PMCM.
Stage
Description
1
An SVSR authorizes an award that requires concurrence by a VSCM/PMCM.
2
The SVSR notifies the VSCM/PMCM according to locally established procedures that a pending award requires concurrence.
3
The VSCM/PMCM (or a designee) reviews the award action to determine whether it is correct.  If he/she determines the award action is
  • correct, the process ends with the action described in Stage 6, or
  • incorrect, the process continues with the action described in the next stage.
4
The VSCM/PMCM/designee returns the award to the SVSR or VSR that made the error.
5
The process resumes with the action described in Stage 3 after the SVSR or VSR
  • corrects the error
  • generates and/or authorizes the award, and
  • notifies the VSCM/PMCM/designee according to locally established procedures.
6
The VSCM/PMCM/designee provides concurrence.
Reference:  For more information about the process described in the above table, see the NWQ Playbook.

 

3.  General Information on Denials


Introduction

This topic contains general information on denials, including

Change Date

February 19, 2019

III.v.2.A.3.a.  Definition:  Denial

A decision is considered a denial if, after review of a claim or issue and all evidence associated with it, VA makes a formal decision to
  • not award a benefit the claimant is seeking
  • confirm and continue a prior decision (this includes rating decisions that confirm and continue a disability rating following a routine future examination or hospitalization of a Veteran), or
  • reduce or discontinue benefits.

Note:  The initial establishment of a noncompensable disability rating for a SC disability is not considered a denial.  Although compensation is not payable for the disability (except, potentially, under 38 CFR 3.324), the noncompensable rating may entitle the Veteran to other VA benefits, such as medical care under 38 CFR 17.37(b) and 17.38.


III.v.2.A.3.b.  Authority of the Authorization Activity to Make Decisions That Affect an Individual’s Entitlement to VA Benefits

The authorization activity has the authority to make basic eligibility determinations.  It also has the authority to decide
  • the effect an individual’s income and/or net worth has on his/her entitlement to income-based benefits
  • whether entitlement to additional benefits for a dependent or dependents exists, and
  • whether entitlement to A&A under 38 CFR 3.351(c)(2) exists, based on the status of the following individuals as a patient in a nursing home:
    • Veteran in receipt of Veterans Pension
    • surviving spouse or parent in receipt of DIC
    • surviving spouse in receipt of Survivors Pension, or
    • spouse of a Veteran when the Veteran is in receipt of disability compensation.
Restrictions:  The authorization activity does not have the authority to
  • determine whether service treatment records support a claim for disability compensation, or
  • deny without a rating decision a claim for survivors’ benefits that involves the issue of service connection (SC) for the cause of death.
Note:  If basic eligibility is established and the claim requires consideration of medical evidence of record, refer it to the rating activity for review.  Claims of this nature require a formal, coded rating decision.
Exception:  M21-1, Part III, Subpart v, 2.A.3.c describes conditions under whichthe authorization activity may deny a claim without a rating decision.
References:  For more information on

III.v.2.A.3.c.  Conditions Under Which the Authorization Activity May Deny a Claim

The authorization activity may deny a claim for disability compensation or survivors benefits without a rating decision under any of the following conditions:
  • a legal bar to entitlement exists
  • the claimant does not respond within 30 days to a request for evidence needed to determine whether or not there is a legal bar to entitlement, such as in cases involving continuous cohabitation, or
  • in survivors benefit cases, the claim is one in which
    • SC for the cause of death was not specifically claimed, and
    • there is no reasonable probability that the cause or contributory cause of death was related to service (including, but not limited to, death due to accident or natural disaster, homicide, or execution for a crime).
Notes:
  • Resolve any issues regarding basic eligibility or bars to benefits beforeconsidering SC.  In accordance with 38 CFR 3.159(d), VA should notcontinue providing assistance with a claim if there is no reasonable possibility that assistance will substantiate the claim.
  • If VA concurrently denies SC for the cause of death and awards pension, make the following entry on the corresponding award print:  SC death benefits denied – M21-1, Part III, Subpart v, 2.A.3.c.
  • Claims processors must include procedural and review rights in decision notices that inform a claimant of a decision that authorization activitymade (without referral to the rating activity) to deny entitlement to a claimed benefit.
References:  For more information on

III.v.2.A.3.d.  Requirement to Receive and Review All Required Evidence Before Denying a Claim

Unless there is a statutory bar to entitlement to benefits, the authorization activity must not deny any claim until VA has
  • received and reviewed all evidence required to make a decision, or
  • exhausted all reasonable means of obtaining the evidence, and, for records from Federal sources, determined that either
    • the record does not exist, or
    • further efforts to obtain the record would be futile.
Note:
  • A formal claim requires a formal decision and notification.  However, VA’s review for inferred issues on its own initiative (as explained in M21-1, Part IV, Subpart ii, 2.A.1.a and M21-1, Part III, Subpart iv, 6.B.5.a) does notnecessarily require a formal decision and notification if the inference would result in a denial.
  • Do not initiate development of an inferred issue unless the evidence indicates VA may be able to award the corresponding benefit.  (It is notVA’s policy to raise an issue for the purpose of denying the associated benefit.)
References:  For more information on

III.v.2.A.3.e.  Incomplete Applications and Benefit Requests That Are Not Filed on a Prescribed Form

Do not process a denial if a claimant has failed to submit a
References:  For more information on handling

 

4.  Denials Based on a Claimant’s Failure to Furnish Requested Evidence


Introduction

This topic contains information on denials that are based on a claimant’s failure to furnish requested evidence, including

Change Date

March 21, 2018

III.v.2.A.4.a.  Handling a Claimant’s Failure to Submit Evidence VA Requested

If a claimant fails to submit evidence within a time period VA specified,
  • refer his/her claim to the rating activity (if a rating decision is required)
  • process a denial (or award benefits, if other evidence of record supports a grant of entitlement to all or some of the benefits the claimant is seeking), and
  • prepare a decision notice.
Important:
  • If VA denies any portion of a claim because the claimant failed to submit evidence VA requested, the decision notice must
    • state this fact
    • explain that other evidence of record does not support the claim, and
    • inform the claimant he/she must furnish the evidence VA requested within one year of the date of the decision notice in order to remain entitled to benefits from the original date of claim, if VA later establishes entitlement.
  • Prepare a new decision notice if VA previously denied a claim based on a claimant’s failure to submit evidence, then VA subsequently
    • makes another determination of non-entitlement based on additional evidence the claimant furnished within one year of the date of the previous notice of denial, or
    • denies the claim solely on legal grounds.
References:  For more information on

III.v.2.A.4.b.  Handling a Claimant’s Failure to Report for a VA Examination

The table below describes the process for handling cases in which a claimant fails to report for a VA examination without good cause.
Stage
Who Is Responsible
Action
1
Development Activity
Refers the claim to the rating activity for consideration.
2
Rating Activity
Decides the claim in accordance with principles set forth inM21-1, Part I, 1.C.3.m.
3
Rating Activity
Routes the rating decision to the authorization activity after the claimant’s VSO (if the claimant selected one) has had an opportunity to review it.
4
Authorization Activity
Processes an award and/or denial and issues notification to the claimant.
Important:  If a denial is based on the claimant’s failure to report for an examination, the decision notice must
  • inform the claimant that VA cannot favorably decide his/her claim without an examination, and
  • advise the claimant to
    • notify VA when he/she is ready to report for an examination, or
    • submit a properly executed disability benefits questionnaire.
References:  For more information about

III.v.2.A.4.c.  Handling an Abandoned Claim

If a claimant fails to provide evidence within one year of VA’s request and VA has not decided the claim as of the expiration of the one-year period, consider the claim abandoned.
Important:  It is not necessary to advise a claimant of his/her review rights when the claimant has abandoned his/her claim.
Reference:  For additional information about abandoned claims, see

 

5.  Special Denial Procedures


Introduction

This topic contains information on special denial procedures, including


Change Date

February 19, 2019

III.v.2.A.5.a.  Changing the Basis of a Previous Denial

If VA reviews or reconsiders a claim it previously denied and decides to change the basis of the denial, it must
  • reprocess the denial according to the instructions in M21-1, Part III, Subpart v, 2.A.2.c, and
  • if necessary, make appropriate system selections to
    • add any new favorable findings related to the basis of the new denial, and/or
    • overturn any and all findings that
      • were formerly found favorable to the claimant under 38 CFR 3.104(c), but
      • are no longer applicable.
References:  For more information on

III.v.2.A.5.b.  References to Other Special Denial Procedures

The table below contains references to other special denial procedures.
For more information on …
See …
notifying a claimant that election of pension is not in his/her best interest
notifying a claimant of a denial that is based on his/her income or net worth
notices to State public assistance agencies
preparing a death gratuity certification letter
denying a request for release of information or amendment of records
denying claims from certain foreign residents
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