Visual Presentation Slides for Internal Use Only
Higher-Level Review Returns
January 2024
The Bottom Line
A higher-level reviewer who finds a duty to assist (DTA) error or
exercises difference of opinion (DoO) authority issues a higher-
level review (HLR) return for the affected issue(s).
38 C.F.R §§ 3.2502, 3.2601
Lesson Objectives
•
Define the purpose and scope of an HLR return
•
State how VBA controls and tracks HLR returns
•
List the Veterans Service Representative (VSR) responsibilities
for processing HLR returns
•
Describe relevant VBA applications and required system
updates for processing HLR returns
Lesson Objectives Continued
•
List the steps required to conduct common types of return
development
•
Detail the action to take with unclear development
instructions
•
Identify the proper development action based on example
HLR return instructions
•
Identify when to refer a return to rating or authorization
References
•
Public Law 115-55
, The Veterans Appeals Improvement and
Modernization Act of 2017 (Appeals Modernization Act (AMA))
•
M21-5, Chapter 5
,
Higher Level Review Procedures
•
M21-1, III.ii.1.A
,
Requesting Evidence from Federal Record Custodians
•
M21-1, III.ii.1.B
,
Department of Veterans Affairs (VA) Requests for
Information from the Social Security Administration (SSA)
•
M21-1, III.ii.3
,
Requesting Evidence from Private Health Providers
(PHPs)
•
M21-1, IV.i.2
,
Requesting Examinations
Objective
Define the purpose and scope
of an HLR return
Purpose of an HLR Return
•
The Appeals Modernization Act (AMA) became effective on
February 19, 2019
•
Higher-level reviewer performs
de novo
review on an HLR request
–
Deny the issue
–
Grant the issue
–
Return the issue
•
HLR return
–
duty to assist (DTA) error
–
difference of opinion (DoO)
Scope of an HLR Return
•
Service verification
•
Additional service treatment records (STR)
•
Private medical records (PMR)
•
VA outpatient treatment records (OPT)
•
Social Security Administration (SSA) records
•
Examinations and/or medical records
•
Employment information
•
Question
: On what date did the AMA become effective,
offering Veterans a higher-level review option for
disagreements with VBA decisions?
•
Answer
: AMA was implemented on February 19, 2019.
Knowledge Check #1
Objective
State how VBA controls and
tracks HLR returns
HLR Return Form
•
VA Form 20-0999,
Higher-Level Review Return
•
Contains the development instructions
•
Completed for the affected issues
End Products and Dates of Claim
Claim Labels
Based on the type of claim, ensure that Caseflow assigns the
proper claim label to the EP 040 as follows:
If the DRO selected difference of opinion, ensure the EP 040 has the 040DO claim
label to indicate it is a difference of opinion.
Proper Tracking of DTA Errors
To ensure proper tracking of DTA errors, assign the appropriate
DTA special issue as follows:
•
Scenario
:
An HLR is returned for an exam for increase in diabetes. An
EP 020 is established with the claim label “
HLR DTA Error- Non-Rating
”
and special issue of
DTA—PMRs
.
•
Question
:
Are the EP, claim label, and special issue correct?
•
Answer
:
No, the EP, claim label, and special issue are not correct. The
EP on an HLR return should be in the 040 series. The claim label should
be “HLR DTA Error – Rating” since the return category is a rating issue.
The special issue should be
DTA—Exam/MO
.
Knowledge Check #2
Objective
List the Veterans Service Representative (VSR)
responsibilities for processing HLR returns
VSR Responsibilities
•
Send HLR DTA letter
•
Complete the development required on the HLR return
•
Systems compliance
–
Confirm claim label, EP, date of claim, and contentions
•
Mark as
–
Ready for Decision (RFD) for rating issues
–
Ready to Work (RTW) for non-rating issues
VA Form 20-0999 Section I
Identifying
information
for claimant
List of
returned
issues with
date of VA
decision
notice
VA Form 20-0999 Section II
Categories of
development
required
Explanation of
checked boxes
and
development
VA Form 20-0999 Section III
Favorable
findings
(could
indicate
these are
on rating
decision)
DRO
information
VA Form 20-0999 Page 2
Additional
information, i.e.
continuation of
development
steps
•
Scenario
:
A higher-level reviewer determines that a DTA error exists
on a claim for increase for the left shoulder and a new examination is
required.
•
Question
:
What is the name of the form on which the reviewer puts
the development directions to correct the DTA error?
•
Answer
:
VA Form 20-0999,
Higher-Level Review Return
. A higher-level
reviewer should put the development directions on a VA Form 20-
0999
.
Knowledge Check #3
Objective
Describe various relevant VBA applications and required
system updates for
processing HLR returns
VBA Applications
•
Caseflow
•
VBMS
•
CAPRI
•
JLV
•
PIES
•
DPRIS
Caseflow
•
Specifically developed for AMA claims
•
Automatically establishes EP 040 after EP 030 is authorized
•
VSR should verify information is correct
–
If not, VSR should correct the information
Editing Contentions in Caseflow
Adding Issues in Caseflow
In order to edit specific parts of any given issue/contention, you
may need to remove that issue and re-add it.
•
Scenario
: The h
igher-level reviewer returns the issue of hearing loss.
Caseflow establishes EP 040 with contention listed as “Service
connection for hearing loss is denied.” You realize this is not worded
correctly.
•
Question
:
How should you edit the contention in Caseflow?
•
Answer
:
In Caseflow, you should edit the contention so that it reads
“hearing loss” instead of “Service connection for hearing loss is denied”
as the issue is hearing loss.
Knowledge Check #4
Objective
List steps required to conduct common
types of HLR return development
Federal Entity Records Request
•
Includes records from service departments, SSA, Office of
Workers’ Compensation (OWC), Vet Centers, National
Personnel Records Center (NPRC), and/or Office of Personnel
Management (OPM)
•
Follow the procedures outlined in M21-1, III.ii.1.A.1 for federal
records
•
Follow the procedures outlined in M21-1, III.ii.1.B for SSA
•
If unable to obtain the records, final notification letter is
required
VAMC Outpatient Treatment Records
•
Use CAPRI and JLV for records dated after 2004
•
Records prior to 2004 require development to the VAMC
•
Follow the procedures outlined in M21-1, III.ii.1.A.2 to obtain
VA medical records not in CAPRI or JLV
Private Medical Records
•
Private health providers require HIPAA compliant
authorization statement signed by the individual
•
Follow the procedures outlined in M21-1, III.ii.3 to request
private medical records properly
•
Applicable VA forms
–
VA Form 21-4142,
Authorization to Disclose Information to the
Department of Veterans Affairs (VA)
–
VA Form 21-4142a,
General Release for Medical Provider Information
to the Department of Veterans Affairs (VA)
Examination and Medical Opinion Requests
•
Request the examination and/or medical opinion in the
normal manner, following procedures in M21-1, IV.i.2
•
Follow the instructions in the return
•
Use ERRA to determine correct location of exam
•
Use the table below to determine which application to use for
examinations:
•
Scenario
: An HLR return instructs that an audio exam is
necessary due to a DTA error on the initial claim.
•
Question
: Which application would you use to determine the
correct location for the exam request?
•
Answer
: ERRA is the application that is used to determine the
correct location for the exam request.
Knowledge Check #5
Objective
Detail the action to take with unclear
development instructions
Unclear Development Instructions
When a VA Form 20-0999 is unclear or conflicting,
•
it requires extra attention from the VSR and
•
work with local Quality Review Team (QRT) or supervisor for
additional assistance
Vague VA Form 20-0999 Scenario
DRO returns the issue of service connection for right shoulder
and directs the following development.
What actions could you take to determine what to do with this
development request as the language is vague?
Scenario Possible Actions
•
Review claims file
•
Determine the proper course of action based on evidence
•
Contact local QRT/supervisor for assistance
•
Scenario
: An HLR return instructs the VSR to submit a request
to the Records Management Center (RMC) to verify a period
of service.
•
Question
: Is this request correct? If not, what should the VSR
do?
•
Answer
: The RMC is not the proper venue for service
verification. VSR should contact the correct records custodian
to verify service.
Knowledge Check #6
Objective
Identify the proper development action based
on example HLR return instructions
Practice Activity
Please refer to the Training Handouts for examples of HLR
return instructions with VSR development action.
This Photo
by Unknown Author is licensed under
CC BY-SA
Objective
Identify when to refer an HLR return to
rating or authorization
Referring Return for Rating/Authorization Activity
•
VA receives the requested evidence
•
VA fulfills its obligation to attempt to obtain evidence
•
Suspense date matures and no additional action is warranted
Referring as Ready for Decision
Role of RVSR
•
Ensure claim is RFD
–
Review return instructions first
•
If additional development is needed, defer back to VSR
•
If development is complete, rate as any other claim
•
Scenario
: You receive an HLR return which instructs you to
request an increase exam. You request the exam, but the Veteran
calls the VAMC and states he is out of town and needs to
reschedule. The VAMC sends VBA the failure to report notification.
•
Question
: Is the claim ready for decision?
•
Answer
: No, the claim is not ready for decision. The Veteran
notified VA of good cause why he could not attend the exam. You
must reschedule the exam before sending the claim ready for
decision.
Knowledge Check #7
Course Summary
HLR Returns:
•
Purpose and Scope
•
Control and Track
•
VSR Responsibilities for Processing
•
Required Applications and System Updates
•
Develop and Refer for Action
Questions?
48
Discuss any additional questions after today’s training locally with experts,
quality staff, and/or management. Management may route any additional
questions requiring OAR assistance to OARADMIN.VBAWAS@va.gov
Next Steps
•
An assessment and satisfaction survey have been assigned to
you in TMS
•
You have unlimited attempts to complete the assessment and
may answer one question incorrectly to achieve a passing
score
•
Be sure to complete the survey and assessment to receive
credit for this training
Slide Note
Course Description:
This course teaches learners the attributes of Higher-Level Review (HLR) Returns and how to process the HLR return.
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