The clinical appeals process is a lesser known remedy for cases where a veteran and healthcare facility reach an impasse on a clinical issue or a decision on a claim for benefits administered by the Veterans Health Administration (VHA). Clinical issues typically pertain to the question of whether a provision or denial of clinical care could result in a different or improved outcome for a veteran. Claims that are appropriate for the clinical appeals process are those that can be appealed to the Board of Veterans’ Appeals, such as reimbursement for non-VA care not authorized in advance, reimbursement for beneficiary travel expenses or reimbursement for home improvements. Bear in mind that certain issues are not remedied through the clinical appeals process. These include prescription for care disputes or those that involve reconsideration procedures covered under other statutes, such as CHAMPVA and Spina Bifida cases. Similarly, decisions that originated at the Veterans Benefits Administration and were adopted by the VHA for decision-making purposes are not disputed as clinical appeals. In essence, knowing whether you can appeal a clinical decision or claim is the first step in the clinical appeals process.
So what should you do if you find yourself faced with a disputable claim? First note that you have one year from the date of the initial decision to request reconsideration. The request entails submitting a reconsideration request in writing to the Director of the healthcare facility of jurisdiction. You must explicitly state why you feel the decision was made in error and include any new and relevant information not previously considered. Note that any request for reconsideration that does not identify the reason for the dispute will be returned to you without further consideration. Once you file the appeal and any supporting evidence, a new decision will be made by the immediate supervisor of the initial VA decision maker. In some cases, your appeal may include a request for a meeting with the immediate supervisor of the initial VA decision-maker. If granted, the meeting will be taped and transcribed upon request, and a copy of the transcription will be provided to you along with a written decision that affirms, reverses, or modifies the initial decision. Once the new decision is rendered and you are notified, it is imperative that you are fully apprised in writing of further appellate rights for an appeal to the Board of Veterans' Appeals. If you still disagree, the appeal will be forwarded to the next tier in the VHA hierarchy, the Veteran Integrated Services Network (VISN), where it may be reviewed as an Internal Clinical Appeal or by Independent External Review. At this point, a final decision will take 30 to 45 days. If you still disagree, the case is forwarded to the Board of Veterans Appeals for further adjudication. In some cases, a veteran may be advised by a service officer to appeal directly to the BVA versus first appealing to the VISN.
Fair and impartial review of disputes regarding clinical determinations is a right due to every veteran who receives care within the VA Healthcare System. As such, the clinical appeals process is an important part of preserving the integrity of the veteran-VA facility relationship. By understanding the clinical appeals framework, a veteran is better equipped to influence decisions that may impact quality of care and clinical outcomes. For those who disagree with a clinical decision and want to appeal, they should stop by or contact the nearest PVA National Service Office in your area to get started. ☺
So what should you do if you find yourself faced with a disputable claim? First note that you have one year from the date of the initial decision to request reconsideration. The request entails submitting a reconsideration request in writing to the Director of the healthcare facility of jurisdiction. You must explicitly state why you feel the decision was made in error and include any new and relevant information not previously considered. Note that any request for reconsideration that does not identify the reason for the dispute will be returned to you without further consideration. Once you file the appeal and any supporting evidence, a new decision will be made by the immediate supervisor of the initial VA decision maker. In some cases, your appeal may include a request for a meeting with the immediate supervisor of the initial VA decision-maker. If granted, the meeting will be taped and transcribed upon request, and a copy of the transcription will be provided to you along with a written decision that affirms, reverses, or modifies the initial decision. Once the new decision is rendered and you are notified, it is imperative that you are fully apprised in writing of further appellate rights for an appeal to the Board of Veterans' Appeals. If you still disagree, the appeal will be forwarded to the next tier in the VHA hierarchy, the Veteran Integrated Services Network (VISN), where it may be reviewed as an Internal Clinical Appeal or by Independent External Review. At this point, a final decision will take 30 to 45 days. If you still disagree, the case is forwarded to the Board of Veterans Appeals for further adjudication. In some cases, a veteran may be advised by a service officer to appeal directly to the BVA versus first appealing to the VISN.
Fair and impartial review of disputes regarding clinical determinations is a right due to every veteran who receives care within the VA Healthcare System. As such, the clinical appeals process is an important part of preserving the integrity of the veteran-VA facility relationship. By understanding the clinical appeals framework, a veteran is better equipped to influence decisions that may impact quality of care and clinical outcomes. For those who disagree with a clinical decision and want to appeal, they should stop by or contact the nearest PVA National Service Office in your area to get started. ☺
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