M21-1 Manual  /  Part II, Subpart iii, Chapter 2, Section D

Claims Based on Reports of Examination or Hospitalization

M21-1, Part II, Subpart iii, Chapter 2, Section D

Overview

In This Section

 This section contains the following topics:
TopicTopic Name
1 Claims Based on Reports of Examination or Hospitalization
2 Claims Based on Reports of Examination or Hospitalization Prior to March 24, 2015

1. Claims Based on Reports of Examination or Hospitalization

Introduction

 This topic contains information on reviewing reports of examination or hospitalization at Department of Veterans Affairs (VA) facilities, military treatment facilities (MTFs), or private healthcare facilities to determine whether claims action is warranted, including
  • handling notice of a report of VA or MTF examination or hospitalization occurring on or after March 24, 2015, and
  • considering evidence of VA or MTF examination or hospitalization occurring on or after March 24, 2015.

Change Date

 June 24, 2021

II.iii.2.D.1.a. Handling Notice of a Report of VA or MTF Examination or Hospitalization Occurring on or After March 24, 2015

 Notice of examination in a Department of Veterans Affairs (VA) facility or military treatment facility (MTF) occurring on or after March 24, 2015, is not a claim. The date of examination will be considered for effective date purposes if a complete claim or intent to file (ITF) is received within one year from the date of examination or hospitalization for the following:
  • a claim for an increased disability evaluation received for one or more conditions treated as part of the examination or hospitalization, or
  • pension, when entitlement to pension was previously denied based on the absence of evidence of permanent and total (P&T) disability.
Important: Notice of hospitalization in a VA facility occurring on or after March 24, 2015, will result in an adjudicative determination as to entitlement to a temporary evaluation under 38 CFR 4.29 or 38 CFR 4.30 as discussed in M21-1, Part VIII, Subpart iv, 8.B and C. However, a report of hospitalization will only result in adjudicative action applicable to disabilities which are currently service-connected (SC) when a rating under 38 CFR 4.29 or 38 CFR 4.30 can be granted. Note: A report of VA examination or hospitalization occurring on or after March 24, 2015, showing a nursing home stay is not sufficient to grant aid and attendance (A&A) without a formal application. References: For more information on
  • considering reports of examination or hospitalization for effective date purposes in subsequent claims, see M21-1, Part II, Subpart iii, 2.D.1.b, and
  • prescribed form requirements for a grant of A&A, see M21-1, Part II, Subpart iii, 1.A.3.

II.iii.2.D.1.b. Considering Evidence of VA or MTF Examination or Hospitalization Occurring on or After March 24, 2015

 If unsolicited VA or MTF medical evidence shows treatment, but not hospitalization over 21 days on or after March 24, 2015, do not establish an end product (EP) to control receipt of this evidence. Ensure the evidence is associated with the beneficiary’s claim folder, as this evidence may be utilized for effective date purposes if a formal claim or ITF is received within one year of the date of treatment. Important: When VA or MTF medical evidence was requested in association with a prior claim but was received after a decision was made, follow the procedures in M21-1, Part II, Subpart i, 2.A.5 for handling late-flowing, solicited mail. Example: Veteran is SC for diabetes mellitus type 2 at 10 percent due to a restricted diet. A VA medical center (VAMC) treatment report dated June 10, 2015, shows a physician prescribed oral medication as part of the diabetic treatment plan. On March 1, 2016, the Veteran submits an ITF for compensation benefits. On September 20, 2016, the Veteran submits a claim for an increase in diabetes mellitus type 2. The Veteran’s
  • date of claim (DOC) is September 20, 2016
  • active ITF date is March 1, 2016, and
  • effective date of increase is June 10, 2015.
An ITF for compensation benefits was received within one year of the treatment warranting an increased evaluation. The Veteran submitted a complete compensation claim within a year of the VA receiving the active ITF.

2. Claims Based on Reports of Examination or Hospitalization Prior to March 24, 2015

Introduction

 This topic contains information on reviewing reports of examination or hospitalization at VA facilities, MTFs, or private healthcare facilities occurring prior to March 24, 2015, to determine whether claims action is warranted, including
  • accepting a report of VA or MTF examination or hospitalization dated prior to March 24, 2015, as a claim
  • establishing a claim based on VA medical treatment prior to March 24, 2015, and
  • accepting evidence of private examination or hospitalization occurring prior to March 24, 2015.

Change Date

 June 24, 2021

II.iii.2.D.2.a. Accepting a Report of VA or MTF Examination or Hospitalization Dated Prior to March 24, 2015, as a Claim

Evidence of examination or hospitalization in a VA facility or MTF (also known as uniformed service facility) occurring before March 24, 2015, is an informal claim for
  • an increased disability rating for an SC disability, or
  • pension, when entitlement to pension was previously denied based on the absence of evidence of P&T disability.
Note: A notice of hospitalization may not suffice as an informal claim if a Veteran with an SC disability(ies) is hospitalized for a disability for which service connection has not been established.

II.iii.2.D.2.b. Establishing a Claim Based on VA Medical Treatment Prior to March 24, 2015

 Follow the steps in the table below if the VA medical evidence shows treatment prior to March 24, 2015, for
  • an SC disability, or
  • manifestations of an SC disability.
StepAction
1 Accept the date of admission for treatment, date of outpatient treatment, or date of examination for an SC disability as the DOC for increased evaluation.
2 Establish and maintain control of the claim.
Important: If unsolicited VA medical evidence, other than reports of hospitalization, shows treatment on or after March 24, 2015, do not establish an EP to control for receipt of this evidence. No further action is needed other than ensuring that records submitted by a claimant are associated with the claims folder, as this evidence may be utilized for effective date purposes if a formal claim is received within one year of the date of treatment. References: For more information on

II.iii.2.D.2.c. Accepting Evidence of Private Examination or Hospitalization Occurring Prior to March 24, 2015

 Private medical evidence may be accepted as a claim if
  • it shows treatment for an SC disability or manifestations of an SC disability prior to March 24, 2015
  • it shows a reasonable probability of entitlement to a benefit, and
  • it was received by VA prior to March 24, 2015.
Note: Once a claim is established, refer it for development or rating activity as necessary. References: For more information on

Source: VA M21-1 Adjudication Procedures Manual, M21-1, Part II, Subpart iii, Chapter 2, Section D (U.S. government work, reproduced for reference). Browse all sections →