Examination Requests Overview

In This Section

Introduction

• who may request an examination
• definition of an appropriate examination facility
• mandatory use of the Examination Request Routing Assistant (ERRA) tool
• scope of practice relative to examinations
• definition of
  • general medical examination
  • specialty examination, and
  • specialist examination
• Veteran’s legal rights at an examination
• contract examination exclusions, and
• examination requests for conditions affected by revised rating schedule criteria.

Change Date

IV.i.2.A.1.a. Who May Request an Examination

IV.i.2.A.1.b. Definition: Appropriate Examination Facility

IV.i.2.A.1.c. Mandatory Use of the ERRA Tool

IV.i.2.A.1.d. Scope of Practice Relative to Examination

IV.i.2.A.1.e. Definition: General Medical Examination

IV.i.2.A.1.f. Definition: Specialty Examination

IV.i.2.A.1.g. Definition: Specialist Examination

IV.i.2.A.1.h. Veteran’s Legal Rights at an Examination

• be accompanied by counsel during an examination, or
• record an examination.

IV.i.2.A.1.i. Contract Examination Exclusions

IV.i.2.A.1.j. Examination Requests for Conditions Affected by Revised Rating Schedule Criteria

Introduction

• overview of examination request tools
• Exam Scheduling Assistant (ESA) tool
• ERRA tool
• interpreting the ERRA tool’s results
• Index of DBQ/Exams by Disability tool, and
• selecting the appropriate application for entering examination requests.

Change Date

IV.i.2.A.2.a. Overview of Examination Request Tools

• obtain assistance in determining whether an examination and/or medical opinion is warranted
• identify the examining facility location closest to the Veteran
• identify the DBQs for the claimed disabilities
• build the examination request, and
• submit the examination request to the VHA or contract examination facility.

IV.i.2.A.2.b. ESA Tool

IV.i.2.A.2.c. ERRA Tool

• application to use for submitting the examination request
• facility routing location
• routing location comments
• examination type comments, and
• approximate distance (from the zip code entered, including driving distance and estimated time).

• This tool is designed as a guide to assist in the routing of compensation and pension (C&P) examination requests. Its use is mandatory, as discussed in M21-1, Part IV, Subpart i, 2.A.1.c. When routing an examination request to a VHA facility, take into account any
  • claimant preferences, or
  • topography/driving concerns.
• 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 VHA or contract examination facility may vary in response to demand and facility availability. Routing location and examination type comments may also be subject to daily updates.

IV.i.2.A.2.d. Interpreting the ERRA Tool’s Results

• the ERRA tool’s functionality, see the Medical Disability Examination Office Policy and Program Management page, and
• EHRM, see M21-1, Part III, Subpart ii, 1.A.2.b.

IV.i.2.A.2.e. Index of DBQ/Exams by Disability Tool

IV.i.2.A.2.f. Selecting the Appropriate Application for Entering Examination Requests

• request, or
• scheduling request.

• interpreting the ERRA tool’s results, see M21-1, Part IV, Subpart i, 2.A.2.d
• inputting examination requests, see M21-1, Part IV, Subpart i, 2.A.9 and 10
• examination requests in
  • CAPRI, see the CAPRI User Manual, and
  • VBMS, see the VBMS Core User Guide, and
• contract examination exclusions, see M21-1, Part IV, Subpart i, 2.A.1.i.

Introduction

• definition of DBQs, and
• use and acceptance of DBQs for VA examination and opinion purposes.

Change Date

IV.i.2.A.3.a. Definition: DBQs

IV.i.2.A.3.b. Use and Acceptance of DBQs for VA Examination and Opinion Purposes

Introduction

• examinations based on ACE
• categories of examinations for which the ACE Process is prohibited, and
• examination requests and ACE.

Change Date

IV.i.2.A.4.a. Examinations Based on ACE

IV.i.2.A.4.b. Categories of Examinations for Which the ACE Process Is Prohibited

IV.i.2.A.4.c. Examination Requests and ACE

• 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.

Introduction

• when to request a general medical examination
• when a general medical examination is not necessary
• conducting a general medical examination, and
• citing medical conditions to be examined.

Change Date

IV.i.2.A.5.a. When to Request a General Medical Examination

• an initial claim is received within one year of discharge from any period (original or non-original) of
  • active service, as defined in 38 CFR 3.6(a), or
  • full-time duty performed in the National Guard, as defined in 38 CFR 3.6(c)(3), or
• an ITF is received within one year of such discharge, and a substantially complete application is received within one year of the ITF.

• individual unemployability (IU)
• service connection (SC) under 38 CFR 3.317, or
• Veterans Pension.

• When requesting a general medical examination to evaluate an initial compensation claim received within one year of discharge, do not request that the examiner also complete specific, individual DBQs for each claimed disability except in cases where claimed contentions require examination by a specialist, as discussed in M21-1, Part IV, Subpart i, 2.A.6.a. This policy applies to examinations requested from VHA and contract examination providers.
• When an initial claim is received within one year of discharge as described above and an examination is needed for one or more claimed issues under the provisions of 38 CFR 3.317, follow the instructions in M21-1, Part VIII, Subpart ii, 1.B.2. If a Gulf War General Medical Examination Disability Benefits Questionnaire is required, do not also request a General Medical – Compensation Disability Benefits Questionnaire, as this may result in duplication of DBQs completed as part of the general medical examination.

• A fully sufficient general medical examination is usually of greater value than a number of uncorrelated specialty examinations.
• If a claim for one or more additional contentions 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. In this situation, order the appropriate specialty DBQ(s) for the additional contention(s).
• 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.

• ITF, see
  • 38 CFR 3.155(b), and
  • M21-1, Part II, Subpart iii, 2.A
• specialist examinations, see M21-1, Part IV, Subpart i, 2.A.6
• requesting examinations related to claims for IU, see M21-1, Part VIII, Subpart iv, 3.B.2, and
• when a rating determination of P&T disability for pension purposes is required and when an examination is needed for pension claims, see M21-1, Part IX, Subpart i, 2.2.e-g.

IV.i.2.A.5.b. When a General Medical Examination Is Not Necessary

• 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.

IV.i.2.A.5.c. Conducting a General Medical Examination

• all disabilities listed in the examination request, and
• any other disabilities the Veteran identifies during the examination.

IV.i.2.A.5.d. Citing Medical Conditions to Be Examined

Introduction

• examinations that must be performed by specialists
• who may request other types of specialist examinations
• when to request a specialist examination, and
• who determines the choice of examiner.

Change Date

IV.i.2.A.6.a. Examinations That Must Be Performed by Specialists

• hearing
• vision
• dental, and
• psychiatric.

IV.i.2.A.6.b. Who May Request Other Types of Specialist Examinations

• the development or rating activity
• the medical examiner, or
• BVA.

IV.i.2.A.6.c. When to Request a Specialist Examination

IV.i.2.A.6.d. Who Determines the Choice of Examiner

• Board-certified specialist in …, or
• specialist who is Board qualified.

Introduction

• who may request a medical opinion
• referring claims for complex medical opinion review
• completing medical opinion requests using the VBMS EMS with CAPRI
• procedure for identifying the evidence in a medical opinion request
• maintaining objectivity in medical opinion requests
• medical opinions required for remands
• requesting medical opinions in claims under 38 U.S.C. 1151
• medical opinions and the
  • Hearing Loss and Tinnitus Disability Benefits Questionnaire, and
  • Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire, and
• avoiding asking for legal conclusions in medical opinion requests.

Change Date

IV.i.2.A.7.a. Who May Request a Medical Opinion

• medical opinions based on stressors involving military sexual trauma
• 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.

IV.i.2.A.7.b. Referring Claims for Complex Medical Opinion Review

• special issue indicators, see M21-4, Appendix E, 2, and
• tracked items, see M21-4, Appendix D, 1.

IV.i.2.A.7.c. Completing Medical Opinion Requests Using the VBMS EMS With CAPRI

• inputting
  • examination requests in CAPRI, see M21-1, Part IV, Subpart i, 2.A.9, and
  • medical opinion requests in CAPRI, see the CAPRI User Manual, and
• using alternate contention names to facilitate appropriate examination request language, see
  • M21-1, Part III, Subpart i, 2.F.2.c, and
  • theAlternate Contention Job Aid.

IV.i.2.A.7.d. Procedure for Identifying the Evidence in a Medical Opinion Request

• tab label
• document receipt date
• document type, and
• date(s) of treatment, injury, or event.

• EMS, see the
  • VBMS Core User Guide, and
  • EMS User Guide
• requirement to identify relevant evidence for an examiner’s review, see M21-1, Part IV, Subpart i, 2.A.8.d, and
• identification of evidence for examiner review in examination and medical opinion requests prepared by an automated process, see M21-1, Part IV, Subpart i, 2.A.8.e.

IV.i.2.A.7.e. Maintaining Objectivity in 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.

IV.i.2.A.7.f. Medical Opinions Required for Remands

IV.i.2.A.7.g. Requesting Medical Opinions in Claims Under 38 U.S.C. 1151

IV.i.2.A.7.h. Medical Opinions and the Hearing Loss and Tinnitus DBQ

IV.i.2.A.7.i. Medical Opinions and the Initial PTSD DBQ

IV.i.2.A.7.j. Avoiding Asking for Legal Conclusions in Medical Opinion Requests

Introduction

• importance of claims folder review
• examinations requiring claims folder review
• requesting examiner review of the claims folder
• requirement to identify relevant evidence for the examiner’s review, and
• identification of evidence for examiner review in examination and medical opinion requests prepared by an automated process.

Change Date

IV.i.2.A.8.a. Importance of Claims Folder Review

IV.i.2.A.8.b. Examinations Requiring Claims Folder Review

IV.i.2.A.8.c. Requesting Examiner Review of the Claims Folder

IV.i.2.A.8.d. Requirement to Identify Relevant Evidence for the Examiner’s Review

IV.i.2.A.8.e. Identification of Evidence for Examiner Review in Examination and Medical Opinion Requests Prepared by an Automated Process

Introduction

• steps to request an examination in CAPRI
• completing a CAPRI examination request, and
• mandatory entry of requester’s contact information.

Change Date

IV.i.2.A.9.a. Steps to Request an Examination in CAPRI

IV.i.2.A.9.b. Completing a CAPRI Examination Request

• The examination location selected should be the appropriate facility identified using the guidance in M21-1, Part IV, Subpart i, 2.A.2.c and d.
• 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 IV, Subpart i, 2.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 requested, delete N/A and enter the date of the pertinent prior examination.
• In REMARKS
  • include all generated and manually entered text
  • do not use manual, regulation, or code citations
  • avoid using acronyms or VBA jargon, and
  • if the examinee is rated incompetent, note that fact.

IV.i.2.A.9.c. Mandatory Entry of Requester’s Contact Information

• entering an ESR
• types of requests requiring supplemental language
• definition of a request for clarification, and
• responding to a request for clarification for vendor examinations.

IV.i.2.A.10.a. Entering an ESR

• ESR submission and acceptance in VBMS will automate the creation of one tracked item for each contention identified in the request.
• If unique circumstances exist in a particular case (for example, the Veteran is immobile or unable to drive due to advanced age), these situational factors should be referred in accordance with the Contract Examination Inquiry Guidelines for assistance in determining if, and what, contract examination mitigation may be necessary.

• types of requests requiring supplemental language, see M21-1, Part IV, Subpart i, 2.A.10.b
• using alternate contention names to facilitate appropriate examination request language, see
  • M21-1, Part III, Subpart i, 2.F.2.c, and
  • the Alternate Contention Job Aid.
• examination suspense dates, see M21-1, Part IV, Subpart i, 2.C.1.a
• contract examination exclusion reasons, see M21-1, Part IV, Subpart i, 2.A.1.i, and
• tracked item suspense and automation relative to examination management, see the
  • VBMS Core User Guide, and
  • EMS User Guide.

IV.i.2.A.10.b. Types of Requests Requiring Supplemental Language

• claim components or attributes for which ESRs in VBMS must be supplemented, and
• language needed to ensure request adequacy and consistency.

Reference: For more information on entering an ESR in VBMS, see

• M21-1, Part IV, Subpart i, 2.A.10.a
• the VBMS Core User Guide, and
• EMS User Guide.

IV.i.2.A.10.c. Definition: Request for Clarification

IV.i.2.A.10.d. Responding to a Request for Clarification for Vendor Examinations

• Responses must be written in a professional manner.
• Responses should be clear and concise regarding any corrective actions taken to resolve the request for clarification.
• All questions posed, information and/or clarification requested, or specific actions indicated must be resolved prior to returning the request for clarification to the contract examination vendor.
• Do not request the contract examination vendor to cancel the examination in the response to a request for clarification.
• Responses must not indicate actions that are contractual in nature. For example, do not make statements indicating that no payment will be rendered for services or informing the contract examination vendor that the ESR will be sent to a different vendor.
• Do not add additional requests, contentions, diagnostics, or requirements that were not included in the original ESR.

• VBMS Core User Guide, and
• EMS User Guide.