Fully Developed ClaimsBy

Tripp CantwellDepartment of Michigan

Objectives

• To describe The Fully Developed Claims (FDC) program

• To explain how to file both Formal and Informal FDC’s

• To explain the value of DBQ’s in the FDC process

• To explain Fast Letter 13-17 and the one year retro requirements

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National Performance

Based on national numbers as of June 1, 2014 for FY 2014:•Nearly 146K FDCs completed, with an average days to complete (ADC) to date of 147.4•Nearly 38K FDCs that have been excluded from the program with an ADC of 248.8•Nearly 682K non FDC claims (traditional claims) completed with an ADC of 261.9•To date, there are nearly 864K total claims completed with an ADC of 242.1

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What is a Fully Developed Claim (FDC)?

• The Fully Developed Claims (FDC) program is an initiative that offers Veterans and survivors faster decisions from VA on compensation, pension, and survivor benefit claims.

• For an FDC, VA will– Retrieve relevant records from a Federal facility, such as a VA

medical center when identified by a claimant– Provide a medical examination, or get medical opinion, if VA

determines it is necessary to decide the claim• VA will send a development letter to the claimant under the FDC

program only when: - A claim for a condition has been previously denied - VA determines that federal records are unavailable

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What’s different about an FDC?

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FDC Program•Provides claimants notice of the evidence necessary to substantiate a claim prior to submission

•Claimants submit all evidence necessary to decide their claim at the time of submission and certify there is no additional evidence

•Significant reduction in processing time

Standard Claim Process•Provides claimants notice of the evidence necessary to substantiate a claim after a claim is received

•Supporting evidence is submitted after the claim is filed - Often awaiting evidence from sources, e.g. private doctors

•Longer processing times

FDC Exclusions (Traditional Claims)

• A few types of claims are not specifically covered by the FDC notice. Examples include:• Claims for Permanent & Total status• Claims for Hepatitis C• Claims for a higher level of SMC (i.e. R-2)

• Administrative Exclusions:IE.. Needs non-Fed evidence development, Evidence received after

FDC is CEST’d, Claimant declined FDC processing, FDC certification incomplete, Additional claim submitted, Claim pending, Appeal pending, Necessary form(s) not submitted, Failure To Report to exam

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Submitting an FDC

• By filing one or more of the VA approved FDC forms:• VA Form 21-526ez Fully Developed Claim (Compensation)• VA Form 21-527ez Fully Developed Claim (Pension)• VA Form 21-534ez Fully Developed Claim (Application for DIC,

Death Pension, and Accrued Benefits)• Obtaining an eBenefits account to file online at

www.ebenefits.va.gov

Please note: The new forms are dated August 2013. Only the forms dated August 2013 or later will be accepted into the FDC program .

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Submitting an FDC

• A claimant must submit copies of Disability Benefit Questionnaires (DBQ’s) or their private treatment records for VA to consider in order to remain eligible for the FDC program

• Private medical evidence includes: - Treatment notes from private physicians - Hospital records, Outpatient records - National Guard/Reserve records - Any medical records related to the claimed disability

• Medical records alone typically will NOT replace the VA examination requirement

If the claimant submits a completed VA Form 21-4142 for a private provider the claim will be excluded from the FDC process

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Disability Benefit Questionnaires

• DBQs are downloadable electronic forms that, once completed by a private physician with an active medical license, serve as the equivalent to an examination at a VA facility– DBQs can speed the Fully Developed Claims process by providing

medical information that is directly relevant to determining a disability rating

– Claimant has the option of visiting a private health care provider to complete these at their cost instead of waiting for an appointment at a VA facility

• Submitting an appropriately completed DBQ(s) along with an FDC can eliminate the need to attend a VA examination

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What types of claims can be FDC?

1. Service connection (original, new, secondary, and reopened) 2. Service connection based on a period of active duty for training or inactive

duty training3. Increased disability compensation4. Individual Unemployability 5. Temporary total disability rating due to hospitalization or due to surgical

or other treatment6. Compensation under 38 U.S.C. 11517. Increased benefits based on the need for aid and attendance or based on

an additional disability or housebound status (SMC)8. Specially adapted housing or special home adaptation 9. Automobile allowance or adaptive equipment10.Benefits based on a Veteran’s helpless/seriously disabled child

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What types of claims can be FDC? (cont.)

11. Improved Pension 12. Special Monthly Pension (Aid and Attendance or housebound benefits)13. Improved Pension benefits based on a Veteran’s helpless/seriously

disabled child14. Accrued benefits15. DIC based on service-connected cause of death 16. DIC based on 38 U.S.C. §131817. DIC based on active-duty-for-training or inactive-duty-training death18. Survivor’s pension and Parents’ DIC19. 38 U.S.C §1151 DIC20. Increased survivor benefits (aid and attendance or housebound)21. Benefits for a Veteran’s helpless/seriously disabled child

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VA’s Duty to Assist

• The EZ forms provide notification required by 38 C.F.R§5103 at the time the claimant applies for benefits.

• Compensation claims (1-10 on the previous slide) MUST be submitted on VA Form 21-526EZ

• Pension claims (11-13 on the previous slide) MUST be submitted on VA Form 21-527EZ

• Survivor claims (13-21 on the previous slide) MUST be submitted on VA Form 21-534EZ• All 3 of these forms satisfy the DTA requirements of 38 C.F.R§5103

• All 3 of these forms can also be electronically completed and submitted at www.ebenefits.va.gov

• Requirements for the submission of additional forms for “Special Circumstances” are described in the next 3 slides

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Application Special Circumstances

• Guard and Reserve members, must submit all service treatment and personnel records in the custody of their Unit(s)

• If claiming dependents, must submit VA Form 21-686c, Declaration of Status of Dependents (with ALL birth and marriage documentation)

• If claiming a child in school between ages of 18 and 23, must submit VA Form 21-674, Request for Approval of School Attendance

• If claiming seriously disabled (helpless) child, must submit all relevant medical records pertaining to the child’s disabilities before obtaining the age of 18

• If claiming Post Traumatic Stress Disorder (PTSD), a completed VA Form 21-0781, Statement in Support of Claim for Service Connection for PTSD; if claiming PTSD based on Personal Trauma, VA Form 21-0871a

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Application Special Circumstances (cont.)

• If claiming Individual Unemployability (IU), a completed VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, and a completed VA Form 21-4192, Request for Employment Information in Connection with a Claim for Disability Benefits

• If claiming a Specially Adapted Housing or Special Home Adaptation, a completed VA Form 26-4555, Application in Acquiring Specially Adapted Housing or Special Home Adaptation

• If claiming Auto Allowance, a completed VA Form 21-4502, Application for Automobile or Other Conveyance and Adaptive Equipment

• If claiming additional benefits because the Veteran or his/her spouse requires Aid and Attendance, a completed VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, If claiming Aid and Attendance, based on nursing home attendance, completed VA Form 0779, Request for Nursing Home Information in Connection with Claim for Aid and Attendance

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Application Special Circumstances (cont.)

• If claiming DIC as the parent of the Veteran, all necessary income and net worth information and, if claimant benefits as the foster parent of the Veteran, a completed VA Form 21-524, Statement of Claiming to Have Stood in Relation of Parent

• Survivor Claims require the submission of the Veterans Death Certificate (unless he/she died on active duty)

• Dual Compensation and Pension claims MUST be submitted separately on VA Forms 21-526EZ and 21-527EZ

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Exclusions from the FDC Program

• An applicant can be excluded from the FDC program for various reasons, including:• The claimant indicates he/she does not want VA to process his/her claim

under the FDC program• The claimant has a claim pending at the time VA receives the EZ form • The claimant has an appeal pending at the time VA receives the EZ form and

the claims folder is not located at the regional office (RO) of jurisdiction• The claimant fails to simultaneously submit any of the additional items VA

requires to process his/her specific claim• Further evidence is needed from the claimant such as• -(a) private medical care provider(s), or• -records in the custody of the Veteran’s Guard/Reserve unit

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Exclusions from the FDC Program

• The claim requires a character of discharge determination • Completion of NA Form 13055, Request for Information Needed

to Reconstruct Medical Data, (by the claimant) because his/her service treatment records were destroyed by a fire at the National Personnel Records Center (NPRC) in 1973

• The Veteran fails to report for a VA examination and asks VA to reschedule it (unless VA is solely at fault because it, for example, did not provide the examining facility with the claimant’s correct mailing address), or

• The Veteran submits another claim, additional evidence, or a notice of disagreement after submitting the FDC

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FDC Program Development

• The only development VA undertakes in connection with an FDC is to request:• A VA Examination• To request Federal records in the custody of the Federal government

(This includes records in the custody of VA medical centers but excludes records in the custody of a Veteran’s Reserve/Guard unit(s) or records at NPRC that can only be obtained if the claimant completes NA Form 13055), VA must undertake the development described in M21-1MR, Part III, Subpart i, 3.B.6. and/or

• If a claimant submits an FDC in an effort to reopen a previously denied claim, VA must undertake the development described in M21-1MR, Part III, Subpart i, 3.B.7.

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FDC Program Development (cont.)

• For both Federal Records and Reopened FDC’s when notifying the claimant of the VA’s findings it should include the following:

“We received your claim and your request to participate in the Fully Developed Claim (FDC) Program. Though you indicated you have no other information or evidence to give VA to support your claim, we are required to send you this notice. If you have information or evidence not previously submitted to VA that supports your claim, we recommend you submit it. As a reminder, if you submit any additional information or evidence at this point, VA will remove your claim from the FDC Program Expedited Process and process it in the Standard Claim Process.”

• The VA will not wait for a response to the letter before undertaking the development actions

• The VA will allow the claimant 30 days to respond to the letter. If the claimant submits additional evidence, then the claim is removed from the FDC program

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FDC Program Development (cont.)

• When a claim is excluded from the FDC program, either at initial receipt or subsequently, the claimant is notified using language such as:

“We cannot process your claim under the Fully Developed Claim

Program because…we received evidence requiring further

development after the claim was received.you did not report for a scheduled VA examination.you did not sign your FDC application.

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Informal or Incomplete Claims

• To submit an Incomplete (online) or Informal claim, use VA Form 21-4138 or a letter with the following statement:

“The American Legion as POA or as Next Friend of Claimant, pursuant to 38 C.F.R. 3.155(a) on behalf of the claimant informs the VA of the claimant’s intent to apply for compensation and/or pension benefits under the FDC Program. This statement is to preserve the effective date for entitlement to benefits. The veteran’s date of birth is 10/19/1951.

Claimant understands they have one year to complete the claim or they will lose the effective date of this claim.”

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Informal or Incomplete Claims

• If a claimant identifies a specific contention (e.g., left leg, diabetes, etc) the VA will consider it a formal application. It will place the claim under end product control (e.g., EP 020) effective the date of receipt of the communication, and it will be moved forward for processing.

• Also if a claim is filed for one of the Special Circumstances such as PTSD, Agent Orange exposure, Military Sexual Trauma (MST), etc., and the claim is submitted without the proper forms and further development from the claimant is needed, then the claim must be removed from the FDC program (ie..submitting a VA Form 21-4142)

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One-year Retroactive DateOne-year Retroactive Date

On August 6, 2012, the President signed a comprehensive legislative package, the “Honoring America Veterans and Caring for Camp Lejeune Families Act of 2012,” PL 112-154. Section 506 of this Act amends 38 U.S.C.§5110 to allow up to a one-year retroactive effective date for awards of disability compensation based on fully developed original claims.

August 2, 2013 Fast Letter 13-17 Processing Fully Developed Original Claims Received from August 6, 2013 through August 5, 2015 further defined this benefit.

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Eligibility for the one-year retroactive dateEligibility for the one-year retroactive date

• The claim must be compensation – no other types of claims are eligible

• The claim must be original, an initial formal (complete) claim filed by a Veteran or their representative

• The Veteran must have separated from his/her last period of active duty service more than one year ago

• The claim must be received from August 6, 2013 through August 5, 2015• The claim must be received on a VA Form 21-526EZ. Veterans can

also apply through eBenefits using VONAPP Direct Connect (VDC)• If any of these requirements are not met, VA will determine if

the claim is still eligible for processing under the FDC program

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Calculating the one-year retroactive dateCalculating the one-year retroactive date

The evidence of record must support the evaluation assigned from the effective date. For example; if evidence submitted with the FDC shows the level of disability existed for one year prior to submission of the claim, then process the award with a one-year retroactive effective date. If, however, the evidence of record supports less than one-year of disability, process the award accordingly Unless there is evidence clearly supporting a staged rating, the rating should be consistent through the entire retroactive period.

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Calculating the one-year retroactive dateCalculating the one-year retroactive date

• Claimants are eligible to receive retroactive pay and an effective date calculated as whichever is the earlier of

- the date up to one year prior to receipt of the complete FDC if the facts support such an effective date, or - the date of receipt of an informal claim for which a formal (complete) FDC was subsequently received

• In either case, the effective date may not be more than one year prior to the date the formal (complete) FDC claim is received.

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Calculating the one-year retroactive dateCalculating the one-year retroactive date

• If a claimant initiates an application for an original FDC compensation claim online on January 1, 2013, (considered the date of claim), but does not submit the completed electronic application until September 1, 2013, the effective date for any benefit awarded would be September 1, 2012, or one year from the date VA received the fully developed electronic claim.

• The one-year retroactive pay is always calculated from the date the formal claim is filed.

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Calculating the one-year retroactive dateCalculating the one-year retroactive date

• If evidence of record submitted with an FDC shows the level of disability existed for one year prior to submission of the claim, then the claim should be awarded with a one-year retroactive effective date

• If there is medical evidence clearly showing that the claimed medical condition did not exist, or had not manifested to a compensable degree, either during the one year prior to the date of claim, or following the date of claim, and evidence is received supporting the disability while the claim is pending, then the effective should be based on the specific facts in the case.

Important: The one-year retroactive effective date cannot be granted for claims removed from the FDC program

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Time to Gather EvidenceTime to Gather Evidence

• Lock in an effective date by paper or online

• A claimant can start a claim online at https://www.ebenefits.va.gov, save the incomplete claim. Then complete the submission of the claim and all the supporting evidence once it is gathered

• A claimant has one year from the date the claim is initiated to complete the submission of the fully developed claim to preserve the initiation date for benefit payment

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Forms and Information

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Download any VA Form including EZ Forms at: http://www.va.gov/vaforms/

DBQs can be downloaded at: http://www.benefits.va.gov/COMPENSATION/dbq_ListByDBQFormName.asp

FDC Website is located at: http://www.benefits.va.gov/FDC/index.asp

eBenefits: www.eBenefits.va.gov

eBenefits and SEPeBenefits and SEP

Filing an electronic claim keeps the claim digital and allows VSO’s to work in the Stakeholder Enterprise Portal (SEP).–Enter/Update Dependency claims–Accept/Decline new Power of Attorney requests–Check the status of pending claims–Upload supporting documents–View payment history–Complete some online claims forms; VA Form 21-526ez, VA Form 21-686C, VA Form 21-674, VA Form 21-4502, and VA Form 21-2680. VA Form 21-0781 and VA Form 21-8940 have been integrated into the 21-526EZ and the questions that need to be answered for those forms will be brought up through that process.

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Questions

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