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Updated Jul 22, 2024

In This Section
This section contains the following topics:
Topic
Topic Name
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2
3
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1.  General Claim Considerations

Introduction
This topic discusses general claim considerations, including

Change Date

 February 19, 2019

VI.i.1.A.1.a.  Final Stage in Adjudicating a Claim
The final stage in adjudicating a claim, after all relevant evidence (to include Federal tax information (FTI)) has been collected and reviewed, and a rating decision prepared (if necessary), is to
  • award benefits when entitlement exists, and/or
  • deny benefits when entitlement does not exist.
Reference:  For more information on FTI, see M21-1, Part XIV, 4.A–D.

VI.i.1.A.1.b.  Responsibility for Awarding or Denying Benefits
A single claim typically involves multiple issues the Department of Veterans Affairs (VA) must resolve.  The authorization activity is responsible for ensuring VA makes a decision to award or deny entitlement to benefits for each issue a claimant raises.
The authorization activity must
  • address all issues based on
    • eligibility criteria, and
    • any rating decision, and
  • inform the claimant of the decision on each issue.
Notes:
  • Many adjudication actions will be a combination of awarding and denying entitlement.
  • The end product controlling the claim must remain pending until VA resolves each of the issues the claimant raised in that claim.

VI.i.1.A.1.c.  Requirement to Reduce or Withhold Payments
Even if VA determines a claimant is eligible for monetary benefits, to include disability compensation for one or more service-connected (SC) disability(ies), VA may have to reduce or withhold payments if
  • the claimant is a Veteran who
    • received separation benefits, or
    • is receiving military retired pay (MRP), or
  • VA has proposed to rate the claimant incompetent.
References:  For more information on reducing or withholding payments based on

VI.i.1.A.1.d.  Reviewing a Supplemental Claim
For a supplemental claim, the process for requesting information from a claimant and other sources is the same as it is for an initial claim.
If basic eligibility criteria (such as Veteran status, or wartime and minimum active duty service requirements for pension claims) are met, the rating activity must review the following types of supplemental claims:
  • claims for benefits involving (a) specific disability(ies), and/or
  • claims in which benefits were previously discontinued due to a change in special eligibility, such as no longer being
    • permanently and totally disabled, or
    • in need of aid and attendance (A&A).
Important:  The rating activity does not need to review pension claims to make a disability determination when income or net worth bar pension entitlement.
Reference:  For more information on supplemental claims, see

2.  General Information on Processing Decisions

Introduction
This topic contains general information on processing decisions, including

Change Date
July 22, 2024

VI.i.1.A.2.a.  Responsibility for Processing Rating Decisions
After rating decisions are completed they are routed directly to the authorization activity, which is responsible for processing rating decisions.

VI.i.1.A.2.b.  Effective Date of Payment Under 38 CFR 3.31
It is important to understand the difference between the effective date of payment and the effective date of entitlement.
Under 38 CFR 3.31, VA may not pay monetary benefits based on an original, supplemental, or increased award of compensation, pension, or Dependency and Indemnity Compensation (DIC) for any period prior to the first day of the calendar month following the month in which the beneficiary became entitled to the benefit.
Example:
Scenario:  The rating activity assigns an increased disability rating to a Veteran’s SC back disorder effective April 21, 2022.  (This represents the effective date of entitlement.)
Result:  The effective date of the corresponding increase in the Veteran’s compensation is May 1, 2022.  (This represents the effective date of payment.)
Exception:  Effective October 1, 2011, Section 605 of Public Law 111-275 amended 38 U.S.C. 5111 to allow VA to pay disability compensation from the date of entitlement to said benefit to any Veteran who retires or separates from active duty due to a catastrophic disability.  For VA purposes, “catastrophic disability” means a permanent, severely disabling injury, disorder, or disease that compromises the ability of the Veteran to carry out the activities of daily living to such a degree that they require
  • personal or mechanical assistance to leave home or bed, or
  • constant supervision to avoid physical harm to self or others.

VI.i.1.A.2.c.  Award-Processing Responsibilities
The table below describes who is responsible for specific actions during the award process.
Who Is Responsible
Actions
Veterans Service Representative (VSR)
  • Conduct a cursory review of the rating decision, to include the code sheet, in an attempt to identify any obvious errors, such as failure to consider entitlement to Chapter 35 benefits when a total disability rating is granted and no future examination is required.
  • Access the RATING screen in the Veterans Benefits Management System – Awards (VBMS-A) to validate data contained in the rating decision and notify the rating activity if any inconsistencies exist.
  • Enter additional data pertaining to the decision into the claims-processing system, as applicable.
  • Generate an award.
  • Ensure, as applicable, that the award document fully reflects all new and/or increased entitlements implemented by the associated rating decision and/or authorization determination(s).
  • Prepare a decision notice for the claimant.
  • For pension and Parents’ DIC cases only:  Ensure documentation of calculations made to determine the rate of benefits (such as calculations of medical expenses, net worth, and waived overpayments) are included in the electronic claims folder.
  • Route the award to a Senior VSR (SVSR).
Notes:
  • The only entry or update VSRs may make on the RATING screen is to select one of the override buttons along the bottom of the screen to ensure the appropriate effective date is generated when implementing award actions such as
    • reducing a disability rating, or
    • switching a Veteran’s disability rating from a total rating based on individual unemployability to a 100-percent schedular rating (or vice versa).
  • If the decision notice contains FTI, follow the instructions in M21-1, Part VI, Subpart i, 1.B.2.
  • The successful generation of adjusted payment rates from the earliest implicated effective date – for awards converted from the Benefits Delivery Network – may require the entry of an appropriate control date in the ONLY GENERATE NEW AWARD LINES FROM field on the claims-processing system’s RECORD DECISIONS screen.
  • The processing of a decision is commonly referred to as an “award” action, regardless of whether the decision
    • constitutes a grant or denial of benefits, or
    • results in an adjustment of benefits.
References:  For more information on
SVSR
  • Review the award and decision notice for accuracy. (Return the award and decision notice to the VSR for correction if errors exist.)
  • Authorize the award.
  • Date the decision notice with the expected date of mailing.
  • Release the following for mailing to the claimant:
    • decision notice
    • copy of the rating decision (if applicable), and
    • any pertinent enclosures.
  • Return the paper claims folder to the files activity (if a paper claims folder was used in the award/authorization process).
Notes:
Important:
  • In the VBMS awards-processing environment, the returning of an award or decision notice to a VSR for correction is known as a deferral.  The National Work Queue (NWQ) Playbook contains instructions (under the heading VBMS Deferrals) that claims processors must follow to properly manage such deferrals.
  • The Veterans Benefits Administration’s mission is to serve Veterans and their eligible dependents and survivors in the most timely and accurate manner possible.
    • It is only appropriate to extend suspense or diary dates if it is necessary for a specific adjudicative action.  Suspense dates must always correspond with specific actions and should not be arbitrarily extended under any circumstance.
    • When employees handle a claim, they are expected to take the most full and complete action possible on a claim every time – including development, rating, and promulgation actions – to move a claim forward to accurate completion in the claims process.  Every effort should be made to move the claim to the next processing cycle each time it is handled.

VI.i.1.A.2.d.  Circumstances Under Which a VSR May Authorize Their Own Award Action
A VSR may promulgate a rating decision and authorize the corresponding award action (taking the actions described in both rows of the table in M21-1, Part VI, Subpart i, 1.A.2.c) under the following circumstances:
Exceptions:
  • VSRs may not self-authorize the award action if promulgation of the rating decision will result in a reduction or discontinuation of benefits.
  • The policy described in this block does not apply to award actions taken by pension management centers.
Reference:  For more information on self-authorizing an award action in VBMS-A, see the VBMS Awards User Guide.

VI.i.1.A.2.e.  Awards That Require VSCM or PMCM Concurrence 
Some awards require concurrence by a Veterans Service Center Manager (VSCM) or Pension Management Center Manager (PMCM) (or a designee of one of these managers) in addition to authorization by an SVSR.  They include
  • awards having a net effect of a payment of at least $40,000, and
  • awards that were generated using the GENERATE AWARD OVERRIDE function.
References:  For more information on the

3.  General Information on Denials

Introduction
This topic contains general information on denials, including

Change Date
April 16, 2021

VI.i.1.A.3.a.  Definition:  Denial
A decision is considered a denial if, after review of a claim or issue and all evidence associated with it, VA makes a formal decision to
  • not award a benefit the claimant is seeking
  • confirm and continue a prior decision (this includes rating decisions that confirm and continue a disability rating following a routine future examination or hospitalization of a Veteran), or
  • reduce or discontinue benefits.
Note:  The initial establishment of a noncompensable disability rating for an SC disability is not considered a denial.  Although compensation is not payable for the disability (except, potentially, under 38 CFR 3.324), the noncompensable rating may entitle the Veteran to other VA benefits, such as medical care under 38 CFR 17.37(b) and 17.38.

VI.i.1.A.3.b.  Authority of the Authorization Activity to Make Decisions That Affect an Individual’s Entitlement to VA Benefits
The authorization activity has the authority to make basic eligibility determinations.  It also has the authority to decide
  • the effect an individual’s income and/or net worth has on their entitlement to income-based benefits
  • whether entitlement to additional benefits for a dependent or dependents exists, and
  • whether entitlement to A&A under 38 CFR 3.351(c)(2) exists, based on the status of the following individuals as a patient in a nursing home:
    • Veteran in receipt of Veterans Pension
    • surviving spouse or parent in receipt of DIC
    • surviving spouse in receipt of Survivors Pension, or
    • spouse of a Veteran when the Veteran is in receipt of disability compensation.
Restrictions:  The authorization activity does not have the authority to
  • determine whether service treatment records support a claim for disability compensation, or
  • deny without a rating decision a claim for survivors’ benefits that involves the issue of service connection (SC) for the cause of death.
Note:  If basic eligibility is established and the claim requires consideration of medical evidence of record, refer it to the rating activity for review.  Claims of this nature require a formal, coded rating decision.
Exception:  M21-1, Part VI, Subpart i, 1.A.3.c describes conditions under which the authorization activity may deny a claim without a rating decision.
References:  For more information on

VI.i.1.A.3.c.  Conditions Under Which the Authorization Activity May Deny a Claim
The authorization activity may deny a claim for disability compensation or survivors benefits without a rating decision under any of the following conditions:
  • a legal bar to entitlement exists
  • the claimant does not respond within 30 days to a request for evidence needed to determine whether or not there is a legal bar to entitlement, such as in cases involving continuous cohabitation, or
  • in survivors benefit cases, the claim is one in which
    • SC for the cause of death was not specifically claimed, and
    • there is no reasonable probability that the cause or contributory cause of death was related to service (including, but not limited to, death due to accident or natural disaster, homicide, or execution for a crime).
Notes:
  • Resolve any issues regarding basic eligibility or bars to benefits before considering SC.  In accordance with 38 CFR 3.159(d), VA should not continue providing assistance with a claim if there is no reasonable possibility that assistance will substantiate the claim.
  • If VA concurrently denies SC for the cause of death and awards pension, enter the following as a remark on the corresponding award document:  SC death benefits denied – M21-1, Part VI, Subpart i, 1.A.3.c.
  • When notifying a claimant of a decision that authorization activity made (without referral to the rating activity) to deny entitlement to a claimed benefit, authorization activity must include the following in the decision notice, just as the rating activity includes them in rating decisions:
    • reasons and bases for the decision
    • laws and regulations relevant to the claim
    • a summary of the evidence authorization activity considered
    • element(s) necessary to grant the claim that were not met, and
    • findings that are favorable to the claimant under 38 CFR 3.104(c).
References:  For more information on

VI.i.1.A.3.d.  Requirement to Receive and Review All Required Evidence Before Denying a Claim
Unless there is a statutory bar to entitlement to benefits, the authorization activity must not deny any claim until VA has
  • received and reviewed all evidence required to make a decision, or
  • exhausted all reasonable means of obtaining the evidence and, for records from Federal sources, determined that either
    • the record does not exist, or
    • further efforts to obtain the record would be futile.
Note:  A formal claim requires a formal decision and notification.  However, VA’s consideration of subordinate and within-scope issues associated with a claim (as explained in M21-1, Part V, Subpart ii, 3.A) does not necessarily require a formal decision and notification if such consideration would result in a denial.
References:  For more information on

VI.i.1.A.3.e.  Incomplete Applications and Benefit Requests That Are Not Filed on a Prescribed Form
Do not process a denial if a claimant has failed to submit a
References:  For more information on

4.  Denials Based on a Claimant’s Failure to Furnish Requested Evidence

Introduction
This topic contains information on denials that are based on a claimant’s failure to furnish requested evidence, including handling

Change Date
April 24, 2020

VI.i.1.A.4.a.  Handling a Claimant’s Failure to Submit Evidence VA Requested
If a claimant fails to submit evidence within a time period VA specified,
  • refer the claim to the rating activity (if a rating decision is required)
  • process a denial (or award benefits, if other evidence of record supports a grant of entitlement to all or some of the benefits the claimant is seeking), and
  • prepare a decision notice.
Important:
  • If VA denies any portion of a claim because the claimant failed to submit evidence VA requested, the decision notice must
    • state this fact
    • explain that other evidence of record does not support the claim, and
    • inform the claimant they must furnish the evidence VA requested, along with VA Form 20-0995, Decision Review Request:  Supplemental Claim, within one year of the date of the decision notice in order to remain entitled to benefits from the original date of claim, if VA later establishes entitlement.
  • Prepare a new decision notice if VA previously denied a claim based on a claimant’s failure to submit evidence, then VA subsequently
    • makes another determination of non-entitlement based on additional evidence the claimant furnished within one year of the date of the previous notice of denial, or
    • denies the claim solely on legal grounds.
References:  For more information on

VI.i.1.A.4.b.  Handling a Claimant’s Failure to Report for a VA Examination
The table below describes the process for handling cases in which a claimant fails to report for a VA examination without good cause.
Stage
Who Is Responsible
Action
1
development activity
Refers the claim to the rating activity for consideration.
2
rating activity
Decides the claim in accordance with principles set forth in M21-1, Part IV, Subpart i, 2.F.1.a.
3
rating activity
Routes the rating decision to the authorization activity.
4
authorization activity
Processes an award and/or denial and issues notification to the claimant.
Important:  If a denial is based on the claimant’s failure to report for an examination, either the rating decision or the decision notice must
  • inform the claimant that VA cannot favorably decide the claim without an examination, and
  • advise the claimant to
    • notify VA when they are ready to report for an examination, or
    • submit a properly executed disability benefits questionnaire.
References:  For more information on

VI.i.1.A.4.c.  Handling an Abandoned Claim
If a claimant fails to provide evidence within one year of VA’s request and VA has not decided the claim as of the expiration of the one-year period, consider the claim abandoned.
Important:  It is not necessary to advise a claimant of their review rights when the claimant has abandoned their claim.
Reference:  For more information on abandoned claims, see

5.  Special Denial Procedures

Introduction

 This topic contains information on special denial procedures, including

Change Date

 August 10, 2020

VI.i.1.A.5.a.  Changing the Basis of a Previous Denial
If VA reviews or reconsiders a claim it previously denied and decides to change the basis of the denial, it must
  • reprocess the denial according to the instructions in M21-1, Part VI, Subpart i, 1.A.2.c, and
  • if necessary, make appropriate system selections to
    • add any new favorable findings related to the basis of the new denial, and/or
    • overturn any and all findings that
      • were formerly found favorable to the claimant under 38 CFR 3.104(c), but
      • are no longer applicable.
References:  For more information on

VI.i.1.A.5.b.  References to Other Special Denial Procedures
The table below contains references to other special denial procedures.
For more information on …
See …
notifying a claimant that election of pension is not in their best interest
notifying a claimant of a denial that is based on their income or net worth
eligibility determinations regarding the Department of Defense’s death gratuity
denying a request for release of information or amendment of records
denying claims from certain foreign residents