In This Section

This section contains the following topics:

Introduction

This topic contains general information on requests for Federal records, including

• Department of Veterans Affairs’ (VA’s) responsibility to assist claimants in obtaining evidence
• electronic requests for records from a Federal entity
• written requests for records to a Federal entity
• requesting outpatient treatment records (OPTRs) from a military treatment facility (MTF)
• obtaining records from a Vet Center
• reviewing for and obtaining records from the Veteran Readiness and Employment (VR&E) activity, and
• final notification to claimants that VA is unable to obtain relevant Federal records.

Change Date

III.ii.1.A.1.a. VA’s Responsibility to Assist Claimants in Obtaining Evidence

The Department of Veterans Affairs (VA) assists claimants in establishing entitlement to benefits by making reasonable efforts to obtain evidence needed to support a claim, whether that evidence is held by a Federal or non-Federal entity.

The procedures described in this section represent the minimum efforts VA must make in order to comply with the duty-to-assist requirements in 38 CFR 3.159.  If there is a reasonable expectation that development actions beyond those described in corresponding blocks could result in the procurement of records to support a pending claim, such additional actions shall be taken.

Important:

• Claimants that meet eligibility requirements for priority record request processing, as described in M21-1, Part III, Subpart ii, 2.D.1.a, must have the corresponding corporate flashes and/or special issue indicators attached to the claim at the intake or development stage, as appropriate.
• The Veterans Benefits Administration (VBA) may request copies of the medical records upon which the Social Security Administration (SSA) based its decision, if there is an indication the
  • claimant has filed a claim for or is receiving disability benefits from SSA, and
  • medical records may be pertinent to a claim for
    • increased disability compensation
    • a 100-percent disability rating based on individual unemployability (IU)
    • disability pension, or
    • additional benefits based on being housebound or requiring the aid and attendance of another person.

References:  For more information on

• VA’s duty to assist, see 38 CFR 3.159
• assisting with Federal records, see M21-1, Part III, Subpart i, 2.C.1
• assisting with non-Federal records or private records, see M21-1, Part III, Subpart i, 2.C.2
• requesting records from SSA, see M21-1, Part III, Subpart ii, 1.B
• when to obtain SSA records in IU claims, see M21-1, Part VIII, Subpart iv, 3.B.4.a
• adding
  • corporate flashes, see M21-1, Part III, Subpart i, 2.F.1.b, and
  • claim-specific special issues, see M21-1, Part III, Subpart i, 2.F.2.f and g, and
• appropriate use of
  • corporate flashes, see M21-4, Appendix E.1, and
  • special issue indicators, see M21-4, Appendix E.2.

III.ii.1.A.1.b.  Electronic Requests for Records From a Federal Entity

VBA encourages obtaining records electronically, when feasible, and has established means to communicate with various Federal record custodians.  The different tools VBA uses have their own tailored request mechanisms and follow-up procedures.

The table below identifies those record types and where to find specific procedures for obtaining them.

• M21-1, Part III, Subpart ii, 2.A.4
• M21-1, Part III, Subpart ii, 2.C.2-6

• M21-1, Part III, Subpart ii, 2.E
• M21-1, Part VI, Subpart ii, 2
• M21-1, Part XII, Subpart i, 4.C

III.ii.1.A.1.c.  Written Requests for Records to a Federal Entity

The table below describes the procedure for sending written requests for records to a Federal entity.  This includes requests for records from

• service academies
• the Office of Workers’ Compensation
• Vet Centers, and
• NPRC and if necessary, the Office of Personnel Management (OPM), when Federal civilian employment records are needed.

Important:

• If VA obtains the records at any point in this procedure
  • stop taking the steps described in the table below, and
  • decide the claim after all other development actions are complete.
• NPRC has specific requirements that individuals and third parties must follow to request Federal civilian employment records.  Instructions are located on the Official Personnel Folders, Federal (non-archival) Holdings and Access website.
• NPRC may not be able to provide all civilian employment information identified on VA Form 21-4192, Request for Employment Information in Connection With Claim for Disability Benefits.  NPRC will provide available information and instruct claims processors to request the remaining information from OPM.
• Faxing or mailing a request for records to SSA is only permitted when the SSA- Government-to-Government Services Online (SSA-GSO) interface is down for an extended period, as indicated in M21-1, Part III, Subpart ii, 1.B.2.c.

References:  For more information on

• submitting requests for records to SSA, see
  • M21-1, Part III, Subpart ii, 1.A.1.a, and
  • M21-1, Part III, Subpart ii, 1.B
• requesting records from service academies, see M21-1, Part III, Subpart ii, 2.F.5.d
• information sharing with OPM, see M21-1, Part XIII, Subpart ii, 2.D, and
• the relevancy of records, see M21-1, Part III, Subpart i, 2.E.

III.ii.1.A.1.d.  Requesting OPTRs From an MTF

Veterans and their beneficiaries may continue receiving outpatient treatment at an MTF after the Veteran has been discharged from military service.  The table below provides instructions for obtaining outpatient treatment records (OPTRs) from an MTF.

References:  For more information on

• requesting medical records using VA Form 21-8359, see M21-1, Part III, Subpart ii, 2.C.1.f
• using JLV, see https://jlv.med.va.gov/JLV/, and
• handling unsolicited MTF OPTRs received in the claims folder, see M21-1, Part II, Subpart iii, 2.D.

III.ii.1.A.1.e.  Obtaining Records From a Vet Center

Vet Center medical records are considered Federal records in VA’s constructive custody.  These records are not retrievable through the Compensation and Pension Record Interchange (CAPRI) because the Vet Center provides mental health services that are protected under the Health Insurance Portability and Accountability Act (HIPAA).  When a Veteran has been treated at a Vet Center, regional offices (ROs) must

• obtain a completed VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA), andVA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA), and
• follow the steps for Federal records development outlined in M21-1, Part III, Subpart ii, 1.A.1.c.

Important:  Do not take any additional action if the claimant does not authorize the release of the Vet Center records.

References:  For more information on

• the notice of inability to obtain Federal records, see M21-1, Part III, Subpart i, 2.C.3.b
• VA Forms 21-4142 and21-4142a, see M21-1, Part III, Subpart ii, 3.1.b, and
• Vet Center records, see Dunn v. West, 11 Vet.App. 462 (1998).

III.ii.1.A.1.f.  Reviewing for and Obtaining Records From the VR&E Activity

VR&E began using VBMS to store electronic Counseling/Evaluation/Rehabilitation (CER) records for all new claims initiated after December 2018 and completed scanning all existing paper CER folders in December 2022.

Before requesting records directly from VR&E, claims processors must first review the electronic claims folder (eFolder) for the following documents which contain the information necessary to process an IU claim:

• VA Form 28-1902b, Counseling Record – Narrative Report, and
• VA Form 28-1902f, Feasibility Determination—Narrative Report.

Notes:

• VR&E documented the Veteran’s entitlement and feasibility of achieving a vocational goal on VA Form 28-1902b until February 2019, when the feasibility determination was removed and documented on a separate VA Form 28-1902f.
• The Veteran is notified of failure to report to VR&E’s initial evaluation appointment using VR-15, Missed Appointment 10-day Letter.  If the Veteran does not respond to the notification letter,they are notified that the determination of entitlement to Chapter 31 benefits was not made due to lack of information and the claim was disallowed using VR-58, Chapter 31 Adverse Decision Letter.
• Occasionally the Veteran’s VR&E records are not correctly labeled in the eFolder and may be indexed as VR&E General or VR&E Correspondence.

Follow the steps in the table below if a thorough review of the claims folder does not result in the records being located.

III.ii.1.A.1.g.  Final Notification to Claimants That VA Is Unable to Obtain Relevant Federal Records

If efforts to obtain records from a Federal entity are ultimately unsuccessful, ROs must prepare a final notification letter and send it to the claimant.

Exceptions:  If the unavailable Federal records are

• STRs, the RO must first attempt to locate the records in JLV before sending the final notification letter
• VAMC or VR&E records, the RO must follow the instructions in M21-1, Part III, Subpart ii, 1.A.2.g–i, or
• fire-related records, and the Veteran fails to provide enough information to submit a request to reconstruct the records via the Personnel Information Exchange System, follow the procedures in M21-1, Part III, Subpart ii, 2.F.1.c or f, whichever is applicable, instead of sending the final notification letter.

Important:

• All claims processors can prepare final notification letters for any type of Federal record.
• The claims processor preparing the final notification letter may determine how to format the list of records, facilities, disabilities, treatment dates, date ranges, etc., based on the individual case, as long as each set of unavailable records is clearly identified.

References:  For more information on

• accessing JLV, see https://jlv.med.va.gov/JLV/, and
• the relevancy of records, see M21-1, Part III, Subpart i, 2.E.

Introduction

This topic contains information on obtaining VA medical records, including

• VA medical records and the requirement to obtain relevant records
• electronic recordkeeping of treatment at VAMCs
• information and records available via
  • CAPRI, and
  • JLV
• determining whether an electronic VA Form 10-7131, Exchange of Beneficiary Information and Request for Administrative Action, should be submitted
• checking the status and following up on electronic VA Form 10-7131 requests
• concluding VA medical records do not exist
• determining if a final notification letter for VAMC records is warranted, and
• preparing a final notification letter for VAMC or VR&E records.

Change Date

III.ii.1.A.2.a.  VA Medical Records and the Requirement to Obtain Relevant Records

VA medical records include records documenting

• inpatient and outpatient treatment received
  • at a Veterans Health Administration (VHA) facility, or
  • by a contractor under VHA’s Community Care, also known as the Veterans Community Care Program (VCCP), MISSION Act, or formerly known as the Veteran’s Choice Program, and
• Vet Center records.

VBA must associate any relevant records pertaining to the claimed condition(s), including those identified by the claimant, unless the RO concludes that it is reasonably certain the records do not exist.

Important:

• When a claim that includes an automation-eligible contention is received, VBA utilizes automated medical data retrieval tools called Health Data Repository (HDR) and Standards and COTS Integration Platform (SCIP) that package all available VHA records (including Community Care records in VHA possession) and upload the complete set of records into the eFolder using the document type VAMC Other Output /Reports.  The initial HDR and SCIP uploads contain the earliest available electronic treatment reports up through records available the date HDR and SCIP initiated the bulk records retrieval, alleviating the need for claims processors to do extensive manual records retrieval during current and future claims development.
• If the claimant does not indicate treatment at a VAMC or provide dates of treatment, ROs must
  • perform the enterprise search in CAPRI
  • review JLV for VAMC treatment or Community Care records (or indication of treatment) as described in M21-1, Part III, Subpart ii, 1.A.3, and
  • ensure any relevant treatment records not already obtained by SCIP are associated with the Veteran’s claims folder.

Notes:

• Establish necessary controls to ensure the return of the requested reports.
• If the identified VAMC records are available entirely in CAPRI or JLV, it is not necessary to create a tracked item to confirm that the records have been uploaded directly into the eFolder.
• The RO must associate the relevant records to the eFolder when
  • development action is first being taken on the claim, or
  • if no development action is necessary, before routing the claim for rating activity review and consideration.
• The rating activity is responsible for
  • a final review of CAPRI and JLV to ensure all relevant records have been associated with the eFolder
  • associating additional records that have been identified during the final review, and
  • ensuring the records are appropriately documented in the decision.

References:  For more information on

• the relevance of records, see M21-1, Part III, Subpart i, 2.E
• VBA’s automated medical data retrieval tools, see the
  • Health Data Repository Quick Sheet, and
  • Standards and COTS Integration Platform (SCIP) Quick Sheet
• enterprise search function, see the CAPRI User Manual
• obtaining VA records using VA Form 10-7131, Exchange of Beneficiary Information and Request for Administrative Action, see M21-1, Part III, Subpart ii, 1.A.2.e and f
• concluding VA records do not exist, see M21-1, Part III, Subpart ii, 1.A.2.g
• obtaining records from a Vet Center, see M21-1, Part III, Subpart ii, 1.A.1.e
• obtaining Community Care records, see M21-1, Part III, Subpart ii, 1.A.3
• VCCP, see VHA’s Community Care website, and
• the exchange of information between ROs and VA medical facilities, see M21-1, Part X, Subpart iii, 1.A.1.

III.ii.1.A.2.b.  Electronic Recordkeeping of Treatment at VAMCs

VHA completed the transition to electronic recordkeeping at all VAMCs in late 2004.  Text-based medical treatment records and information are generated by VHA in the legacy electronic health record (EHR) system called Computerized Patient Record System (CPRS).  Digitized third-party private medical records (PMRs) provided by the Veteran, Community Care, testing and imaging records (such as, but not limited to echocardiograms, audiometric tests, x-rays, Goldmann-Bowl perimetry charts, etc.) are generated/stored in the legacy EHR system Veterans Information Systems Technology Architecture (VistA).

VBA claims processors access the electronic health records using CAPRI and JLV.  Treatment that occurred prior to the transition to electronic recordkeeping has been archived by VHA; therefore, claims processors should always consider submitting an electronic VA Form 10-7131 request for archived records when treatment is alleged at a VAMC prior to 2005.

VHA has begun the Electronic Health Record Modernization (EHRM) Initiative that will transition all VAMCs to a new EHR system shared with the Department of Defense.  VAMCs that convert to the new EHR system will no longer create records in VHA’s legacy systems or utilize functionality that interfaces with CAPRI.  All claims processing personnel are able and required to access and obtain converted electronic treatment records through JLV; however, special pilot program ROs and personnel will be responsible for processing certain stages of claims, as directed in the EHRM National Process Memorandum.

Notes:

• VHA employees access electronic VA Form 10-7131 requests for Veteran health records using the Automated Medical Information Exchange (AMIE) program at most VAMCs.
• Electronic VA Form 10-7131 requests for archived records held by an EHR-converted VAMC will be submitted by VBA employees and received by VHA employees using the new Cerner application.

References:  For more information on

• records available via
  • CAPRI, see M21-1, Part III, Subpart ii, 1.A.2.c, and
  • JLV, see M21-1, Part III, Subpart ii, 1.A.2.d
• determining whether a VA Form 10-7131 should be submitted, see M21-1, Part III, Subpart ii, 1.A.2.e
• EHRM, see the EHRM website
• CAPRI, see the CAPRI User Manual, and
• JLV, see JLV Help.

III.ii.1.A.2.c.  Information and Records Available via CAPRI

CAPRI provides VBA claims processors access to text-based medical treatment records and information generated by VHA (i.e. – CPRS records).  It can also be used to locate information about when the Veteran first applied for care by VA, as well as when the Veteran enrolled for care at specific VAMCs.

The registration date is the date the Veteran applied for VA healthcare and predates the enrollment system.  This date applies to all VAMCs and is not unique to each individual facility.  It can be found under the REPORTS tab by selecting VIEW REGISTRATION DATA and reviewing the APPLICATION INFORMATION field.

The enrollment date is the date the Veteran was entered into the specific VAMC’s computer system and is unique for each VAMC the Veteran visited.  Enrollment date-tracking was implemented in 1996 and can be found under the REPORTS tab by selecting PATIENT PROFILE MAS (Full) and reviewing the ENROLLMENTS field.

Exception:  CAPRI does not provide access to EHR records, VistA records, photos, diagnostic imaging (such as x-ray, magnetic resonance imaging (MRI), computed tomography (CT) scan, etc.), or Community Care records.  JLV must be used to obtain these records, as indicated in M21-1, Part III, Subpart ii, 1.A.2.d.

Notes:

• CAPRI and the enterprise search function will indicate the claimant has treatment at the CERNER (200CRNR) – Treatment Records Exist “facility” when treatment reports exist at an EHRM-converted VAMC.
• A warning message indicating the records cannot be obtained through CAPRI will be displayed to users who attempt to access the “facility” and EHR information.
• When communicating with VHA employees regarding electronic treatment records, be mindful that the AMIE and Cerner applications are used by VHA to access and view electronic VA Form 10-7131 requests.  The employees may not understand references to CAPRI.

References:  For more information on

• viewing and obtaining records via CAPRI, see the CAPRI User Manual, and
• the different applications used to send and receive electronic VA Form 10-7131 requests, see M21-1, Part III, Subpart ii, 1.A.2.b.

III.ii.1.A.2.d.  Information and Records Available via JLV

JLV provides VBA claims processors access to both text and image-based medical treatment records and information generated by, or in the possession of, VHA.  This includes

• all treatment records accessible via CAPRI (i.e. CPRS records
• treatment records created in EHR, and
• VistA scanned or imaged records such as, but not limited to
  • echocardiograms, audiometric tests, x-rays, Goldmann-Bowl perimetry charts
  • Community Care records, and
  • private health provider (PHP) records submitted by the Veteran to VHA.

Important:  Medical treatment during military service that took place at an MTF or VAMC that converted to the new EHR system will not be included in the certified STRs.  These clinical records must be obtained using JLV.

References:  For more information on

• accessing JLV, see https://jlv.med.va.gov/JLV/, and
• using JLV, see
  • JLV Help
  • JLV Quick Tips, and
  • the JLV User Guide.

III.ii.1.A.2.e.  Determining Whether an Electronic VA Form 10-7131 Should Be Submitted

When a Veteran alleges VA treatment, but no records are found in either CAPRI or JLV, the RO must then determine whether

• the records exist, but are inaccessible through CAPRI or JLV and require an electronic VA Form 10-7131 request to obtain the records, or
• it is reasonably certain the records do not exist.

Factors to consider when determining whether an electronic VA Form 10-7131 should be submitted for records that are not available in CAPRI or JLV include:

• whether the treatment occurred prior to
  • full implementation of electronic record-keeping, and/or
  • the registration and enrollment date shown in CAPRI
• if there is evidence of treatment at a VAMC during the identified time period in
  • CAPRI, and/or
  • the claims folder
• responses to prior VA Form 10-7131 requests, and
• if the records are relevant to the claim.

Use the table below to determine when to submit an electronic VA Form 10-7131 and the date range of treatment the request should cover.

Important:

• Electronic VA Form 10-7131 requests in CAPRI must
  • include the dates of treatment in the REMARKS section, and
  • check the OTHER/EXAM (REVIEW/REMARKS) box.
• When evidence in the claims folder contradicts the information displayed in CAPRI, always base the request off the information provided by the Veteran and what is available in the claims folder.
• Do not submit a VA Form 10-7131 request for records covering a period of treatment that has been previously requested, unless a response from VHA was not received.
• When an electronic VA Form 10-7131 request is needed for pre-2005 treatment records at a VAMC that has converted to the new EHR system, follow the special procedures, as indicated in M21-1, Part III, Subpart ii, 1.A.2.b.

Example:  A Veteran indicates treatment at Loma Linda VAMC from 1994 to present.  A review of CAPRI displays a registration date in 1997 and treatment beginning October 7, 2001.  The claims processor locates treatment records from Loma Linda VAMC in the claims folder for treatment from January 22, 1994, through December 31, 1995.  The information in the claims folder contradicts what is provided in CAPRI, therefore, the Veterans statement of treatment and the available evidence in the claims folder should dictate what records need to be requested.  Duplicate requests for treatment records should not be submitted; therefore, an electronic VA Form 10-7131 request should be submitted for treatment from January 1, 1996, through October 6, 2001.

References:  For more information on

• CAPRI, see the CAPRI User Manual
• JLV, see JLV Help
• accessing JLV, see https://jlv.med.va.gov/JLV/
• submitting a VA Form 10-7131 request via CAPRI, see the CAPRI User Manual
• locating Veteran enrollment and registration data, see M21-1, Part III, Subpart ii, 1.A.2.c, and
• the relevancy of records, see M21-1, Part III, Subpart i, 2.E.

III.ii.1.A.2.f.  Checking the Status and Following Up on Electronic 10-7131 Requests

Follow the steps in the table below when checking the status or conducting a follow-up on an electronic VA Form 10-7131 request after the initial 30-day suspense period has expired and the records are not in the eFolder.

References:  For more information on

• following up on electronic VA Form 10-7131 requests, see the CAPRI User Manual
• contacting the VAMC
  • ROI staff, see the VAF 10-7131 Request Contact List, and
  • HIM Chief, see the HIM roster
• JLV, see JLV Help
• accessing JLV, see https://jlv.med.va.gov/JLV/
• the relevancy of records, see M21-1, Part III, Subpart i, 2.E
• actions taken when an RO is unable to obtain relevant VAMC records, see M21-1, Part III, Subpart ii, 1.A.2.h and i, and
• converting and uploading e-mails, see M21-1, Part II, Subpart ii, 2.A.1.b.

III.ii.1.A.2.g.  Concluding VA Medical Records Do Not Exist

ROs can reasonably conclude VA records do not exist when a Veteran indicates treatment at a VA facility

• for a period earlier than their
  • registration date (if one is present), or
  • enrollment date (if one is present), when the indicated treatment began or after 1996
• for a specific condition during a timeframe when other electronic records exist for the Veteran (and the records cannot be found electronically), or
• if the attempts outlined in M21-1, Part III, Subpart ii, 1.A.2.e and f for records not electronically accessible in CAPRI/JLV are unsuccessful.

Exception:  Do not conclude records are nonexistent without first attempting to obtain the records using VA Form 10-7131, when evidence in the claims folder contradicts the registration or enrollment information displayed in CAPRI.

After concluding that VAMC records do not exist, claims processors must determine whether a final notification letter is warranted, as indicated in M21-1, Part III, Subpart ii, 1.A.2.h.

References:  For more information on

• registration and enrollment dates, see M21-1, Part III, Subpart ii, 1.A.2.c
• determining whether a VA Form 10-7131 should be submitted, see M21-1, Part III, Subpart ii, 1.A.2.e
• JLV, see JLV Help, and
• accessing JLV, see https://jlv.med.va.gov/JLV/.

III.ii.1.A.2.h.  Determining if a Final Notification Letter for VAMC Records Is Warranted

Claims processors must consider the circumstances of the individual claim when making conclusions on whether records exist and if a final notification letter is required.  These may include, but are not limited to, the following considerations:

• VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, does not require a claimant to identify a date range of treatment, if the treatment occurred at a VAMC between 2005 and present, because VA can electronically search, identify, and obtain these records in CAPRI and JLV without needing more specific detail.  In this circumstance, if VA is able to obtain any treatment records at the identified facility, for the identified disability, during this time frame, all identified records will be considered obtained.  Therefore, a final notification letter is not required.
• Claims processors are not to create a final notification letter for any VAMC treatment records sought via the required CAPRI enterprise search and JLV review, when the claimant has not explicitly identified treatment at a VAMC.
• Electronic claim submission services require specific calendar start and end dates when entering a date range for treatment.  The claimant may not have the ability to list a more general start and end period (month/year) for the treatment period.
• Treatment for a disability does not always require continued evaluation and review on a weekly or monthly basis.  Gaps in treatment during a date range provided by the claimant should be expected and should rarely necessitate the documentation of unavailability or non-existence.
• Obtaining relevant reports of treatment that occur prior to or after, but approximately close to, the starting and ending date(s) of treatment provided by the claimant, should be considered sufficient for the purposes of obtaining all identified records for the indicated disability(ies).

Important:  The phrase approximately close to, in relation to start and end dates, cannot be explicitly defined.  For the purposes of determining if a final notification letter is required, concluding that obtained treatment falls within an approximately close to range must be determined on a case-by-case basis.  The claimant may provide a treatment start date that began over 20 years ago.  In that case, approximately close to may mean within a few years.  If the claimant provides a much more recent start date, a gap of more than a few months may not be appropriate.

Example:  With the above considerations in mind, a final notification letter would not be required if

• the claimant indicates treatment end date(s) of “to present” or provides end date(s) that closely align to the corresponding intent to file (ITF) or claim submission date(s), and
• claims processors obtain records of treatment approximately close to the identified start date(s) through the current date.

Reason:  By identifying “to present,” or identifying an end date aligning to the ITF/claim submission date because the electronic claim submission process will not allow a future date, the claimant is asking VA to obtain all records of treatment since the identified treatment start date.  The treatment VA obtains between the start date and the current date would satisfy this request and a final notification letter would not be necessary.

III.ii.1.A.2.i.  Preparing a Final Notification Letter for VAMC or VR&E Records

Under 38 CFR 3.159(e), ROs are required to notify the claimant when they conclude reasonably identified VA medical or VR&E records do not exist or further efforts to obtain them would be futile.

When the RO is unable to obtain the records, prepare a final notification letter that identifies the

• VAMC/VR&E office(s)
• disability(ies) and/or reason for treatment/counseling, and
• date range of the unavailable records.

Important:

• The format of the final notification letter may be determined based on the individual case, as dictated by M21-1, Part III, Subpart ii, 1.A.1.g.
• Apply the same case-by-case considerations identified in M21-1, Part III, Subpart ii, 1.A.2.h, when documenting records that are unavailable.

References:  For more information on

• determining relevancy of records, see M21-1, Part III, Subpart i, 2.E, and
• the notice of inability to obtain Federal records, see M21-1, Part III, Subpart i, 2.C.3.b.

Introduction

This topic contains information on Community Care records, including

• general information on Community Care
• Federal vs. non-Federal Community Care records
• identifying when Community Care has been ordered and locating records
• when VBA has a duty to assist obtaining Community Care records
• circumstances where VBA will not develop for Community Care records, and
• labeling Community Care documents in the eFolder.

Change Date

III.ii.1.A.3.a.  General Information on Community Care

VHA provides eligible Veterans with hospital care, medical services, and extended care services through PHPs under the VCCP if VA

• cannot offer the care or services the Veteran requires
• does not operate a full-service VA medical facility in the Veteran’s area, or
• established eligibility for care under prior Veterans Choice Program criteria.

VHA coordinates health care by ensuring timely scheduling of medical appointments, maintaining continuity of care and services, coordinating among regional networks, and ensuring that eligible Veterans do not experience a lapse in care or an unusual or excessive burden in accessing care.

This service will be generally referred to as Community Carefor the purpose of discussions relating to Veteran treatment records.  VHA will create a consult note or record in its system that will generally document

• when Community Care is requested/ordered
• the health issue/condition it pertains to, and
• the purpose of the Community Care.

Reference:  For more information on the VCCP, see VHA’s Community Care website.

III.ii.1.A.3.b.  Federal vs. Non-Federal Community Care Records

Community Care records are not considered Federal or VA records until they are in VA possession, despite the fact VA is paying for the medical care.  VHA has an obligation to obtain complete copies of Community Care records after treatment.  These records are scanned or uploaded into VHA’s electronic record.  VBA obtains the records from VHA

• manually through JLV, or
• utilizing SCIP, an automated medical data retrieval tool that packages all available VHA records (including Community Care records already in VHA possession) and uploads the complete set of records into the eFolder using the document type VAMC Other Output /Reports.

In rare circumstances, VHA may fail to obtain the records.  The unobtained records are considered non-Federal records and, whenever necessary, must be pursued following private medical record development procedures found in M21-1, Part III, Subpart ii, 3.

References:  For more information on

• obtaining relevant VA medical records, see M21-1, Part III, Subpart ii, 1.A.2.a
• VBA’s automated medical data retrieval tools, see the Standards and COTS Integration Platform (SCIP) Quick Sheet, and
• when VBA has a duty to assist obtaining Community Care records, see M21-1, Part III, Subpart ii, 1.A.3.d.

III.ii.1.A.3.c.  Identifying When Community Care Has Been Ordered and Locating Records

VHA currently documents Community Care in

• the progress note(s) in the Veteran’s health record, and
• the actual treatment record(s) as scanned or imported documents.

The notes identifying a completed course of Community Care are labeled as Community Care – Consult Result Note or Community Care Result Note and the records are attached to the progress note as an image.  The records attached to these notes are considered the complete record from the Community Care provider.

Important:

• Claims processors must utilize JLV to review and obtain Community Care records from VHA’s legacy and new EHR systems.
• When the completed Community Care result note does not contain attached records, additional development actions must be undertaken by VBA as discussed further in M21-1, Part III, Subpart ii, 1.A.3.d.

Note:  The Community Care provider may send VHA some medical records prior to the completion of the entire authorized course of treatment.  These intermediate sets of records can be found attached to notes titled Community Care – Coordination Plan Note.

References:  For more information on

• electronic health recordkeeping by VHA, see M21-1, Part III, Subpart ii, 1.A.2.b and c
• historical ways Community Care was documented by VHA, see the VBA JLV TIP Sheet Viewing Community Care (Non-VA) Records, an
• locating scanned Community Care records in JLV, see the Community Partner/Non-VA Care Documents section in the JLV Quick Tips guide.

III.ii.1.A.3.d.  When VBA Has a Duty to Assist Obtaining Community Care Records

Under 38 CFR 3.159(c)(3), VBA has a duty to assist obtaining the missing non-Federal records when they are relevant to a claim.  However, the pursuit of the non-Federal Community Care records based on VBA recognizing VHA’s unsuccessful attempts is a one-time requirement.  Any future attempts to obtain the non-Federal Community Care records would require the Veteran or authorized representative to identify them as relevant to a pending claim and provide completed release forms, as discussed in M21-1, Part III, Subpart ii, 3.

This one-time process includes the following actions (as applicable):

• development actions related to missing or incomplete VA Forms 21-4142 and 21-4142a
• initiating the PMR Retrieval Program process, and
• remediating requests rejected by the PMR contractor.

Important:  VBA’s duty to assist obtaining Community Care records is also triggered without specifically being identified by the Veteran or authorized representative when all the following are true:

• IU is put at issue or claimed and a service-connected disability associated with IU has been treated under Community Care
• VHA was unsuccessful in obtaining the complete records, and
• VBA has not previously attempted to obtain the records.

References:  For more information on

• development actions related to missing or incomplete VA Forms 21-4142 and 21-4142a, see M21-1, Part III, Subpart ii, 3.1.d
• initiating the PMR Retrieval Program process, see M21-1, Part III, Subpart ii, 3.2.f, and
• remediating requests rejected by the PMR contractor, see M21-1, Part III, Subpart ii, 3.2.h.

III.ii.1.A.3.e.  Circumstances Where VBA Will Not Develop for Community Care Records

VBA will not make efforts to obtain Community Care records when

• the Veteran provides, or VBA previously requested and received copies of, PMRs that cover the date(s) of treatment and condition(s) treated by the Community Care private healthcare provider
• prior VBA attempts to obtain the Community Care records were unsuccessful and the Veteran was appropriately notified (via the development letters and/or decision notice), or
• the records are determined not to be relevant to the pending claim.

References:  For more information on

• claimant notification when PMRs are unavailable, see M21-1, Part III, Subpart ii, 3.1.g, and
• relevancy determinations, see M21-1, Part III, Subpart i, 2.E.1.

III.ii.1.A.3.f.  Labeling Community Care Documents in the eFolder

Labeling Community Care documents using eFolder functionality is a best practice but is only required when

• VHA was unable to obtain a complete copy of treatment from the Community Care provider, and
• VBA has obtained the missing records.

Make use of bookmarks, annotations, and subject lines to identify a document that contains the Community Care records VHA did not previously obtain.

Important:

• Do not change the document index labels for records uploaded by the SCIP automation platform.
• Do not isolate or separate Community Care records from their original source documents for the purpose of identification (i.e., do not split a PMR document in the eFolder into multiple documents, upload Community Care records in JLV separate from the main VAMC records grouping, etc.).

References:  For more information on

• eFolder maintenance, see M21-1, Part II, Subpart ii, 2.A.1.e and h, and
• records uploaded by the automation platform, see
  • M21-1, Part III, Subpart ii, 1.A.2.a
  • M21-1, Part III, Subpart ii, 1.A.3.b, and
  • Standards and COTS Integration Platform (SCIP) Quick Sheet.