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Updated Sep 18, 2024

In This Section

  
This section contains the following topics:
 
Topic Topic Name
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9 Claims Assistant (CA) Task Based Quality Review Checklist
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1.  Overview of the Quality Review Team (QRT)

 
 
 

Introduction

  
This topic contains an overview of the QRT, including the

Change Date

  
October 1, 2020

3.A.1.a.  Purpose of the QRT 

  
The decision review operations center (DROC) Quality Review Team (QRT) Program establishes a team of dedicated Quality Review Specialists (QRSs) with a focused emphasis on quality in the DROCs and alignment with the policy and procedures issued by the Office of Administrative Review (OAR).
 
The purpose of the QRT is to improve the quality and timeliness of disagreement claims processing and decrease the amount of work performed on individual cases.  This is accomplished by evaluating quality, reviewing error trends, providing training and mentoring on identified error trends, and performing monthly individual quality reviews.

3.A.1.b. QRT Composition

  
Each local QRT is comprised of at least one Authorization QRS (AQRS) and one Rating QRS (RQRS).  It is recommended that a ratio of 1:10 be used to determine the number of RQRS employees to the number of Rating Veterans Service Representatives (RVSR) and Decision Review Officers (DRO) and 1:14 be used to determine the number of AQRS employees to the number of Veterans Service Representatives (VSR) and Claims Assistants (CA) required to support the DROC.
 
Employees selected for the QRS position must meet their specific performance standards for quality.  Once selected for the QRS position, employees must participate in all proficiency assessments administered by OAR.
 

  2.  Duties of the QRT 

 
 
 

Introduction

  
This topic contains information on the duties of the QRT, including

Change Date

  
August 17, 2021

3.A.2.a.  Primary Duties of the QRT

  
The following list outlines the primary duties performed by QRTs:
  • Monthly Individual Quality Reviews (IQRs) for all CAs, VSRs, RVSRs, DROs, and QRSs
  • In-Process Reviews (IPRs)
  • Peer reviews of errors
  • Veterans Benefits Management System (VBMS) Deferral Mitigations
  • VBMS-Rating (VBMS-R) Override Review
  • Expanded and enhanced reviews
  • Mentoring, feedback, and training on quality trends, and
  • Special reviews identified by OAR.

3.A.2.b.  QRT Involvement in Training

  
QRT is responsible for providing training as it relates to the identification of error trends.  All other trainings (including Vitural and In-Person Progression (VIP), Challenge, national and local training, etc.) are the joint responsibility of the QRT, CAs, VSRs, RVSRs and DROs.
 
Note:  Second signature reviews associated with training activities are the joint responsibility of the QRT, CAs, VSRs, RVSRs, and DROs.

3.A.2.c.  Other Areas of QRT Involvement

  
Other areas in which QRT (inclusive of QRT coaches/assistant coaches) may be involved include
  • providing specific training recommendations as they pertain to quality at the employee level and DROC level, to improve quality based on the results of reviews,
  • conducting monthly meetings with DROC leadership and the DROC Training Manager, or designated training coordinator, to identify trends and specific recommendations,
  • working with Training Managers, or designated training coordinators, to create and provide specific training identified by error trends and analysis, and
  • using national and local results to identify recurring issues at the individual or team level that require additional training.
Note:  QRSs may assist the DROC with second signature work (trainee reviews, special monthly compensation (SMC) reviews, etc.) only when the QRT is up-to-date with primary QRT duties (IQRs, IPRs, mentoring).
 

3.  QRT Management/Supervision Duties

 
 

Introduction

  
This topic contains information about QRT management/supervision duties, including responsibilities of the QRT coach and/or other QRT supervisor. 

Change Date

  
August 23, 2024

3.A.3.a.  Responsibilities of the QRT Coach and/or Other QRT Supervisor

  
The QRT supervisor (coach/assistant coach) is responsible for the efficient operation of the QRT and its responsibilities.
 

Responsibility

Description
National error corrections
Responsible for managing National Quality errors per M21-5, Chapter 3, Section B, National Quality Reviews.
IQRs completed in Quality Management System (QMS)
1.  Responsible for managing the error correction process, including
  • coordinating corrections, and
  • managing rebuttal process.
2. Responsible for managing error correction notifications via the error correction detail in QMS.

3. Responsible for completion of QRTIQRFINAL review type in QMS within two business days of receipt in queue.

4. Responsible for validating IQRs are corrected appropriately per QMS cited directive by the QRS.

Reference:  For more information, see the QMS User Guide.
IPRs completed in QMS
1. Responsible for managing the error correction process, including
  • coordinating corrections, and
  • managing rebuttal process.
2. Responsible for managing error correction notifications via the error correction detail in QMS.
 
3. Responsible for validating IPRs are corrected appropriately per QMS cited directive by the QRS.
 
Reference:  For more information, see the QMS User Guide.
Mentoring
Responsible for notifying and mentoring employees regarding performance measures associated with, but not limited to
  • IQR results,
  • error overturns resulting from employee rebuttal process,
  • peer review feedback,
  • Proficiency assessment performance,
  • Skills Certification Test results,
  • mentoring, and
  • training surveys.
Error trend analysis
1. Responsible for  analyzing appropriate quality metrics to determine areas for training and mentoring.
 
2. Responsible for coordinating with DROC Training Managers to identify training courses to address error trends.
 

4.  Fundamentals of Quality Reviews

 
 
 

Introduction

  

Change Date

  
August 23, 2024

3.A.4.a.  Overview

  
The fundamentals of a quality review are listed below.
  • Perform a comprehensive review and analysis of all elements of processing the specific claim, issue, transaction, task, or end product (EP).
  • The standard for an error is where the decision made rises to the level of a clear and unmistakable error (CUE) or a clear violation of current regulations or directives.
  • The QRT must provide a regulation citation, manual reference, or other appropriate reference to support every error call, regardless of the type of quality review.
  • Personal feelings must not enter into the error call.  The only consideration is what the evidence shows and how it should be applied to the appropriate reference.

3.A.4.b.  Misclassified Errors

  
Errors will not be removed on reconsideration merely because the error was misclassified on the appropriate checklist or due to insufficient supporting reference.  Removing known errors on cases on the mandated random sample is contrary to sound quality control principles and provides stakeholders with inaccurate data.
 
Notes:
  • In these cases, the error will be upheld, but reclassified in the QMS  database to reflect the most appropriate classification.
  • This process will not affect the employee’s right to ask for an additional reconsideration using the local reconsideration procedures.

3.A.4.c.  Deselections

  
To ensure a statistically valid sample, every effort will be made to perform a quality review on all cases identified via QMS.
 
The Office of Performance Analysis and Integrity (PA&I) provides claim numbers to QMS based upon specific system transactions by individuals. Therefore, generally, there should be an actionable transaction appropriate for quality review.
 
In rare instances, when a review may not be appropriate, the QRS will propose to deselect the case if there is no other alternative.
 
Examples of incorrect deselection reasons include deselecting because the QRS is not trained in the review type, the transaction is already authorized or second signed, or there’s a large number of issues on the IQR.
 
Examples of proper deselections include deselecting because the documents associated to the transaction under review are no longer viewable to the QRS (for example, the rating decision, award, or correspondence).
 
The deselected case will be forwarded via QMS to the QRT coach (or appropriate designee) for verification and final deselection approval.
 
References:  For more information on
 

3.A.4.d.  Grace Period for IQRs

  
QRT will have a 30-calendar day grace period for any substantive procedural changes in the M21 series of manuals before citing deficiencies as critical errors.  The grace period is counted as 30-calendar days after the relevant Veterans Affairs (VA) Key Changes document is published. This does not include minor grammatical changes or relocation. The QRS must ensure that the specific block being cited was subject to substantive change before applying a grace period.
 
An error noted prior to the expiration of the 30-calendar day grace period should be recorded on the checklist to ensure the employee is made aware of the change and a correction to the case will be required.  However, the employee will not be cited for a quality error. 
 
Instructions for indicating these errors on the appropriate checklist are found in M21-5, Chapter 3, Section A.5.c.
 
Example: VA Key Changes document showing new manual guidance is published on January 22, 2024, so the grace period includes the next 30 calendar days. Errors will be cited on or after February 21, 2024, for any errors relevant to the specific citation.
 
Notes: 
  • Guidance issued through other means, such as interim guidance or guidance issued by the Office of Administrative Review (OAR) that contains specific claim processing instructions, does not warrant a grace period unless specifically provided by OAR. DROCs may not locally determine if a grace period is warranted.
  • DROCs may ask for an extension of a grace period, when applicable, by contacting OAR at vbawasoarqualitytrn@va.gov. 

3.A.4.e.  Error Narratives: Required Elements

  
Every error narrative must include
  • a statement of the error,
  • a statement of the facts, and
  • supporting references. 
The table below describes each of the required error narrative elements.
 
Element
Description
Statement of the Error
The QRS should provide a specific statement that clearly identifies the error cited.
 
Example: Heart Disability Benefits Questionnaire (DBQ), dated July 18, 2017, is insufficient for rating purposes because required Minimal Essential Testing Strategy (METS) or estimate was not provided. 
Statement of the Facts
The QRS should provide a concise statement of the facts that outlines the evidence supporting the finding of an error.
 
Example:  The VA examiner did not provide a well-supported rationale for the Medical Opinion.  Examiner noted there were no records from service to support onset of symptoms during Active Duty.  However, the service treatment records (STRs) contain multiple records showing treatment for the claimed right knee arthritis.
 
Notes:
  • The QRS should generally refrain from including specific corrective action in the narrative.
  • A judgment or a difference of opinion reflecting a possible better practice or solution will not be recorded as a comment.
Supporting References
The QRS should provide all appropriate references to support the error citation.  The references should be organized in a logical order and clearly separated.
 
Appropriate references include
Appropriate references do not include
  • court cases without a supporting manual citation or regulation
  • local policy directive
  • Fast Letters or Training Letters (unless relevant based upon a retroactive award), or
  • information from QMS Chatter. 

3.A.4.f.  Error Narratives: Multiple Error Citations

  
If multiple errors are cited, each error should be discussed independent from the others.  Each error should include the three elements of a narrative as noted in M21-5, Chapter 3, Section A.4.e.

3.A.4.g.  Error Narratives:  Use of Error Question and Descriptors

  
Reviews completed in QMS should not include a reference to the question or descriptor.  The checklist questions and/or descriptors may be adjusted; therefore, the order of the descriptors as they appear in QMS may change.
 
QMS has built in functionality to sort the user selections for error trend analysis purposes.

3.A.4.h.  Definition:  Cascading

  
Cascading is the result of citing multiple errors based upon the same basis, or root cause.

3.A.4.i.  Avoiding the Cascade Effect

  
Once the QRS has determined the root cause of an error, the QRS should cite no other errors as a natural result of the initial root cause error.
 
Once the root cause error has been identified, the QRS should review the claim as if the decision in error was correct, when reviewing the remainder of the claim.
 
QRS should capture all errors associated with a decision. VBA approved reporting systems will provide accuracy rates.
 
Examples:
  • Service connection (SC) is improperly granted because there was no event in service, but the assigned evaluation and effective date are otherwise correct.
    • Once the QRS has determined that the root cause of the error is the improper grant of SC due to lack of an event in service, they should continue to review the decision as if the grant were correct.  In this case, only a single error should be cited for the improper grant of SC.  The QRS would be incorrect to cite additional errors based upon the assigned evaluation and effective date.  Per the scenario, the evaluation assigned and effective date were correct based upon the evidence of record.  The assigned evaluation and effective date are not in error based solely upon the fact that the grant of SC itself was improper.
  • SC is improperly granted because there was no event in service.  Additionally, the assigned evaluation and effective date are incorrect based upon the evidence of record.
    • Once the QRS has determined that the grant of SC was improper, they should continue to review the decision as if the grant were correct.  In this example, the assigned evaluation was incorrect based upon evidence of record, so a separate error should be cited for the incorrect evaluation.  Similarly, the effective date was incorrect based upon the evidence of record, so the error for an incorrect effective date should be cited as well.
  • A VSR generates the wrong effective date for a dependent, which results in an incorrect notification letter.
    • The VSR would be called for one error for the incorrect effective date.  The subsequent error (incorrect notification letter) would not be called because it was caused by and the direct result of the original effective date error.

3.A.4.j.  Expanded Reviews 

  
Expanded sample sizes based on the amount set forth in the national performance standards for each position will be reviewed for quality purposes if a routine review of an employee’s work demonstrates the need for quality improvement.
 
Note: Effective October 1, 2020, expanded reviews are not applicable to VSRs and RVSRs. Effective January 1, 2021, expanded reviews are not applicable to DROs. However, management retains the option to select below threshold employees for an enhanced sample, as noted in M21-5, Chapter 3, Section A.4.k.
 
Note:  After reviewing all local quality data for an employee, the QRT supervisor will initiate a request to the DROC Manager (DROCM) or designee for an expanded review due to a demonstrated deficiency in quality.
 
Important:  Approval for the requested expanded review will come from the DROCM or designated appointee.  Expanded reviews must be established in the appropriate VBA system.
 
Reference:  For more information on expanded reviews, see the QMS User Guide.

3.A.4.k. Enhanced Sampling

  
Management may use enhanced sampling if a routine review of a VSR, RVSR, or DRO’s work demonstrates the need for quality improvement.
 
Note: After reviewing all local quality data for an employee, the QRT supervisor will initiate a request to the DROC Manager (DROCM) or designee for an enhanced sample review due to a demonstrated deficiency in quality.
 
Important: Approval for the requested enhanced sample will come from the DROCM or designated appointee. Enhanced sample reviews must be established in the appropriate VBA system.
 

3.A.4.l. Interim Guidance

  
VBA Central Office interim guidance supercedes the instructions found in M21-1 or other VA procedural references for quality review purposes. While the interim guidance is in effect, quality errors should be cited in instances where claims processors clearly do not follow the interim procedures correctly.
 
This includes citing systems compliance errors for incorrectly utilizing (or failing to properly add) corporate flashes or special issue indicators not listed as critical errors in M21-4, Chapter 6, Appendix A.d and e, but that are required by the interim procedures.
 
Interim procedures documents located on the Compensation Service webiste or other VA-maintained websites may be used as a valid reference for the error citation.
 
Note: Interim guidance must be implemented immediately. Grace periods will not apply to interim guidance unless one is specifically provided by OFO or OAR.
 

 5.  Individual Quality Reviews (IQRs)

 
 

Introduction

  

Change Date

  
August 23, 2024

3.A.5.a.  Purpose of IQRs 

  
A review of the individual’s work is intended as a performance measure to ascertain the quality element in that individual’s performance standard.
 
An IQR is intended to provide an evaluation of an individual’s work product to determine if the minimal standard for correctness has been met.
 
IQRs are the review of randomly-selected cases per month for those employees who have a quality element in their performance standards.  This review determines the employee’s individual quality level as part of their overall performance evaluation.
 
The intent of the performance standard is to obtain an average of three IQRs per month for each VSR, RVSR and DRO employee and five IQRs per month for each CA employee to assess the quality element in the standard.

3.A.5.b.  Review Criteria for IQRs

  
The QRT will be responsible for performing IQRs as identified by QMS.  These reviews will consist of a random selection of work based on the amount set forth in the national performance standards for each position. IQRs are randomly selected by PA&I and other computerized statistical models based on the available sample of work completed by the identified employee.
 
 

 

3.A.5.c.  Standard for Review of IQRs

  
The QRS will review all associated actions that were taken or should have been taken associated with the transaction under review.  IQRs should not be a de novo review of the entire case file but limited to the actions of the individual for whom the review is being completed.
 

Checklist

Standard of Review
Task-Based Quality Review Checklists
  • The review is a task-based review.
  • Each checklist question is a stand-alone question. The QRS will apply each question in the checklist for each contention to determine if that task was successfully met.
  • An “NA” response is recorded for each checklist question that does not apply to the actions taken by the employee associated with the transaction(s) under review.
  • Multiple errors may be cited within a single task.
  • A single error noted within a single task will result in no credit for that task.
  • When completing a review, the QRS should only uncheck the “Critical Error” box within each question if the noted error is within 30 days of a manual change as noted in M21-5, Chapter 3, Section A.4.d.

Important: Reviewers should evaluate the actions taken, or that should have been taken, based on the transaction date selected for review. Critical errors should not be cited for deficiencies that were found and corrected by the employee on the same day as the transaction date selected for review.

Example 1: On November 4, 2022, a VSR sends a Section 5103 notice to the Veteran and adds a tracked item with a 30-day suspense. The same day, the VSR realizes the 5103 development letter was not required and updates the tracked item disposition to “In Error.” A VSRIQRPRE is generated for the November 4, 2022 transaction.

Analysis: A critical error related to sending the unnecessary Section 5103 notice should not be cited because the VSR caught and corrected the mistake on the same day as the transaction selected for the IQR.

Note: Because quality reviews are selected based on a specific date, quality reviewers should only consider actions taken, or that should have been taken, up to the date of the transaction under review. Corrections completed the same day are considered part of the transaction under review. If corrective action occurred on a later date, even by the same employee, this is a separate and distinctly different transaction that is not considered as part of the transaction selected for review.

Example 2: A VSR orders and incorrect examination on April 18, 2022. On April 21, 2022, an RVSR completes a partial rating on the claim and corrects the examination request. On May 24, 2022, the same VSR conducts follow-up development. A VSRIQRPRE is generated for the May 24, 2022 follow-up development transaction.

Analysis: The reviewer should evaluate the VSR actions that were taken, or that should have been taken, on May 24, 2022. A critical error should not be cited for ordering an incorrect examination on April 18, 2022 because as of May 24, 2022 the examination request was accurate and no corrective action was required.

Note: If the examination request dated April 18, 2022 was not corrected as of May 24, 2022, then it would be appropriate to cite a critical error.

References: For more information on

3.A.5.d.  Recording Method for IQRs

  
DRO, RVSR, VSR, CA, and QRS reviews must be completed in QMS. 

3.A.5.e.  Peer Reviews

  
Peer reviews are required for all errors cited on any IQR type. Peer reviewers are responsible for ensuring that 
  • cited errors are appropriate,
  • errors are properly documented with applicable references,
  • the remainder of the checklist has been properly completed to include correctly indicating the applicability of other tasks, and
  • ensuring that there are no missed errors that should have been cited by the initial reviewing QRS.
 
Obvious errors that were not cited by the initial QRS should be cited and forwarded for correction per the appropriate instructions in the QMS User Guide.
 
QMS will automatically route all claims that have identified errors on initial review to a QRS with authority to perform peer reviews.  The results of the peer reviews will be documented in QMS.
 
Important: Once the initially reviewing QRS has submitted their review, the checklist cannot be changed by anyone except the peer reviewer. Coaches are not to manually reassign a review that has been forwarded to the peer reviewer level to the initial reviewer for corrections to the checklist.
 
References:  For more information on QMS, see the QMS User Guide.  

3.A.5.f.  Peer Review Disagreements

  
As with overturning an error, the only basis for disagreeing with an error during the peer review is because the initial QRS’s error call is clearly incorrect, based in fact or law. Mere disagreements in judgement do not meet this threshold.
 
If a peer reviewer disagrees with an initial reviewer on IQRs completed in QMS, the following process must be followed.
 
The peer reviewer must contact the initial reviewer to discuss the review in order to reach a consensus regarding the appropriate outcome prior to selecting Agree or Disagree in QMS.  This discussion should be expedited to ensure timely resolution of the pending quality review.  The initial reviewer and peer reviewer should make all efforts to resolve any inconsistencies to avoid the need for a third QRS review. If the initial reviewer cannot be reached, the peer reviewer must annotate the attempt in the comment box in QMS, to include date and time of the attempt.
 
All QRSs are reminded to ensure that cited errors meet the standard for a critical error as a CUE or violation of policy or directive.
 
The Peer, Final, and QRTIQRFinal review levels in QMS all function identically. The most important function at these review levels is to ensure that the checklist is completed consistent with the finding(s) of the review. When performing the review, the reviewer has the option to either agree or disagree. If the checklist is acceptable and no changes are required, select Agree, provide a comment in the text box, and select Submit Review. The review will move forward to a “Complete” or “Error Pending” status.
 
If the reviewer finds any discrepancies with the checklist present at the Peer, Final, or QRTIQRFinal review levels, to include only changing a task question response from “Yes” to “NA” or “NA” to “Yes,” select Disagree, add a comment, and submit, which will allow edits to be made to the checklist. Once all updates to the checklist are completed, the reviewer will need to select Review Summary at the bottom of the checklist to proceed to the “Review Summary Page” and verify the checklist accepted the changes. Select Submit Review if all checklist changes are complete. The QRTIQRRET level is designated for reviews returned to the initial reviewer. When performing the review at this level, the reviewer will follow the same process of reviewing the checklist.
 
Important: When a review is returned, selecting Agree will not allow for changes to the checklist – Agree means the displayed checklist requires no changes. If the reviewer selects Disagree, the checklist can be modified. This function allows the initial reviewer to work with the previous subsequent reviewer to make agreed upon changes if necessary.

3.A.5.g. Notification to Employees

  
Once an IQR is finalized, the employee and their designated coach will immediately receive notice of any errors that were cited through automatic QMS email notification procedures. Emails will have the subject line “Notification of Error Correction.”
 
An employee may also receive notice when a review is completed, even if no error is cited. If selected for a QRTIQR, notification to the employee will be dependent on when the QRTIQR is finalized.
 
Note:  If an employee does not receive an email notice of a cited error, this is indicative that the DROC did not submit all the needed information when entering the employee into the Workforce and Time Reporting System (WATRS). Failure to include the employee’s WIT ID when submitting the employee for WATRS access will result in employees potentially not receiving automatic notification from QMS.
 

 

3.A.5.h.  Corrective Action Time Limits for IQRs

  
The employee has five (5) business days to correct any errors following notification or file a reconsideration request as outlined in M21-5, Chapter 3, Section A.5.i. If the employee files a reconsideration request and the error is upheld, the employee has five (5) business days from the notification of the decision to correct the error(s) or to submit a secondary reconsideration request.
 
The five (5) business day timeliness requirement may be extended when the employee is not in a duty status during the reconsideration period for one of the following reasons:
  • employee was on leave for a full day,
  • employee was off work due to a compressed work schedule or “in-lieu of” holiday due to a compressed work schedule, or
  • other extenuating circumstances resulting in the employee being in a non-duty status as documented by a coach.

Employees needing an extensio due to leave or other extenusating circumstance must coordinate with their coach prior to entering their reconsideration request. Coaches are responsible for documenting days the employee was not in a duty status for each full business day during a reconsideration period by entering a review comment in QMS. If the extenuating circumstance is leave, coaches should not document the type or reason for leave.

When calculating the number of business days in the reconsideration period, the first full business day following the date of notification of the error is day one.

Example 1: Employee is notified of an error on Thursday, May 25, 2023. The employee submits a reconsideration request on Friday, June 2, 2023.

Analysis: The reconsideration request is considered timely. May 29, 2023 is a holiday, so the employee receives an additional calendar day so that they receive five (5) full business days to submit a reconsideration.

Example 2: The employee is notified of the first reconsideration decision on Thursday, June 15, 2023 and is on leave from Tuesday, June 20 through Friday, June 23, 2023. The employee submits a secondary reconsideration request on Monday, July 3, 2023.

Analysis: The secondary reconsideration request is not timely. To be timely, the request must have been entered into QMS by the close of business on June 29, 2023. This will result in the error being upheld.

Note: If the employee does not wish to submit a reconsideration request, the employee will perform the accept and correct actions in QMS. If the error does not require corrective action, the employee only needs to accept the error for the record to successfully close.

3.A.5.i.  Reconsideration Requests on Employee Performance Reviews in QMS

  
For all employees completing work at a DROC, the following steps must be followed when disagreeing with an error on an IQR in QMS. For more specific information, refer to the QMS User Guide. 
 
Step
Action
1
 
After being notified of an error, the employee has five business days to express disagreement in QMS.
2
 
Disagreements with error calls more than five business days after notification will not be entertained, except in rare circumstances as determined by the DROC QRT coach or designee.  Rare circumstances would include vacation or an illness that prevents the employee from submitting the written disagreement in the documented timeframe. 
 
Note: Extension requests must be in writing and submitted via e-mail.
3
Select Initiate Recon and type the reconsideration narrative in the comments box. All reconsideration requests must include
  • a rationale for disagreement
  • reference(s) to support the disagreement

Employees should not copy and paste the error citation into their request. This information is viewable by the individual deciding the reconsideration request.

Note: At this point, the error correction has not been resolved. The employee is still responsible for managing and monitoring the “Error Correction” records noted in the “Error Correction Detail” page.
4
All IQR reconsiderations will automatically route to a QRS with at least one (1) year of experience completing quality reviews. QMS will route reconsiderations to a QRS that was not involved with the initial review and to the greatest extent possible, a QRS that is not at the DROC with the initial reviewer or employee reviewed.
 
For non-IQR review types, the error correction record will route to the DROC queue of the employee reviewed. Coaches are responsible for issuing reconsideration decisions on non-IQR review types at a local level. This responsibility may also be delegated to a QRS with the appropriate skill set. Non-IQR review types should
have a reconsideration decision issued within five (5) business days of the employee’s submitted request.
5
Once a reconsideration decision is made, the employee will receive notification of the decision by email. The email subject line will include “A Reconsideration Decision has been made on your initiated Recon.” The subject line will indicate if it was the first or second level reconsideration decision.
6
If the error was overturned, no further action is required of the employee.
 
If the error was mitigated, the employee must take corrective action and indicate in the error correction record that the error was both accepted and corrected to successfully close the correction record. The employee must complete corrective action within five (5) business days of notification.
 
If the error was upheld, the employee must determine if they accept the first level reconsideration decision. If the employee accepts the reconsideration decision, they have five (5) business days to take corrective action and close the error correction record.
 
If the employee does not accept the decision, they have five (5) business days to submit a second level reconsideration request.
7
Upon submission of a second level reconsideration request, an IQR reconsideration request will route to a QRS for a decision. QMS will route to a QRS unassociated with the initial review and reconsideration decision to the greatest extent possible.
 
For non-IQR review types, the error correction record will route to the DROC queue of the employee reviewed. Coaches are responsible for issuing reconsideration decisions on non-IQR review types at a local level. This responsibility may also be delegated to a QRS with the appropriate skill set. Non-IQR review types should have a reconsideration decision issued within five (5) business days of the employee’s submitted request.
8
Once a decision is made, the employee will receive notification of the decision by email. The email subject line will include “A Reconsideration Decision has been made on your initiated Recon.” The subject line will indicate if it was the first or second level decision.
9
If the employee continues to disagree with the reconsideration decisions and the local supervisor agrees that the employee continues to have a substantive argument that was not adequately considered, the local QRT coach will work with the QRT coach from the station that completed the second reconsideration decision to schedule a call between the upholding QRS, the employee, and both QRT coaches. At the conclusion of the call, the final deciding QRS will determine if a change in outcome is warranted. If no change is warranted, the reconsideration decision in QMS will stand.
 
If the QRS determines that the error should be overturned or mitigated, the coaches will work together to return the error correction record to the QRS for updates. When taking action in QMS, the deciding QRS is required to provide a comment when resetting the error correction record, indicating that the reset is following a conference with the employee and coaches. The date of the meeting is to be provided by the QRS.
10
This is the final reconsideration decision, even if a less favorable decision is issued to the employee.
 
If the error was overturned, no further action is required of the employee.
 
If the error was mitigated, the employee must take corrective action and indicate in the error correction record that the error was both accepted and corrected to successfully close the correction record. The employee must take corrective action within five (5) business days.
 
If the error was upheld, the employee has five (5) business days to take corrective action and close the error correction record.
 
Important: If the first level reconsideration decision is to overturn or mitigate the error (meaning the error is changed so that it does not count as a critical error against the employee’s performance), QMS will not prevent the employee from submitting a second level reconsideration request. However, if the employee submits a second level reconsideration request and the decision is to uphold the error, then this final decision will override the prior reconsideration decision. This means the error will be counted against the employee’s quality performance metric. Employees are responsible for understanding the outcome of a reconsideration decision and the impact the decision has on their quality.
 
Note: DROCs may forward disputed reconsideration decisions to OAR Quality and Training at VBAWASOARQUALITYTRN@va.gov to determine if a national training opportunity exists. However, OAR Quality Assurance will not provide responses on individual errors or reconsiderations and the decisions made by the QRS are considered final.
 

3.A.5.j.  Deciding Reconsideration Requests

  
The only basis for a reconsideration during the peer review is that the initial QRS’s error call is clearly incorrect, based in fact or law. Mere disagreements in judgement do not meet this threshold.
 
If an error was correctly cited, but the references included with the error narrative are incorrect, then the error should not be overturned. QMS must continue to correctly record the valid error cited by the QRS. When completing the reconsideration decision, the deciding QRS or management official should provide the correct references that support the cited error.
 
Errors may not be overturned due to instances of locally issued guidance, such as instructions from a coach or QRS on how to handle a particular claim.

3.A.5.k.  Non-IQR Reconsideration Decision Timeliness

  
DROC management has five (5) business days following the submission of a non-IQR error reconsideration request, which includes the appropriate write-up and supporting references, to issue a formal decision. QMS must be updated with the final decision and any relevant reference used when considering the reconsideration request.
 
Non-IQR reconsideration requests will route automatically to the DROC queue for the DROC of the reviewed employee. Employees will receive an email notifying them once a reconsideration decision has been issued.
 
All employees are responsible for entering their reconsideration rationale into QMS. When issuing a decision on the reconsideration, all rationale and supporting references must be included in QMS. It is not sufficient to state that an error was overturned through local procedures when references are appropriately cited and documented in QMS.

3.A.5.l.  Mitigation of Errors Cited on IQRs

  
In some situations, mitigation of cited errors may be appropriate. Mitigation of an error is distinct from overturning an error because the only acceptable reason for overturning an error is that the error citation was incorrect (i.e., it was not a CUE or a clear violation of current regulations or directives).
 
Mitigation of an error during the reconsideration process results in the “Critical Error” box being unselected. Mitigation is to be used when the error citation was valid but is not to be counted against the employee’s performance for the period during which the error was cited. The error will still require corrective action within the five (5) business day timeliness requirement.
 
Acceptable reasons for mitigating an error are
  • instances that OAR has instructed to be cited as a correctable comment, but the QRS cited as a critical error,
  • the error was incorrectly cited as a critical error during an applicable grace period when the QRS failed to uncheck the “critical” box, or
  • the employee is in a training status (during which IQRs are not to be completed) but is not properly recorded in the Workforce Information Tool (WIT).

Reference: For more information on grace periods, see M21-5, Chapter 3, Section A.4.d.

6.  QRT IQRs

 
 

Introduction

  

Change Date

  
November 15, 2023

3.A.6.a. Purpose of QRT IQRs

  
A review of the individual’s work is intended as a performance measure to ascertain the quality element in that individual’s performance standard.
 
A QRT IQR is intended to provide an evaluation of an individual QRS’s work product to determine if the minimal standard for correctness has been met.
 
QRT IQRs are the review of five randomly-selected cases per month (on average) for the QRS.  This review determines the employee’s individual quality level as part of their overall performance evaluation.
 
The intent of the performance standard is to obtain an average of five per month over the entire fiscal year for each employee to assess the quality element in the standard.

3.A.6.b.  Review Criteria for QRT IQRs

  
QRSs are responsible for performing IQRs identified by QMS on other QRSs. QRT IQRs, with cited errors, will be routed via QMS to a QRT coach for peer review.  These reviews will consist of a random selection of work based on the amount set forth in the national performance standards.  The selection of actions, while random, will reflect an appropriate mix of work performed by the employee throughout the month (i.e., not from a single day or single week). However, when a QRS is not working the appropriate mix of work on an ongoing basis to provide a mix of work for the QRS, the selected reviews are to be accepted.

3.A.6.c.  Standard of Review for QRT IQRs

  
The standard of review for QRT IQRs is to ensure accurate completions of the quality checklists used for DRO, RVSR, VSR, and CA IQRs. The QRT IQR will encompass a thorough assessment of the QRS’s completed checklist in its entirety to ensure that the minimum standard for review has been met on the initial quality review.
 
The minimum standard includes proper selection of “Yes,” “No,” and “NA” on the checklist task questions.
  • The minimum standard for review is to ensure all “No” responses on the checklists rise to the level of a clear and unmistakeable error (CUE) or a clear violation of current regulations or directives.
  • The minimum standard for review is to ensure all “Yes” responses on the checklists account for the proper actions implicitly or explicitly taken by the DRO, RVSR, VSR, or CA for the transactions(s) under review.
  • The minimum standard for review is to ensure all “NA” responses on the checklists do not apply to the transaction(s) under review.
  • Selecting the proper checklist responses to reflect the appropriate answer for each task is important to ensure the DRO, RVSR, VSR, or CA receives credit for work completed correctly or ensuring the employee does not receive undue credit for work not applicable to the transaction under review.

A QRS performing a QRT IQR will select either “Agree” or “Disagree” with the initial review performed. If an error is found on the initial review, to include only changing a task question response from “Yes” to “NA” or “NA” to “Yes,” the reviewer performing the QRT IQR will identify the task question(s) in error in the comment box along with a complete error narrative.

QRT Performance Errors are required when correcting question responses to reflect the appropriate answer for a task because it is important to ensure DROs, RVSRs, VSRs, and CAs receive credit for work completed correctly or to ensure the employees do not receive undue credit for work not applicable to the transaction(s) under review.

When changing a response to a question, only changes to questions 1 through 11 on the DRO, VSR, and RVSR checklists and the entirety of the CA checklist are considered critical. A change to a non-critical question is not considered a performance error against the QRS.

Important: A performance error is warranted any time the checklist is found to be in error for a critical question. Whether something rises to the level of a benefit entitlement error is irrelevant when conducting and completing IQRs.

Example 1:  An RQRS is completing a review on the Rating Decision Complete (RDC) transaction.  The previous RQRS marked the review correct.  The RQRS conducting the QRT IQR determined that the evaluation for sleep apnea was incorrect because the RVSR did not assign a 50 percent evaluation based upon use of a CPAP.  The RQRS will “Disagree” with the initial review and will include the following narrative in the comment box: “Error for incorrect evaluation of sleep apnea. The RQRS failed to cite a Task 7 error on the RVSR.”
 
A coach reviewing this disagreement on a QRTIQRFinal review would indicate that a performance error is appropriate against the RQRS who completed the initial review. 
 
Example 2: An AQRS is completing a review on the claim transaction for generating an award (Award). The previous AQRS marked a Task 9 error because the award did not include a withholding for military retired pay. The AQRS conducting the QRT IQR determined that a withholding was not required. The AQRS will “Disagree” with the initial review and will include the following narrative in the comment box: “No error is present. The AQRS incorrectly cited a Task 9 error on the VSR.”
 
A coach reviewing this disagreement on a QRTIQRFinal review would indicate that a performance error is appropriate against the AQRS who completed the initial review.
 

3.A.6.d.  Recording Method for QRT IQRs 

  
In QMS, an IQR on a QRS is identified as QRTIQR in the Review Level column in the My Reviews view, which can be accessed by clicking on the Review Landing Page tab.  You can also identify whether the IQR selected is for a QRS by reviewing the Review Detail screen.  If QMS selects an IQR for a QRS, the QRT Performance Review box is checked on the Review Detail screen. 
 
To open the review, click on the review name in the Review Name column, which will open the Review Details screen.  To see additional information, select the Review Summary button from the Review Detail screen.
 
To begin the review:
  • Select the Perform Review button on the Review Detail screen.
  • Scroll down to Claim Review – Initial Review Process which will display the recorded review to include any errors cited and error citation box.
  • After completing a review of the QRS’s review, scroll down to the Subsequent Reviewer Decision section, which includes the My Comments, Agree and Disagree.
  • The reviewer will complete the My Comments box and select either the Agree or Disagree button depending on the outcome of the case.  If the reviewer selectes Disagree, the reviewer provides the error narrative with the error category from the associated quality review checklist.
Note:  A comment is required regardless of whether the Agree or Disagree option is selected.
 
If the reviewer agrees with the QRS’s initial review, they will input a comment, select the Agree button, and click the Submit button.  Once the QRS selects the Submit button, the review is complete.
 
If the reviewer disagrees with the QRS’s initial review, the checklist completed during the initial review will require modification and/or correction.  When the Disagree option is selected, the reviewer is returned to the initial review page that contains the Claim Information with the quality marks and comments provided by the initial reviewer.  The reviewer will cite any additional errors found and/or correct any of the errors called on the initial review.  After correcting the corresponding checklist, the reviewer selects the Review Summary button.  They will also notate the error that was cited or should have been cited from the applicable checklist.  Once the review checklist is updated and the error narrative is input in the comment box, the reviewer will select the Submit Review button and the review is complete.
 
Reference:  Refer to the QMS User Guide for QRT IQR routing rules and procedures.
 

3.A.6.e.  QRT IQR-FINAL Review Level and QRT Coach Responsibilities

  
QRT IQRs with cited errors will be routed via QMS to a QRT coach for peer review. 
 
All QRT IQRs that result in a Disagree are routed to the QRTIQRFINAL review level.  This level is directed to a QRT coach for their determination on the outcome of the review.  The coach performs the review using the same steps listed above.
 
Important:  If the coach is agreeing with the changes to the review made by the last individual that reviewed the case, this indicates the QRTIQRFINAL individual is approving the changes and the disagreement indicated by the QRTIQR reviewer.  A disagreement at the QRTIQRFINAL level is used if the coach does not agree with the subsequent reviewer’s determination.
 
 

7.  In Process Reviews (IPRs)

 
 

Introduction

  
This topic contains information about IPRs, including

Change Date

  
May 24, 2024

3.A.7.a.  Purpose of IPRs

  
An IPR is a specialized review designed to correct deficiencies identified during the claims process and to identify training opportunities.
 
Immediate feedback will be provided to employees so that prompt corrective action can be taken to resolve deficiencies. 

3.A.7.b.  Review Criteria for IPRs

  
DROCs should conduct IPRs based on local error trends and analysis. Selection and tracking of these reviews are completed outside of QMS based on local DROC procedures.
 
IPRs may be developed by OAR based upon error trends noted on quality review metrics. New IPR checklists are released on an as-needed basis.
 
When applicable, OAR will create and manage IPR case selection based upon national error trend analysis. QMS will automatically route and assign cases based upon individuals or claims processes.
 
DROCs do not have a monthly requirement of IPRs to complete.

3.A.7.c.  Standard of Review for IPRs

  
IPRs are designed to be a quick touch review with emphasis on specific error trends.  The QRS should not perform a full end to end review of the entire claim. The QRS should limit the review to the basic information needed to determine whether the action completed by the employee under review was complete and correct under the appropriate IPR checklist.
 
Errors not within the scope of the specific IPR checklist noted during the review should be identified and corrected per quality error correction procedures.

3.A.7.d.  Recording Method for IPRs

  
DROCs must track IPRs locally and must maintain an IPR log throughout the FY. At a minimum, the IPR log should include the following information specific to each IPR:
  • Reviewed employee
  • Date of IPR
  • Identified task error(s)
  • Date error(s) corrected by the reviewed employee
Targeted OAR IPRs will be documented in QMS and notification of any error follows the standard WMS notification procedures.

3.A.7.e.  Corrective Action Time Limits for IPRs

  
The employee has five business days after notification of an error to correct it.

3.A.7.f.  Rebuttal Process for Disagreements on IPRs

  
IPRs are non-punitive and therefore there is no formal rebuttal process for errors cited. Any disagreements should be handled by the reviewed employee’s DROC QRT coach.
 
Note: Reconsiderations for targeted IPRs completed in QMS are to be submitted through QMS and proper routing procedures will be applied.
 
M21-5, Chapter 3, Section A.5.k contains additional information on how reconsiderations flow through QMS.
 

8.  Veterans Benefits Management System (VBMS) Reviews

 
 

Introduction

  
This topic contains information about VBMS reviews, including

Change Date

  
March 2, 2020

3.A.8.a.  VBMS Deferral Mitigation Requests

  
VBMS deferral functionality allows a claims processor to return a claim to an earlier place within the claims cycle to correct erroneous actions.  Using VBMS deferral functionality is required for any situation in which a claim returns to a previous step in the process, which involves all relevant details to include
  • a manual reference
  • most appropriate reason(s) for deferral, and
  • relevant electronic claims folder (eFolder) document bookmarks.
In the event the claims processor assigned the claim for corrective action disagrees with the deferral, the claims processor will email a brief narrative to the QRT supervisor and copy their supervisor within five business days of receipt of the deferral.  The narrative must identify why the claims processor disagrees with the deferral and provide a reference to support the disagreement.
 
Note:  Failure to include a supporting reference in the initial deferral is not grounds for automatic mitigation.
 
The QRS will follow the instructions noted in the VBMS User Guide for processing deferral mitigation requests.

3.A.8.b.  VBMS-R Overrides Review

  
VBMS-R functionality allows the decision maker to override various rules-based outcomes.  If an override is completed, the Local Quality Review IPR special issue is created and added to the rating decision.  This override appears in the QRT Override table on the Override Review tab on the Home Screen.
 
The DROC QRT coach will locally manage the distribution of these claims to the QRS for review.  The QRT coach will also manage any resulting case correction to ensure corrections are completed within two business days of notification of the override denial.
 
The QRS will follow the instruction in the VBMS-R User Guide for review of the cases with the Local Quality Review IPR special issue.
 

 9.  Claims Assistant (CA) Task Based Quality Review Checklist

 

Introduction

  
This topic contains information on the CA Quality Review Checklist, including

Change Date

  
October 1, 2021

3.A.9.a.  CA Quality Review Checklist

  
 
For review of the CA Task Based Quality Review Checklist please refer to M21-4, Chapter 6, Appendix C.a.
 
 
 
     

3.A.9.b.  Instructions and Guidelines for CA Review

  

For review of the Instructions and Guidelines for CA Review please refer to M21-4, Chapter 6, Appendix C.b.
 
10.  Veteran Service Representative (VSR) Task Based Quality Review Checklist
 

Introduction

  
This topic includes the

Change Date

  
October 16, 2020

3.A.10.a. VSR Task Based Quality Review Checklist

  
For review of the VSR Task Based Quality Checklist please refer to M21-4, Chapter 6, Appendix A.a.
 

3.A.10.b.  Instructions and Guidelines for VSR Review

  
For review of the Instructions and Guidelines for VSR Review please refer to M21-4, Chapter 6, Appendix A.b.

3.A.10.c.  VSR Review Elements

  
For review of the VSR Review Elements please refer to M21-4, Chapter 6, Appendix A.c.

3.A.10.d.  Systems Compliance Errors – Corporate Flashes

  
For a complete list of system compliance errors – corporate flashes please refer to M21-4, Chapter 6, Appendix A.d.

3.A.10.e. Systems Compliance Errors – Special Issues

  
For a complete list of system compliance errors – special issues please refer to M21-4, Chapter 6, Appendix A.e
 
 
 

11.  Rating Veterans Service Representative (RVSR) Task Based Quality Review Checklist

 
 

Introduction

  
This topic contains information on the RVSR Task Based Quality Review Checklist, including

Change Date

  
October 16, 2020

3.A.11.a.  RVSR Task Based Quality Review Checklist

  
For review  of the RVSR Task Based Quality Review Checklist please refer to M21-4, Chapter 6, Appendix B.a. 

3.A.11.b.  Instructions and Guidelines for RVSR Review

  
For review of the Instructions and Guidelines for RVSR Review please refer to M21-4, Chapter 6, Appendix B.b.

3.A.11.c.  Rating Review Elements

  
For review of the Rating Review Elements please refer to M21-4, Chapter 6, Appendix B.c. 
 
 

12.  Decision Review Officer (DRO) Task Based Quality Review Checklist

 
 

Introduction

  
This topic contains information on the DRO Task Based Quality Review Checklist, including

Change Date

  
July 8, 2024

3.A.12.a.  DRO Task Based Quality Review Checklist

  
Below is a sample of the DRO Task Based Quality Review Checklist.
 
Rating Specific Questions
1. Were all claimed issues addressed and decided?
☐ Yes
☐ No
☐ NA
Error Description
A claim for service connection was received but not addressed or decided
☐
A claim for secondary service connection was received but not addressed or decided
☐
A claim for an increased evaluation was received but not addressed or decided
☐
Entitlement to a claimed ancillary benefit (SAH, SHA, DEA, Paragraph 29 or 30 etc.) was not addressed
☐
The issue of competency was claimed but was not addressed
☐
Entitlement to SMC or SMP A/A or HB was not addressed
☐
Entitlement to another level of SMC was not addressed
☐
The issue of IU was claimed but was not decided
☐
A proper claim of the existence of a CUE was not decided (to include effective date due to alleged CUE)
☐
Claimed issue for IDES was not addressed (IDES program only)
☐
Entitlement to pension was not addressed
☐
Entitlement to DIC was not addressed
☐
Entitlement to accrued benefits was not addressed
☐
Entitlement to spousal A/A was not addressed (survivors pension)
☐
Entitlement to spousal Housebound was not addressed (survivors pension)
☐
Entitlement to dental treatment was not decided (only when referred by a VA treating facility via VA Form 10-7131)
☐
The SOC/SSOC did not address an issue on appeal when required
☐
Entitlement to an earlier effective date for an issue on appeal was not decided or addressed (appeals)
☐
The decision failed to address an issue requiring adjudication (specific to supplemental and/or HLR claims) (AMA)
☐
A partial decision was warranted but not completed
☐
2. Were all inferred and/or ancillary issues addressed?
☐ Yes
☐ No
☐ NA
Error Description
Entitlement to unclaimed complications of disabilities (e.g., nerve involvement due to the back, ALS or Parkinson’s complications, etc.) was not addressed when appropriate
☐
Entitlement to an inferred issue based upon related disability (e.g., tinnitus grant when HL is claimed and SC warranted) was not addressed
☐
Entitlement to IU was not addressed when appropriate
☐
An evaluation under 38 CFR 3.324 (multiple non-compensable SC disabilities) was not determined when required
☐
The issue of competency not addressed
☐
Entitlement to DEA was not addressed
☐
Entitlement to service connection for conditions found on examination but not claimed was not considered (IDES only)
☐
Entitlement to pension (including extra-schedular under 3.321b) was not considered when required
☐
Entitlement to SMC or SMP A/A or HB was not addressed when required
☐
Entitlement to Special Home Adaptation or Special Adaptive Housing was not addressed when required
☐
Entitlement to Auto/Auto Adaptive Equipment was not addressed when required
☐
Entitlement to another level of SMC was not addressed when required
☐
Entitlement to medical care under 38 U.S.C. 1702 was not addressed when required
☐
3. Was all necessary development to obtain all indicated evidence (excluding VA Examination) completed prior to deciding the claim?
☐ Yes
☐ No
☐ NA
Error Description
New and Relevant evidence was submitted necessitating development for other identified evidence prior to deciding the issue (AMA)
☐
The service treatment or personnel records are needed
☐
VAMC treatment records were not obtained and uploaded to the eFolder when required
☐
Other Federal records were not obtained (such as Social Security records, prison records or Vet Center records) when required
☐
Development for non-VA treatment records is required
☐
IU development is not complete (excluding examinations – e.g., missing 8940, employment history, 4192 development, signed 4140 etc.)
☐
AO exposure development is not complete
☐
PTSD development is not complete (stressor verification/information, etc.)
☐
The development for other special issues is not complete (risk factors for hepatitis C, project SHAD, etc.)
☐
5103 Notice was not provided
☐
Advisory Opinion from Compensation or Pension needed but not completed
☐
4. Were all necessary examinations and medical opinions requested and sufficient?
☐ Yes
☐ No
☐ NA
Error Description
VA examination was needed but was not requested
☐
VA medical opinion was needed but was not requested
☐
The VA examination was insufficient (necessary information is missing or the eFolder not reviewed when required)
☐
The VA medical opinion was insufficient (opinion was requested but not provided or the eFolder not reviewed when required)
☐
The supporting rationale for a required VA medical opinion was missing, incomplete or not supported by the evidence
☐
The medical opinion request failed to include pertinent information for consideration in the opinion and such consideration was not provided (evidence review, etc.)
☐
VA examination was warranted based on a change in law or policy but was not requested (newly added presumptive condition, etc.)
☐
Overdevelopment- an examination was requested by the DRO but was not needed (e.g., sufficient private DBQ on file, etc.)
☐
Overdevelopment – a VAE was ordered by the DRO but there is no basis in the regulations for establishing SC for the underlying disability
☐
Aggravation was not addressed in the examination when required
☐
An incorrect examination or DBQ was requested
☐
New and Relevant evidence was submitted necessitating a VAE prior to deciding the issue (AMA)
☐
Overdevelopment – a medical opinion was requested by the DRO but was not needed
☐
5. Was the grant of all issues correct?
☐ Yes
☐ No
☐ NA
Error Description
Service connection was not warranted but was established
☐
Service connection is not warranted for a symptom or lab finding (pain, proteinuria, etc.)
☐
The rating established additional service connection for a condition which was previously established as a grant on the code sheet (i.e., same condition service connected twice on code sheet)
☐
The rating established an improper presumptive grant (condition not compensable during appropriate time frame or not covered by presumption)
☐
The rating incorrectly granted a condition as aggravated without appropriate consideration
☐
Service connection was not warranted due to a regulatory restriction (congenital defect, willful misconduct, etc.).
☐
Service connection was not warranted as there was “clear and unmistakable” evidence to overturn past favorable findings (AMA)
☐
6. Was the denial of all issues correct?
☐ Yes
☐ No
☐ NA
Error Description
New and relevant evidence wsa submitted which warrants a grant of the issue (AMA)
☐
Service connection was warranted as there was no “clear and unmistakable” evidence to overturn past favorable findings (AMA)
☐
Service connection was warranted but was not established
☐
Service connection was warranted for an undiagnosed illness (Gulf War Undiagnosed Illness) or MUCMI
☐
The rating denied service connection for a condition which was already established as SC on the code sheet
☐
The rating improperly denied a presumptive condition when SC was warranted
☐
The rating incorrectly denied a condition as not aggravated without appropriate consideration
☐
Issue(s) decided on SOC/SSOC for which no NOD has been received
☐
Decision maker did not address all elements not met for denials
☐
Failed to readjudicate issue on the merits when new and relevant evidence was of record
☐
7. Were the evaluations assigned correct to include SMC coding and the combined evaluation?
☐ Yes
☐ No
☐ NA
Error Description
A condition or conditions were under-evaluated
☐
A condition or conditions were over-evaluated
☐
Pyramiding – separate evaluations were established for two or more diagnostic codes where such is prohibited by the rating schedule (e.g., sleep apnea and asthma separately evaluated)
☐
Pyramiding – the same symptoms were used to evaluate two or more conditions separately
☐
Separate evaluations were warranted for one SC disability (e.g., knee LOM and instability)
☐
Separate evaluations were not warranted for the SC disability (e.g., bilateral flatfoot under DC 5276)
☐
The bilateral factor was improperly applied or not applied when required
☐
Convalescence or Hospitalization was incorrectly established or denied
☐
A reduction was proposed or completed but was not warranted or the associated ancillary benefits were not addressed
☐
A reduction was warranted but was not proposed or completed
☐
The aggravation deduction was not performed when required or shown by the evidence of record
☐
Condition warranted an evaluation as a paired organ or extremity
☐
Evaluation assigned established a violation of the amputation rule
☐
SMC coding was incorrect
☐
Higher Level Review decision failed to grant maximum benefit when DTA error is present, if warranted
☐
8. Are all effective dates assigned correct?
☐ Yes
☐ No
☐ NA
Error Description
Day after discharge effective date was incorrect (warranted or not warranted)
☐
An effective date based on an Intent to File was incorrect
☐
Effective date equal to DOC was not applied or was applied inappropriately
☐
Original DOC was warranted based upon receipt of additional records (e.g., new STRs not previously of record)
☐
An incorrect effective date for increase was applied based upon an increase being factually shown or not shown in the medical evidence of record
☐
The criteria for IU had an incorrect effective date
☐
Increase during appeal period – effective date warranted from original DOC
☐
Increase during appeal period – effective date warranted from date of increase factually shown
☐
Effective date of conditions associated with disease processes per rating schedule (incorporated within rating schedule) incorrectly applied
☐
Incorrect effective date for any other reason not listed
☐
Liberalizing legislation was misapplied for effective date
☐
9. Was the decision free of other deficiencies?
☐ Yes
☐ No
☐ NA
Error Description
Incompetency was improperly proposed or established
☐
A summary of the evidence considered was not provided (AMA)
☐
For denied claim(s), identification of the missing element(s) which are required to grant the claim(s) was not provided
☐
The decision did not identify the criteria to grant the next higher level of compensation (AMA)
☐
Issues were addressed by rating without a proper claim (claim not filed on proper form)
☐
A routine future examination was added to a condition but is not appropriate
☐
A routine future examination was not added to a condition when required (e.g., active cancer, etc.)
☐
The claim was improperly or prematurely certified to BVA (appeals)
☐
The disability(ies) upon which IU was established were not reflected in the rating narrative
☐
Higher Level Review decision failed to provide notice that there was evidence received after the record closed that was not considered
☐
Decision maker considered and listed evidence received after the record closed for a higher-level review
☐
Deferral/HLR Return Specific Questions
10. Were all deferrals/HLR Returns completed necessary and properly recorded?
☐ Yes
☐ No
☐ NA
Error Description
Deferral/HLR Return was completed for records that were not required or were already contained in the C-file
☐
Deferral/HLR Return did not encompass all development that was required or was otherwise incomplete
☐
Deferral/HLR Return was not finalized or was finalized improperly
☐
The order of operations for a deferral/HLR Return was not followed
☐
Deferral/HLR Return form was not completed or uploaded
☐
System Compliance Specific Questions
11. Were all systems updates completed when needed?
☐ Yes
☐ No
☐ NA
Error Description
The POA was not updated correctly on code sheet
☐
The appropriate service period(s) listed on the code sheet was/were not verified (regular active duty)
☐
The appropriate service period(s) listed on the code sheet was/were not verified (active and inactive duty for training)
☐
The proper EP was not reflected on rating decision to include proper DOC for EP
☐
An additional signature for the rating was not obtained when required [e.g., SMC at a rate greater than SMC (l), CUE, proposals to sever SC, etc.]
☐
The codesheet was not correctly updated for final CUE action
☐
Correctable Comments
12. Is the c-file free from other defects requiring correction which are not considered “critical” to the item(s)/transaction currently under review?
☐ Yes
☐ No
☐ NA
Error Description
Past claimed issues have not been addressed or decided
☐
Past inferred and/or ancillary issues have not been addressed
☐
Past necessary development to obtain all indicated evidence (excluding VA Examination) was not completed prior to deciding the claim
☐
When required, past examinations and/or medical opinion were not requested and/or sufficient
☐
The past grant of issues was not correct
☐
The past denial of issues was not correct
☐
The past evaluations(s) assigned was/were not correct, to include the combined evaluation
☐
The past SMC coding was not correct
☐
The past effective date(s) assigned was/were not correct
☐
New and Relevant evidence was submitted but the claim was not decided based on the merits of the claim
☐
Hearing conducted by a decision maker who participated in the proposed adverse action
☐
Higher-Level Review informal conference not held when requested or attempts to schedule not documented properly
 
☐
Decision maker did not issue the subsequent decision after completing the hearing without approved cause
☐
Decision maker did not issue the subsequent decision after completing the informal conference without approved cause
☐
Additional issue(s) raised during the hearing was not completed on the correct form
☐
The laws and regulations applicable to the claim were not provided (AMA)
☐
A claim was invited that cannot be granted (i.e., no basis in the law for a grant)
☐
The decisionmaker did not properly identify or document favorable findings
☐
An issue was addressed in a decision in the incorrect lane or jurisdiction (i.e., no jurisdiction to consider the issue)
☐

3.A.12.b.  Instructions and Guidelines for DRO Review

  
OAR developed these instructions and guidelines to promote consistency and uniformity in the review cases selected for local rating IQRs. Use these instructions/guidelines in conjunction with the DRO Task Based Quality Review Checklist.
 
The DRO Task Based Quality Review Checklist is a task-based checklist. The task-based checklist reviews different tasks taken during the rating and appeals process. The reviewer will review the employee for each task they complete for the case selected. At the time of the review, the reviewer will determine which tasks are applicable. An applicable task is one that is associated with the work performed by the employee and is thus reviewable for quality. There are three possible answers for each of the tasks. A task is considered “accurate” when “Yes” is selected for that task indicating the employee completed activity associated with the question accurately. A task is considered “in error” when “No” is selected for that task indicating the employee completed activity associated with that question “in error”. A task is considered not applicable to the review when “NA” is selected for that task indicating the question is not applicable to the case under review.  
 
Quality is calculated based on “root cause” errors, in order to evaluate the actual cause of the error(s) rather than also calculating all of the subsequent consequences resulting from the initial error.  For example, a decision maker assigns an incorrect evaluation for a condition which warranted a total evaluation (100%).  There are other, separate SC disabilities that combine to be more than 60% disabling.  If the proper evaluation had been assigned, the Veteran would have met the evaluation requirements for statutory housebound benefits.  The decision maker would be cited for one error for the incorrect evaluation.  The subsequent error (failure to take up and grant statutory housebound) would not be cited because it was caused by and the direct result of the original evaluation error.  It would, however, be captured in the comments for training purposes.
 

An error will be recorded when an employee takes an action that violates current regulations, policies, and procedures.  A narrative summary is required with statutory, regulatory, judicial, or manual references for any “error” or “No” answer recorded.  A difference in judgment or opinion reflecting a possible better practice or solution is not captured on the DRO Task Based Quality Review Checklist. 

Overdevelopment, as it relates to the task-based checklist, is taking an incorrect development action that prevents the claim from progressing to completion (materially delays the claim).  This would encompass unnecessary exam/opinion requests, requesting information that is not needed to decide, or requesting information already of record, etc.  For example, a medical opinion regarding the onset of a condition during service was requested, when service connection is otherwise warranted for that condition on a presumptive basis. The opinion would have no material effect on the outcome of the claim and is considered overdevelopment (provided no other development was requested or required, and the opinion request itself resulted in a delay to processing the claim).  Unless the effective date would be affected, the opinion is irrelevant.

Note:  To reach the level of an error, the development directed must clearly be unnecessary and/or erroneous in nature and must also materially affect (for example delay) the claim.  Errors are not to be cited based upon a simple difference of opinion between the decision maker and the quality reviewer regarding evidence sufficient to decide the claim.

3.A.12.c.  DRO Review Elements

  
The following is a list of explanations of the elements of the DRO Task Based Quality Review Checklist. 
 
Rating Specific Questions
1. Were all claimed issues addressed and decided?
All issues filed by a Veteran or properly filed by their representative should be formally addressed and decided in some fashion. This task question applies to issues under the case selected for review that were properly addressed or should have been addressed. This task question also applies to any issue that needs to be addressed and decided based on a review initiated by VA, such as routine future examinations under EP 310, corrections under EP 930, etc. Entitlement to an earlier effective date would generally apply only to an appeal, unless such a claim is filed in conjunction with a CUE, etc.
2. Were all inferred and/or ancillary issues addressed?
All inferred issues which arise from the claim should be addressed.  This would include any ancillary issues, such as entitlement to Dependents’ Educational Assistance (DEA) benefits when a permanent and total evaluation is established, or inferred issues, such as IU that is reasonably raised but not specifically claimed. This would also include any unclaimed issue that is “within scope” of a claimed condition and for which SC is warranted, such as a tinnitus grant when only hearing loss is claimed, a neurological abnormality grant when only a cervical or lumbar spine condition is claimed, a diabetic complication grant when only diabetes is claimed, unclaimed scar grants, etc.
3. Was all necessary development to obtain all indicated evidence (excluding VA Examination) completed prior to deciding the claim?
This task question includes all development items outside of any required VA examination to include advisory opinions from Compensation or Pension.  Please note this does not include items that are purely administrative in origin, so long as all actual development is completed.  For example, the absence of the posttraumatic stress disorder (PTSD) stressor memorandum from the eFolder is not a critical rating error, so long as all necessary development has been completed in the attempt to verify the stressor.  If the necessary development has not been completed, note such as a critical error in the appropriate task question.
4.  Were all necessary examinations and medical opinions requested and sufficient?
This task question pertains solely to errors that arise in relation to a VA examination/medical opinion that was requested or that should have been requested. It does not apply to a deferral that directs a VA examination/medical opinion as errors on deferrals are recorded under Task 10. Please note this encompasses overdevelopment in the form of ordering examinations that are not necessary to decide the claim.  To be an overdevelopment error, the examination requested must have clearly been erroneous (e.g., ordering an examination for a condition for which SC could not be established due to a statutory bar) and materially affect the claim (e.g., delay claim processing in and of itself).  Mere differences of opinion in regard to whether or not the evidence of record was sufficient to decide a claim without an examination are not valid quality errors.
5.  Was the grant of all issues correct?
This task question includes items such as establishing dual service connection and an evaluation for a condition already shown on the Codesheet as service connected, but for which an additional evaluation cannot be established.
6.  Was the denial of all issues correct?
This task question includes improper denial of service connection for issues previously established as service connected on the Codesheet.  In addition, it encompasses issues taken up on a SOC or SSOC for which no appeal was filed (please note this is not for consideration when a separate rating is done by the Appeals team). 
7. Were the evaluations assigned correct to include SMC coding and the combined evaluation?
This task question includes erroneously establishing separate evaluations for a condition that must be evaluated as a single entity (e.g., bilateral flatfoot).  In addition, various forms of pyramiding, improper reductions and failure to grant maximum benefit when DTA error is present, if warranted are accounted for under this question.
8. Are all effective dates assigned correct?
This task question encompasses intent to file (ITF), DOC, and increases during the appeal period as well as various IU scenarios.  Also covered here are incorrect effective dates for ancillary benefits.
9. Was the decision free of other deficiencies?
Items such as incompetency improperly proposed or established, rating issues without a formal claim or addressed in the incorrect jurisdiction or lane, failure to properly utilize routine future examinations, failure to document applicable favorable findings, and failure to provide notice of received evidence after record closed that was not reviewed  fall under this category.
Deferral/HLR Returns Specific Questions
10. Were all deferrals/HLR returns completed necessary and properly recorded?
Items cited under this task question must be clearly erroneous and not based upon a difference of opinion over evidence needed to properly decide a claim.  Completing a deferral for evidence already of record is one example.  Also, failing to finalize or improperly finalizing or uploading the deferral/HLR return is cited here as this will have a negative effect upon the claim work flow (as will failure to follow the proper order of operations).
Systems Compliance Specific Questions
11. Were all systems updates completed when needed?
This task question applies only to the rating decision Codesheet, and it was developed to account for items that slow or misdirect the claims process and require correction. Proper POA, appropriate service period verification, updating the Codesheet for final CUE action, and having the proper EP associated with the decision are included here. Of note, the lack of appropriate third digit modifier does not cause an EP association error under this question; rather, only the lack of an overall appropriate EP will (e.g., an EP 020 and 310 for the same issue). The terminology of “additional signature” denotes those ratings which always require an additional signature (such as CUEs cited on the rating boards/lanes, etc.).  
Correctable Comments
12. Is the eFolder free from other defects requiring correction which are not considered “critical” to the item(s)/transaction currently under review?

This task question houses, and routes correctable comments found during the IQR process.  Correctable comments are those items which are not considered to be a “critical” error on the transaction under review, but which require additional processing to ensure the correctness and/or completeness of the claim in general.

Note: Changing the Task 12 response from “Yes” to “NA” or “NA” to “Yes” does not constitute a QRT Performance Error, as only Task 1-11 are factored into the quality calculation for DROs.