Casey Matuszak

1 MOPH NSO Training March 2012 Orlando, FL

• Define Claims Processing!

• What are the basic elements? • Interview

• ID issues

• ID evidence

• Claim presentation

• Monitoring the claim

• Decision review

• Appeal

• Why is understanding the process important?

MOPH NSO Training March 2012 Orlando, FL

2

A. INTERVIEW

• Assess the client

• Honesty

• Ability to assist in the claim

• Determine validity of the claim

• Determine if pending claim or

appeal exists

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A. INTERVIEW • Establish the role of the client

Being truthful

Active participation

Submitting all documents through

MOPH

Following NSO’s advice

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A. INTERVIEW • Establish the role of the NSO

Advises claimants

Truth in advertising

Actively involved

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B. ID ISSUES

• Interview

• Discussion with family/friends

• Review of folder

Medical records

Past claims

• Think outside the box

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B. ID ISSUES - Scenario 1 VN Vet comes into the office claiming an increase

in his only SC condition, Diabetes, as he went

from medication to insulin. First visit to MOPH. What is the issue?

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B. ID ISSUES - Scenario 2

Vet served 1975-1978. Comes into your office. He is rated

100% P&T for arthritis of the back, knees and hands as

well as asthma and depression. He now wants to claim

SC for hemorrhoids. You haven’t seen this client in 6

years. What issues do you explore?

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B. ID ISSUES – Scenario 3

Vet served 1974-1990. STRs show back strain in 1982 &

1985. Separation exam normal. Filed claim for back

arthritis in 1999 was denied as medical opinion said not

related to service. BVA upheld decision after

independent medical opinion said no relationship. He

now can’t work because of his back which is causing

secondary conditions.

What’s the issue?

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C. ID EVIDENCE • Lay vs. medical evidence

• Review VA File

• Correcting evidence

• Caution

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C. ID EVIDENCE

Don’t Revise History!

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C. ID EVIDENCE – Scenario 1 Vet rated 50% for PTSD for 11 years. Wants

to file increase due to increased

nightmares and anxiety. No treatment last

4 years. Stable marriage, churchgoer,

family man, stable job in insurance sales.

What evidence is needed?

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C. ID EVIDENCE – Scenario 2

Vet SC for migraine headaches 0%. He is

complaining that they are becoming

more frequent and intense. No treatment.

What evidence?

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C. ID EVIDENCE – Scenario 3

62 yr. old VN vet retired from work 6

months ago based on age. SC since 1983

for PTSD 50%, GSW Rt. Leg 20%, DM II

20%. Wants to file for IU.

What evidence if any is needed?

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C. ID EVIDENCE – Scenario 4

OIF vet, STRs indicated back problem – Master

Jumper/w 60+ jumps.. Seen 2x in 91 and 1x in 92

- DX -strain. Retired in 1992.

Filed claim 1999 – denied no continuity of

treatment (self-medicated). In 2002 denied no

N&M evidence. In 2004 DX of DDD, L-2 thru L-5,

w/ severe radiculopathy, can’t work.

What now?

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D. CLAIM PRESENTATION • What should a claim look like?

Professional

Complete

Simple

Skip boiler plate

Copy for file

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D. CLAIM PRESENTATION

• Fully Developed Claim (FDC)

90 Day processing time

FL 10-22 dated 6-15-2010

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D. CLAIM PRESENTATION

• Requirements for a FDC Claim

VA Form 21-526EZ/527EZ

Rating-related–live

Completed FDC Certification

Necessary info to “fully develop” the

claim

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D. CLAIM PRESENTATION • Veteran’s FDC claim disqualified if

Reserve & guard STRs must be developed,

Vet fails to report for VAE,

Additional information is required,

Pending claim exists

Supplemental claim is filed

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D. CLAIM PRESENTATION • VA FORM 21-526EZ/527EZ

No Dependency Information

Attach 686c

• No VA Form 21-4142

If submitted, claim is not an FDC

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D. CLAIM PRESENTATION

• FDC - INFORMAL CLAIM

“I intend to apply for compensation/pension benefits

under the FDC Program. This statement is to preserve

my effective date for entitlement to benefits. I am in

the process of assembling my claim package for

submission.”

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D. CLAIM PRESENTATION Scenario 1

62 yr. old VN vet retired from work 6

months ago based on age. SC since 1983

for PTSD 50% GSW Rt. Leg 20%, DM II

20%. Wants to file for IU.

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D. CLAIM PRESENTATION Scenario 1

• Explain FDC claim to vet

• File informal claim

• Gather the following

VA forms 21-8940 & 4192

VA Form 21-4138 –vet, wife, peers, supervisor

Medical statement

• File formal claim – 21-526EZ

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E. CLAIM MONITORING

• What

• Why

• How

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E. CLAIM MONITORING – HOW?

• Veterans Claims Management

System Claims Diary

information

Suspense Dates

Long term

Tickle Dates

Short term

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E. CLAIM MONITORING – HOW? • COVERS - Control Of Veterans RecordS

File location

• MAP-D - Modern Award Processing Issues

Evidence

Letters

Explanations

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Three Objectives

1. Defined claims processing

2. Discussed basic elements

3. Better understanding

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