POMS Reference

Table of contents Recent changes
Contact
Back
This change was made on May 11, 2018. See latest version.
Text removed
Text added

DI 22505.022: Developing Medical Evidence of Record (MER) from the Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Medical Facilities

changes
← * →
  • Effective Dates: 03/24/2017 - Present
  • Effective Dates: 05/11/2018 - Present
  • TN 11 (09-11)
  • TN 24 (05-18)
  • DI 22505.022 Developing Medical Evidence of Record (MER) from the Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Medical Facilities
  • A. Introduction to developing MER from the VA VHA medical facilities
  • The VA VHA operates clinics, hospitals, medical centers, and long-term healthcare facilities (nursing homes) that provide health care to former service members. Each VHA medical facility maintains electronic patient records.
  • The VA VHA operates clinics, hospitals, medical centers, and long-term healthcare facilities (nursing homes) that provide healthcare to former service members. Each VHA medical facility maintains electronic patient records.
  • The health information manager and privacy officer at each VHA medical facility work with Social Security Administration (SSA) and the Disability Determination Services (DDS) medical and professional relations officers (MPRO) to coordinate the process for release of patient health information. VHA medical facilities usually transmit claimant health records to SSA and the DDSs in the SSA-DDS Standard Health Summary format via secure web site (i.e., through Electronic Records Express (ERE)). VHA medical facilities provide copies of other specifically requested supplemental records separately via mail, fax, or ERE. The VHA does not disclose medical records to SSA or the DDSs without the patient’s written authorization.
  • The health information manager and privacy officer at each VHA medical facility work with the Social Security Administration (SSA) and the disability determination services (DDS) medical and professional relations officers (MPRO) to coordinate the process for release of patient health information. VHA medical facilities usually transmit claimant health records to SSA and the DDS in the SSA-DDS Standard Health Summary format. VHA medical facilities provide copies of other specifically requested supplemental records separately via mail, fax, or the Electronic Record Express (ERE) upon receipt of a customized request for records. The VHA does not disclose medical records to SSA or the DDS without a valid form SSA-827 (Authorization to Disclose Information to the Social Security Administration).
  • NOTE: You may also need to request a veteran’s military health system medical records. Military health system records cover medical treatment provided while the claimant was on active duty. may be held at a VA Regional Office (VARO) or the VA Records Management Center (VARMC). These VA offices are not part of the VHA and they do not hold VHA medical records. Instead, these VA offices hold military health system medical records of service members who have been discharged from active duty military service. For related instructions, see DI 22505.023, Developing Medical Evidence of Record (MER) from the Military Health System.
  • When SSA Field Office (FO) transfers an initial electronic claim to the DDS, the system automatically generates a request for records via Medical Evidence Gathering and Analysis through the Health Information Technology (MEGAHIT) system to VHA facilities nationally and internationally. An electronically signed SSA-827 (e827) is required in order to obtain the SSA Standard Health Summary for initial claims.
  • IMPORTANT: To avoid duplicative records, the DDS must review records obtained via MEGAHIT before initiating requests for records to the VHA.
  • NOTE: The DDS may also need to request a veteran’s military health system medical records. Military health system records cover medical treatment provided while the claimant was on active duty. These records are held at a VA Regional Office (VARO) or the VA Records Management Center (VARMC). These VA offices are not part of the VHA and they do not hold VHA medical records. Instead, these VA offices hold military health system medical records of service members discharged from active duty military service.
  • For related instructions, see DI 22505.023 Developing Medical Evidence of Record (MER) from Military Health Sources.
  • B. Policy for telephone contacts with VHA medical sources
  • In the unusual case where the claimant is a current VHA medical facility patient and a program medical or psychological consultant determines that a complex medical issue could be resolved by discussion with a medical source, the program medical or psychological consultant may attempt to contact the medical source at the VHA medical facility by telephone for this purpose. See the procedure for documenting medical evidence obtained by telephone in DI 22505.030B.
  • In the rare case where the claimant is a current VHA medical facility patient and a program medical or psychological consultant determines that a complex medical issue could be resolved by discussion with a medical source, the program medical or psychological consultant may attempt to contact the medical source at the VHA medical facility by telephone for this purpose. See the procedure for documenting medical evidence obtained by telephone in DI 22505.030B.
  • C. MPRO role in developing MER from VHA medical facilities
  • The MPRO serves as the primary liaison between the adjudicating component and the VHA medical facility. The MPRO works directly with the designated VHA medical facility representative to develop and maintain an effective business process for transfer of VHA records.
  • The MPRO serves as the primary liaison between the adjudicating component and the VHA medical facility. The MPRO works directly with the designated VHA medical facility representative to develop and maintain an effective business process to transfer VHA records.
  • D. The SSA-DDS health summary
  • D. The SSA-DDS standard health summary
  • The SSA-DDS Health Summary compiles the elements of the claimant’s VHA medical facility electronic health record typically required for Social Security disability adjudication.
  • The SSA-DDS standard health summary compiles the elements of the claimant’s VHA medical facility electronic health record typically required for Social Security disability adjudication.
  • 1. Content of the standard SSA-DDS health summary
  • 1. Content of the SSA-DDS standard health summary
  • The standard summary includes the following, if available:
  • The standard health summary includes the following, if available:
  • a. General information
  • a. Personal information
  • * Brief demographic information
  • * List of all known medical problems
  • * Future appointment dates
  • b. Health records
  • IMPORTANT: Be alert to the possibility that you may need to request supplemental records; see DI 22505.022E.1.e. in this section.
  • The limits shown indicate the maximum number of occurrences included in the report. Except as noted, the standard report includes the patient’s records from the most recent two years of medical treatment (i.e., two years back from the date last seen at the VHA medical facility).
  • * Outpatient visits (limit 150)
  • * Global Assessment of Functioning (no limit)
  • * Progress notes (limit 40)
  • * Surgery reports (limit 10)
  • * Spinal cord dysfunction information (no limit)
  • * Full report of medical procedures (limit 15)
  • * Radiology and Nuclear Medicine Imaging profile (limit 10)
  • * Cytopathology reports (limit 10)
  • * Electron microscopy reports (limit 10)
  • * Microbiology reports (limit 10)
  • * Surgical pathology reports (limit 10)
  • * Oncology information (no limit)
  • * Chemistry and hematology lab results (limit 20)
  • * Inpatient discharge summaries (limit 4 years or 5 occurrences)
  • * Compensation and pension examinations (limit 4 years or 5 occurrences)
  • NOTE: VHA medical facilities perform compensation and pension examinations required to adjudicate claims for VA disability benefits.
  • NOTE: VHA medical facilities perform compensation and pension examinations that they need to adjudicate claims for VHA disability benefits. If the veteran files a Veterans Benefits Administration disability claim, the VARO keeps their records. See Information about Developing Medical Evidence of Records (MER) Military Health Sources DI 22505.023E.2.
  • 2. Modified SSA-DDS health summary
  • IMPORTANT: The standard summary encompasses all VA sites, whereas the traditional summary covers only one VHA site.
  • The MPRO may request that a VHA medical facility tailor the SSA-DDS Health Summary to better meet the needs of the DDS (i.e., to ensure that content and volume of information sent is sufficient and appropriate).
  • 2. Modified SSA-DDS standard health summary
  • If a VHA medical facility provides a modified SSA-DDS Health Summary, report content will deviate from the standard summary information listed in DI 22505.022D.1. Refer to local guidelines for report content.
  • The MPRO may request that a VHA medical facility tailor the SSA-DDS standard health summary to better meet the needs of the DDS (i.e., to ensure that content and volume of information sent is sufficient and appropriate).
  • E. Procedure for developing MER from VHA medical facilities
  • If a VHA medical facility provides a modified SSA-DDS standard health summary, the report content will deviate from the standard summary information listed in DI 22505.022D.1.
  • Refer to local guidelines for report content.
  • E. Procedure to develop MER from VHA medical facilities
  • Make every reasonable effort to help the claimant obtain relevant VHA medical records; see DI 22505.001A.2.
  • Document development efforts in the case development summary worksheet.
  • NOTE: The VHA will not accept wet-signed SSA-827s for MEGAHIT records requests.
  • Document development efforts in the case development summary worksheet using the following guidelines:
  • If…
  • Follow…
  • The claim file is electronic, the SSA-827 is not wet-signed, you need a VHA standard health summary and one of the following:
  • There is no evidence from the VHA in the medical records (yellow) section of the electronic folder (EF); or
  • There is a health information technology (HIT) response document in the blue section of the EF indicating the MEGAHIT evidence transfer did not occur successfully; or
  • You need new or updated evidence from the VHA that is not already in the EF.
  • User Trigger request procedures in DI 22505.022F in this section.
  • You may not use User Trigger if you send a customized request for records.
  • The claim file is electronic, and both of the following apply:
  • You already used the User Trigger request to receive evidence you need from the VHA per procedures (in this section); and
  • Your office uses the electronic Outbound Request (eOR) feature of the ERE.
  • VHA ERE request procedure see DI 22505.022G in this section.
  • NOTE: Use any valid SSA-827.
  • Any of the following apply:
  • The claim file is paper;
  • You still need military health records from the VARO or the VARMC;
  • The SSA-827 is a wet-signed authorization;
  •                            or
  • You still need additional evidence from the VHA after following the User Trigger procedures in this section.
  • Procedures to send requests for VHA records by mail or fax in DI 22505.022H in this section.
  • F. Procedure to use a MEGAHIT User Trigger to request MER from the VHA
  • 1. How to initiate a User Trigger request
  • To initiate a User Trigger request to obtain evidence from VHA:
  • * Confirm the availability of a valid electronic SSA-827;
  • * Using your legacy system or the stand-alone web-based application;
  • * Identify and select the Social Security number;
  • * Search the medical facilities list for “VA sites” and select it;
  • * Enter the requested date range; and
  • * Click on the “Initiate Request” button to make the User Trigger request.
  • You will receive a confirmation notice in the blue section of the EF that the VHA is processing the request. Allow five hours for a response.
  • NOTE: Use only a valid electronic SSA-827 for a VHA request. If the only valid SSA-827 in file is wet-signed, do not use a user trigger request and instead use procedures the in DI 22505.022G or DI 22505.022H.
  • 2. Reasons for the DDS to initiate a MEGAHIT User Trigger request
  • The most common reasons for the DDS to send user triggered HIT requests to the VHA are:
  • * A HIT source was not originally identified by MEGAHIT;
  • * A HIT source is identified after case transfer;
  • * HIT MER in file needs to be updated;
  • * HIT MER is needed for an adjudicative level other than the initial level;
  • * A HIT response document indicates a time out error; or
  • * The dates for MEGAHIT request timeframe are outside of the timeframe needed.
  • NOTE: See DI 81020.020 Electronic Case Development for more information.
  • G. Using ERE to request electronic MER from the VHA
  • 1. Initial request to a VHA facility
  • Send an initial request for medical records to the VHA facility using the ERE eOR function. Allow 10 calendar days for the response. Include a copy of the claimant’s SSA-827.
  • 2. Follow up to the VHA facility
  • If you do not receive a response from the VHA facility within 10 calendar days, use the ERE eOR function to send a follow-up request to the VHA facility. Allow 10 calendar days for a response. Include a copy of the claimant’s SSA-827. See DI 22505.035 Follow-up on Request for Medical Evidence of Record (MER).
  • 3. Insufficient or no response from the VHA facility
  • In rare instances, you may not receive a response from the VHA facility after you send a follow-up request. Alternatively, the VHA facility may provide an incomplete medical history that does not cover all sources identified by the claimant or provides records that suggest supplemental development is necessary.
  • In these circumstances, request military MER by mail using the instructions in DI 22505.022H.
  • H. Procedure to send requests for VHA records by mail or fax
  • 1. Consider which health summary will contain all needed MER
  • Consider which SSA-DDS standard health summary contains the MER you need: either the standard SSA-DDS standard health summary or the modified DDS standard health summary.
  • 2. Send the request(s)
  • * Send a request to each VHA medical facility where the claimant received relevant medical treatment or evaluation. If local experience indicates that a single request will produce records from multiple VHA facilities, you may request records from that source.
  • * Include the claimant’s name, date of birth, and the last four digits of the claimant’s Social Security number.
  • * Include a copy of the SSA-827 with each request.
  • * Do not request a medical opinion from a VHA medical facility. See DI 22505.007C.
  • 1. Initial requests
  • * Send a MER request to each VHA medical facility where the claimant received relevant medical treatment or evaluation.
  • 3. If the SSA-DDS standard health summary does not include or will not include all needed MER
  • * Use a VHA customized request.
  • * Include a date or date range and the type of treatment received.
  • * Follow local instructions to alert the VHA medical facility to the nonstandard request.
  • * Clearly identify and list all additional records you need.
  • NOTE: If local experience indicates that a single MER request will produce records from multiple VHA facilities, you may attempt to obtain the records with one MER request.
  • * Include the claimant’s name, date of birth, and the last four digits of the claimant’s social security number.
  • * Consider whether the SSA-DDS Health Summary contains the needed MER. If the VHA medical facility produces a:
  • * standard SSA-DDS Health summary, see DI 22505.022D.1. in this section.
  • * modified SSA-DDS Health summary, refer to local procedures; see DI 22505.022D.2. in this section.
  • * Request the SSA-DDS Health Summary.
  • * Take the following actions if the SSA-DDS Health Summary does not or would not be expected to include all needed MER from the VHA facility:
  • * Carefully target a supplemental MER request;
  • * Include a date or date range and the type of treatment received;
  • * Follow local instructions to alert the VHA medical facility to the nonstandard request; and,
  • * Clearly identify and separately list any additional records needed.
  • EXAMPLES:
  • * Records from a time prior to that covered by the SSA-DDS Standard Health Summary.
  • * Records of more recent treatment to supplement the SSA-DDS Standard Health Summary already received.
  • * Copies of specific documents (e.g., electrocardiograms, pulmonary function tests, echocardiograms, or audiograms).
  • * Do not request a medical opinion from a VHA medical facility; see DI 22505.007C.
  • * Include a copy of the signed SSA-827 (Authorization to Disclose Information to the Social Security Administration), with each MER request.
  • 4. Examples of records that might require a customized request
  • * Records prior to that covered by the SSA-DDS standard health summary;
  • * Records of more recent treatment to supplement the SSA-DDS standard health summary we received, or
  • * Copies of specific documents (e.g., electrocardiograms, pulmonary function tests, echocardiograms, or audiograms).
  • NOTE: The VHA medical facility will submit a negative response by ERE if the requested records are not available.
  • NOTE: The VHA medical facility submits a negative response by ERE if the requested records are not available.
  • 2. Follow up guidelines
  • 5. Follow up guidelines
  • Use these guidelines for follow up if the VHA medical facility does not respond to an initial request for MER:
  • * Wait 10 – 20 days after the initial request before you follow up. Allow more time if experience indicates.
  • Use these guidelines to follow up if the VHA medical facility does not respond to an initial request for MER:
  • * Wait 10-20 days after the initial request before you follow up. See DI 22505.035.
  • * Send follow up requests by letter. Do not routinely follow up by telephone.
  • * Allow 10 days, or more if experience indicates, for the VHA medical facility to respond to a follow up request.
  • * Notify the MPRO if the VHA medical facility does not respond to the MER follow-up letter.
  • * Allow at least 10 days, or more if experience indicates, for the VHA medical facility to respond to a follow up request. Allow more time for a particular source to reply when experience with that source indicates a longer period is advisable.
  • * Follow local business practices if the VHA medical facility does not respond to the MER follow-up letter.
The materials available at this web site are provided free of charge, for informational purposes only, and without warrant by True Link Financial, Inc., and are not legal advice or Social Security benefits advice. You should contact your attorney to obtain advice with respect to any particular issue or problem, or the Social Security Administration with any general inquiries. Click here to view this section of the POMS on the Social Security Administration website.