Casey Matuszak - Homepage | Military Order of the Purple … Claims... · Casey Matuszak MOPH NSO...
Transcript of Casey Matuszak - Homepage | Military Order of the Purple … Claims... · Casey Matuszak MOPH NSO...
• 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?
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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 – 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 – 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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