[Federal Register Volume 63, Number 39 (Friday, February 27, 1998)]
[Proposed Rules]
[Pages 9990-9992]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-5122]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AJ03


Reconsideration of Denied Claims

AGENCY: Department of Veterans Affairs.


[[Page 9991]]


ACTION: Proposed rule.

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SUMMARY: This document proposes to amend the Department of Veterans 
Affairs' ``Medical'' regulations by adding a new section to set forth 
reconsideration procedures available if requested by an individual or 
entity who made a claim for benefits administered by the Veterans 
Health Administration and who disagrees with the initial decision 
denying the claim. It is anticipated that these procedures would not 
only allow for more reflective decisions at the local level but would 
also allow some disputes to be resolved without the need for further 
appeal to the Board of Veterans Appeals.

DATES: VA must receive comments on or before April 28, 1998.

ADDRESSES: Mail or hand deliver written comments to: Director, Office 
of Regulations Management (02D), Department of Veterans Affairs, 810 
Vermont Avenue, NW, Room 1154, Washington, DC 20420. Comments should 
indicate that they are submitted in response to ``RIN 2900-AJ03.'' All 
written comments received will be available for public inspection at 
the above address in the Office of Regulations Management, Room 1158, 
between the hours of 8:00 a.m. and 4:30 p.m., Monday through Friday 
(except holidays).

FOR FURTHER INFORMATION CONTACT: Troy L. Baxley, Health Administration 
Service (10C3), Department of Veterans Affairs, 810 Vermont Avenue, NW, 
Washington DC, 20420, telephone (202) 273-8301. (This is not a toll-
free number).

SUPPLEMENTARY INFORMATION: This document proposes to amend the 
``Medical'' regulations (38 CFR part 17) by adding a new Sec. 17.133 to 
set forth reconsideration procedures available if requested by an 
individual or entity who made a claim for benefits administered by the 
Veterans Health Administration (VHA) (e.g., reimbursement for non-VA 
care not authorized in advance, reimbursement for beneficiary travel 
expenses, reimbursement for home improvements or structural 
alterations) and who disagrees with the initial decision denying the 
claim in whole or in part. These procedures would not be mandatory and 
a claimant may choose to appeal the denied claim to the Board of 
Veterans Appeals pursuant to 38 USC 7105 without using the new 
reconsideration procedures. The new reconsideration procedures would 
not be applicable in those cases where other specific reconsideration 
procedures apply. For example, there are specific reconsideration 
provisions applicable to denied claims for CHAMPVA and spina bifida 
benefits.
    As set forth in the text portion of this document, the 
reconsideration procedures would provide for a written request for 
reconsideration, reasons why the decision is in error, submission of 
any new and relevant information, opportunity for an informal meeting 
(with transcription upon request), and a written decision.
    This informal reconsideration procedure would allow for more 
reflective decisions at the local level and would allow some disputes 
to be resolved without the need for further appeal to the Board of 
Veterans Appeals.
    This regulation would supersede manual provisions for appeals of 
VHA decisions found at M-1, Part I, Chap. 1, Section X. The manual 
provisions are outdated and confusing, and included references to 
specific procedures that were previously rescinded.

Paperwork Reduction Act of 1995

    The Office of Management and Budget (OMB) has determined that 
proposed 38 CFR 17.133 contains collections of information under the 
Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). Accordingly, 
under section 3507(d) of the Act, VA has submitted a copy of this 
rulemaking action to OMB for its review of the collections of 
information.
    OMB assigns a control number for each collection of information it 
approves. VA may not conduct or sponsor, and a person is not required 
to respond to, a collection of information unless it displays a 
currently valid OMB control number.
    Comments on the proposed collections of information should be 
submitted to the Office of Management and Budget, Attention: Desk 
Officer for the Department of Veterans Affairs, Office of Information 
and Regulatory Affairs, Washington, DC 20503, with copies mailed or 
hand-delivered to: Director, Office of Regulations Management (02D), 
Department of Veterans Affairs, 810 Vermont Ave., NW, Room 1154, 
Washington, DC 20420. Comments should indicate that they are submitted 
in response to ``RIN 2900-AJ03''.

Reconsideration of Denied Claims--Section 17.133

    Title: Reconsideration process available if requested by an 
individual or entity who made a claim for benefits administered by the 
Veterans Health Administration and who disagrees with the initial 
decision denying the claim in whole or in part.
    Summary of collection of information: The provisions of proposed 38 
CFR 17.133 would add a new informal voluntary review process to 
existing appellate rights procedures. The person or entity requesting 
reconsideration would be required to submit such request to the 
Director of the VA healthcare facility of jurisdiction. It must be 
submitted in writing within one year of the date of the initial 
decision. The request must state why the decision is in error and 
include any new and relevant information not previously considered. The 
request for reconsideration may include a request for a meeting with 
the VA decisionmaker, the claimant, and the claimant's representative 
(if the claimant wishes to have a representative present). Such a 
meeting shall only be for the purpose of discussing the issues and 
shall not include formal procedures (such as presentation and cross-
examination of witnesses). The meeting will be taped and transcribed by 
VA, if requested by the claimant, and a copy of the transcription shall 
be provided to the claimant. After reviewing the matter, the 
decisionmaker (the Chief, Health Administration Service, or equivalent) 
shall issue a written decision that affirms, reverses, or modifies the 
initial decision.
    Description of need for information and proposed use of 
information: The information proposed to be collected under 17.133 
appears to be necessary to initiate the reconsideration process.
    Description of likely respondents: Individuals or other entities 
who make a claim for benefits administered by VHA and are denied.
    Estimated number of respondents: 101,652.
    Estimated frequency of responses: one time.
    Estimated total annual reporting and recordkeeping burden: 16,942 
hours.
    Estimated annual burden per collection: 10 minutes per item.
    The Department considers comments by the public on proposed 
collections of information in--
     Evaluating whether the proposed collections of information 
are necessary for the proper performance of the functions of the 
Department, including whether the information will have practical 
utility;
     Evaluating the accuracy of the Department's estimate of 
the burden of the proposed collections of information, including the 
validity of the methodology and assumptions used;

[[Page 9992]]

     Enhancing the quality, usefulness, and clarity of the 
information to be collected; and
     Minimizing the burden of the collections of information on 
those who are to respond, including responses through the use of 
appropriate automated, electronic, mechanical, or other technological 
collection techniques or other forms of information technology, e.g., 
permitting electronic submission of responses.
    OMB is required to make a decision concerning the collection of 
information contained in this proposed rule between 30 and 60 days 
after publication of this document in the Federal Register. Therefore, 
a comment to OMB is best assured of having its full effect if OMB 
receives it within 30 days of publication. This does not affect the 
deadline for the public to comment on the proposed regulations.

Regulatory Flexibility Act

    The Secretary hereby certifies that the adoption of the proposed 
rule would not have a significant impact on a substantial number of 
small entities as they are defined in the Regulatory Flexibility Act 
(RFA), 5 U.S.C. 601-612. Although the adoption of the proposed rule 
could affect small businesses, it would not have a significant impact 
on any small business. Therefore, pursuant to 5 U.S.C. 605(b), the 
proposed rule is exempt from the initial and final regulatory 
flexibility analysis requirements of Secs. 603 and 604.
    There are no Catalog of Federal Domestic Assistance program 
numbers.

List of Subjects in 38 CFR Part 17

    Administrative practice and procedure, Alcohol abuse, Alcoholism, 
Claims, Day care, Dental health, Drug abuse, Foreign relations, 
Government contracts, Grant programs-health, Grant programs-veterans, 
Health care, Health facilities, Health professions, Health records, 
Homeless, Medical and dental schools, Medical devices, Medical 
research, Mental health programs, Nursing homes, Philippines, Reporting 
and recordkeeping requirements, Scholarships and fellowships, Travel 
and transportation expenses, Veterans.

    Approved: February 23, 1998.
Togo D. West, Jr.,
Acting Secretary.
    For the reasons set forth in the preamble, 38 CFR part 17 is 
proposed to be amended as follows:

PART 17--MEDICAL

    1. The authority citation for part 17 continues to read as follows:

    Authority: 38 U.S.C. 501(a), 1721, unless otherwise noted.

    2. In part 17, an undesignated center heading and Sec. 17.133 are 
added to read as follows:

RECONSIDERATION OF DENIED CLAIMS


Sec. 17.133  Procedures.

    (a) Scope. This section sets forth reconsideration procedures 
available to an individual or entity who made a claim for benefits 
administered by the Veterans Health Administration (VHA) and who 
disagrees with the initial decision denying the claim in whole or in 
part. These procedures are not mandatory, and a claimant may choose to 
appeal the denied claim to the Board of Veterans Appeals pursuant to 38 
U.S.C. 7105 without utilizing the provisions of this section. These 
procedures do not apply when other regulations providing 
reconsideration procedures do apply (e.g., CHAMPVA (38 CFR 17.84), 
spina bifida (38 CFR 17.904)). Otherwise, this section applies to all 
claims for VHA benefits (e.g., reimbursement for non-VA care not 
authorized in advance, reimbursement for beneficiary travel expenses, 
reimbursement for home improvements or structural alterations, etc.). 
Submitting a request for reconsideration shall constitute a notice of 
disagreement for purposes of filing a timely notice of disagreement 
under 38 U.S.C. 7105(b).
    (b) Process. A request for reconsideration under this section must 
be submitted in writing to the Director of the healthcare facility of 
jurisdiction within one year of the date of the initial decision. The 
request must state why it is concluded that the decision is in error 
and must include any new and relevant information not previously 
considered. Any request for reconsideration that does not identify the 
reason for the dispute will be returned to the sender without further 
consideration. The request for reconsideration may include a request 
for a meeting with the VA decisionmaker, the claimant, and the 
claimant's representative (if the claimant wishes to have a 
representative present). Such a meeting shall only be for the purpose 
of discussing the issues and shall not include formal procedures (such 
as presentation and cross-examination of witnesses). The meeting will 
be taped and transcribed by VA if requested by the claimant and a copy 
of the transcription shall be provided to the claimant. After reviewing 
the matter, the decisionmaker (the Chief, Health Administration 
Service, or equivalent) shall issue a written decision that affirms, 
reverses, or modifies the initial decision.

    Note to Sec. 17.133: The final decision of the decisionmaker 
will inform the claimant of further appellate rights for an appeal 
to the Board of Veterans Appeals.

(Authority: 38 U.S.C. 511)

[FR Doc. 98-5122 Filed 2-26-98; 8:45 am]
BILLING CODE 8320-01-P