Appeal Your Healthcare Decisions – VA News

Young couple reviews healthcare decisions

As a veteran, you deserve the best healthcare possible. But you may not always agree with the decisions we make about your medical care or whether you’re eligible for some types of care.

If you don’t agree with a decision we’ve made, you can appeal. That’s how.

First, a word about where benefits come from within the VA. The Veterans Benefits Administration (VBA) manages non-healthcare benefits, including service-related compensation, education, dependency and allowance benefits, VA home loans, and life insurance. The Veterans Health Administration (VHA) also has its own set of health benefits involving health care and eligibility for certain health services.

For more information about VBA benefits, visit their website.

Two types of healthcare decisions, two types of appeals

In VA health care, you can appeal two types of decisions: medical determinations and health benefit decisions.

A medical determination is a decision your care team makes about your health care, such as whether to prescribe a certain drug, treatment, or physical therapy. It can also mean a decision to refer you to a community care provider.

A health benefits decision affects whether you qualify for VA health benefits, such as VA health care, VA nursing home and home care, reimbursement for non-VA emergency care, and certain medical devices.

How to challenge a medical determination

You can appeal a medical determination by filing a clinical appeal, which allows other medical professionals to review your medical needs and decide if the determination was correct.

To file a clinical appeal, contact the patient advocate at your VA medical facility and ask to initiate a clinical appeal.

Find your local patient advocate here.

How to appeal a decision about health benefits

If you disagree with a health benefit decision, you can request one of three types of reviews:

  • Top level review
  • Additional Claim
  • Appeal to the Board of Veterans Appeals

You can select the type of review that you think is best for your case.

When and how to request a higher level review

If you believe our decision was wrong and you don’t have new evidence, a higher-level review may be your best option. You cannot submit new evidence, but instead a senior reviewer will review your case again. This reviewer will evaluate the same evidence that was considered above. You must submit an application for a higher level review within one year of the date of the decision.

Young couple reviews healthcare decisions

You can also request an optional one-time informal conference with a senior reviewer to discuss your case.

To request a higher-level review, complete Form VA 20-0996 and follow the submission instructions on the VHA Decision Notification Letter.

Download Form VA 20-0996.

When and how to submit a supplementary application

If you believe our decision was wrong and you have new and relevant evidence that the VA has not yet considered, a supplemental request may be your best bet. We can help you gather any new identifying evidence, such as medical records, to support your claim. A reviewer will decide whether this new evidence changes the decision. You can usually file a supplementary complaint at any time after the decision.

To file a supplemental claim, complete Form VA 20-0995 and follow the submission instructions on the VHA Decision Notification Letter.

Download Form VA 20-0995.

When and how to appeal to the council

If you want a veterans law judge on the Board of Veterans Appeals (council) to hear your case, you can appeal the decision to the council. You must file an appeal with the board within one year of the date of the decision, and you do not need to request a higher-level review or file a supplemental grievance before appealing with the board.

There are three types of board reviews. When you fill out the form, you will need to request which type you would like:

  • Direct Review: If you don’t want to present more evidence or have a hearing
  • Presentation of Evidence: If you wish to present additional evidence without a hearing
  • Hearing with a Veterans Law Judge: If you would like to have a hearing with a Veterans Law Judge with the ability to present new evidence

To appeal a decision to the council, complete Form VA 10182 and submit it to the council. The mailing address is on the form.

Download the VA 10182 form.

How to appeal a Caregiver Support Program decision

If you disagree with a care or services decision under the VA Caregiver Support Program (CSP), you have four options. You can file a clinical appeal or choose one of three options to appeal your benefits decision. For more information, review the CSP decision letter or visit the CSP website.

How to find help with an appeal

If you need help filing a grievance or appeal, you may want to work with an accredited attorney, claims agent, or Veterans Service Officer (VSO). We trust these professionals because they are trained and certified in the VA complaints and appeals process. They can help you with your VA needs.

VSOs work on behalf of veterans and service members, as well as their dependents and survivors. Find out more about the professionals who can help you.

For more information

Visit the VHA Appeals website for more information.

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