M21-5, Appeals and Reviews, Overview

Overview

In This Overview

The M21-5 Overview contains the following topics:

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Introduction

The M21-5, Appeals and Reviews, serves as a general guide for processing legacy appeals, Board grants and remands, and higher-level reviews (HLR) under the Appeals Modernization Act (AMA). This manual also discusses the responsibilities of the decision review operations centers (DROC), their oversight by the Office of Administrative Review (OAR) and both local and national training and quality assurance programs. Additionally, the M21-5 serves as a guide for processing agent and attorney fees.

This manual and its adjudication procedures are based on the statutes and regulations found in title 38 of the United States Code (U.S.C.) and title 38 of the Code of Federal Regulations (CFR), the legal authority governing Department of Veterans Affairs benefits. Therefore, relevant statues and regulations in 38 U.S.C. and 38 CFR take precedence over procedural guidance in the M21-5. The statutes and regulations are overarching legal provisions, while M21-5 procedures are written so adjudicators within Veterans Benefits Administration (VBA) can properly, fairly, and accurately use this manual as a tool to decide claims.

The purpose of the M21-5 is to summarize or restate in plain language the applicable law or regulation and provide guidelines of the adjudication process.

The M21-5 is a guide for processing claims. It is

• not a decision-making tool, and
• not intended to
• direct workload priorities
• determine workload assignments, or
• determine personnel assigned to complete tasks or achieve performance goals.

Note: For more information on workload priorities and assignments, refer to the established performance standards and priorities of the OAR Operations staff, as well as Chapter 1, Field Oversight.

While the M21-5 incorporates and references certain claims-related technical processes and business management tools, it is not intended to substitute the applicable user guides, such as National Work Queue Playbook, or the user references to Caseflow or the Veterans Benefits Management System (VBMS).

M21-5 Guidance

M21-5 users should read its contents in harmony with the collective guidance of Compensation Service, Pension and Fiduciary (P&F) Service, and OAR. The M21-5 is a set of general guidelines designed to provide procedures for the most common situations that may arise in legacy appeals, Board grants and remands, and higher-level reviews (HLR). The complexities of claims processing are considerable, and the M21-5 is not designed to provide policies or procedures for every possible scenario. Users need to apply guidance of the M21-5 on a case-by-case basis, using sound judgment based on the law and apply basic adjudication principles.

Proper application of the M21-5 requires users to read multiple blocks of content in various locations throughout the M21-5, as no one block of content stands alone. Though the M21-5 often includes references and links to relevant content, these references are by no means inclusive.

Generally, actions that claims processors must take and actions they must not take are specifically identified in the M21-5. In the absence of a specific requirement or prohibition, claims processors should use their best judgment when determining the propriety of a given action. When in doubt regarding a significant issue or step, users should seek guidance from their local leadership, quality review personnel, or OAR Quality Assurance.

It is the responsibility of local managers, quality reviewers, and subject matter experts to resolve complex issues. After exhausting all local resources, field users may submit questions to OAR through appropriate channels.

The M21-5 contains adjudication policies, concepts, and procedures but does not dictate workload management or limit the assignment of appropriate work by management that is consistent with job titles and standards. The M21-5 strives to capture the roles that exist within adjudication, but references to job titles are not intended to, and do not limit, the assignment of work.

Employee Responsibility

VBA's mission is to serve Veterans, and their eligible dependents and survivors, in the most efficient and accurate manner.

• It is only appropriate to extend suspense or diary dates if it is necessary for a specific adjudicative action. Suspense dates must always correspond with specific actions and not be arbitrarily extended under any circumstance.
• Employees must take the most full and complete action as possible on the claim each time that it is assigned, whether for development, rating, and promulgation, so that it moves forward to accurate and timely completion.

Reference to Computer Applications

While the M21-5 provides claims-processing guidance, it generally does not provide detailed technical instructions for entering information and navigating individual computer applications. In many instances, when technical guidance is necessary, the M21-5 will mention the appropriate user guide or playbook and provide a link to it. Such guides include, but are not limited to, the Veterans Benefit Management System User Guide, Share User Guide, and National Work Queue Playbook.

M21-5 Structure

The M21-5 is organized into different parts. It starts with an Overview section and a Reference, prior to moving into the administrative sections. Chapters 1 through 3 include Field Oversight, National Training Program, and Quality Assurance. Chapters 4 through 6 relate to specific procedures for processing HLRs. Chapter 7 addresses Controlling Legacy Appeals and Legacy Appeal Procedures. Chapter 8 addresses the agent/attorney fee process and procedures. Please see the M21-5 Table of Contents for a topical list of all content.

The table below shows the structure and number convention for the M21-5.

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The table below demonstrates how to properly refer to M21-5 citations.

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Electronic Access

The M21-5 is available electronically through Knowledge Management (KM). Internal stakeholders can access content via VBA’s Compensation and Pension (CPKM) Portal, and external stakeholders via KnowVA.

For technical issues with access, please contact the Enterprise Service Desk via the YourIT Services website or contact them via phone at 1-855-673-4357 (Option 3).

Changes to the M21-5

The M21-5 is a living document. OAR Program Administration is responsible for updating the M21-5 on a regular basis. Updates may come from new procedural directives, regulatory changes, acts of Congress, judicial interpretations, internal reviews, and user feedback.

Each time OAR publishes an M21-5 change, it adds two documents under the Attachments heading found at the bottom of each M21-5 article in KM. These documents consist of a history of the previously published content and Key Changes.

• The History contains the content as it existed during a given time period. The date in the document name indicates when that content was published.
• Key Changes include the date content was updated, general notes about the change, a table(s) providing a description and location of each significant change, and a copy of the edited version of the content, highlighting new text and using tracked changes to indicate deleted text.

Searching M21-5 Content in KM

Below are some tips for smart and successful searches of the M21-5.

• Searching Basics
• KM searches the content of each article, as well as the article’s title, metadata (which includes the summary sentence and keywords), and attachments.
• KM’s search engine looks for root words and variations of words.
• For example, a search for dependents will search for the word dependents, along with variations of the word like dependent, dependency, depends, and depending. This search will generally produce more search results which can be helpful when searching for a general concept and not a specific word.
• On the other hand, a search for "dependents" (using quotation marks) will only search for the word dependents. This search will generally produce less search results than the one above and is helpful when searching for a specific word or phrase.
• Limit the Topic
• Another good tip is to limit the pool of content to search.
• For example, if you are looking for information in only the M21-5, start by narrowing your search to only that topic. Using Browse Topics, drill down to the M21-5.
• By entering your search word(s) or phrase into the field labeled Search within this topic, KM’s search engine will limit its search to just the content of the M21-5, instead of searching all of the content in the Compensation and Pension KM portal.
• KM’s Searching Algorithm
• The search engine uses a complex algorithm to provide the user a list of search results.
• There are two key factors in this algorithm:
• The number of times the search engine finds the search word(s) or phrase. The more times the search engine finds the search word(s) or phrase in the article (and in the article’s title, metadata, and attachments), the more relevant that article is in the search results.
• The popularity of the article.
• KM’s search engine considers which articles are trending and which are popular. Trending and popularity are impacted by the number of times users access a given article and the number of times they rate it as useful. The more popular the article, the closer to the top of the search results it will appear.