Review of Health Care Decisions

This policy replaces the following VPPM 2 policy: 5.7 Health Care Review.

Purpose

This policy provides direction on the review of decisions made under the Veterans Health Care Regulations (VHCR).

Policy

Definitions

1. Review (appeal): a process involving a full review of the decision by a new decision maker at a higher level of decision making. This process should not be confused with reconsideration, where an original decision is reopened and reconsidered by the primary (original) decision maker, because new evidence was provided or because there was an error of decision. Reconsiderations are not addressed in this policy, as they are not authorized in the VHCR.
2. Legal representative: a person who has the client’s written permission, or authority granted through legal process, to act on the client’s behalf.

General

3. Clients and/or their legal representatives are to be notified of any decision regarding benefits provided under the VHCR, when operationally feasible.  
4. The decision letter must include the rationale for the decision and notify the client or legal representative of their right to request a review of the decision.
5. Only clients or their legal representative have the right to request a review of a decision. Providers are not to be considered as legal representatives and have no right of appeal.
6. Clients may apply for up to two levels of review of any decision. 
7. A request for review must  be submitted in writing to the Department within 60 calendar days of receipt of the Department's original decision or first level review decision. This period may be extended in cases where extenuating circumstances (e.g. illness) do not permit submission within the 60-day period.
8. Clients or their legal representatives should be encouraged to state the reason(s) for their request for review, as this may allow for a fuller consideration of the issues surrounding the decision under review.
9. Decisions are not to be reviewed by the original decision-maker. The person conducting a second-level review of the decision must not have conducted a first level review of that decision.
10. The second-level review decision shall be the final departmental decision.

Termination of Reviews

11. A review may be terminated at the written request of the client. Termination may also occur with the permission of the client, when the issue has been successfully resolved.
12. A review requested while the client is alive will not be terminated solely due to the subsequent death of the client.

References

Veterans Health Care Regulations