6.2. Clinical Appeals
The Director of the VHA facility is responsible for attempting to resolve any clinical disputes. VHA healthcare facilities are supposed to be the first point of contact for disputes and every effort should be made to resolve disputes as close to the point of care as possible. It is also the facility Director's responsibility to provide written notice of the facility's final determination to the patient, or the patient's representatives. This notification must also describe the clinical appeals process to the claimant.
That's right! Not only must the VA notify you in writing but they must also provide you with information regarding how to initiate a clinical appeal. So do not let the VA simply tell you "no." Make them put it in writing and inform you of your appellate rights. It may be necessary for you, or your representative, to force the issue with the VA. If the VA will not comply send them a polite and professional letter demanding a written notice of why your request was denied and also request VA provide you with a notice of your appellate rights. Be sure to make a copy of this letter and mail it in some manner that allows you to track and confirm receipt.
In theory the Chief Medical Officer (CMO) acts as an intermediary between the veteran and the facility and all efforts to resolve the dispute are sent to the CMO by the medical facility. The CMO determines the patient's current medical needs and acts to notify the patient and or representative that their appeal has been received and requests that submission of supporting documents be submitted within one week where applicable.
Next the CMO develops a decision paper regarding the appeal and sends it to the Veterans Integrated Service Network (VISN) Director. The VISN Director then makes a decision whether or not to request an external audit.
Whether an external audit is requested or not ultimately the veteran and their representative receive a final decision within 30 to 45 days. The decision will officially place the veteran on notice of what the VA decided in their appeal. If the appeal was a clinical appeal regarding a VA medical decision the appeal is over as the decision cannot be appealed to the Board. There may be unofficial action a veteran can take but there is no official appellate review after this decision is issued.
Please remember that both a clinical appeal and an administrative appeal can follow the above path. Although an administrative appeal could be prosecuted in this manner it is usually advantageous to follow the traditional or administrative appeal process.