TN 11 (09-11)
DI 22505.022 Developing Medical Evidence of Record (MER) from the Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Medical Facilities
A. Introduction to developing MER from the VA VHA medical facilities
The VA VHA operates clinics, hospitals, medical centers, and long-term healthcare facilities (nursing homes) that provide health care to former service members. Each VHA medical facility maintains electronic patient records.
The health information manager and privacy officer at each VHA medical facility work with Social Security Administration (SSA) and the Disability Determination Services (DDS) medical and professional relations officers (MPRO) to coordinate the process for release of patient health information. VHA medical facilities usually transmit claimant health records to SSA and the DDSs in the SSA-DDS Standard Health Summary format via secure web site (i.e., through Electronic Records Express (ERE)). VHA medical facilities provide copies of other specifically requested supplemental records separately via mail, fax, or ERE. The VHA does not disclose medical records to SSA or the DDSs without the patient’s written authorization.
NOTE: You may also need to request a veteran’s military health system medical records. Military health system records cover medical treatment provided while the claimant was on active duty. may be held at a VA Regional Office (VARO) or the VA Records Management Center (VARMC). These VA offices are not part of the VHA and they do not hold VHA medical records. Instead, these VA offices hold military health system medical records of service members who have been discharged from active duty military service. For related instructions, see DI 22505.023, Developing Medical Evidence of Record (MER) from the Military Health System.
B. Policy for telephone contacts with VHA medical sources
In the unusual case where the claimant is a current VHA medical facility patient and a program medical or psychological consultant determines that a complex medical issue could be resolved by discussion with a medical source, the program medical or psychological consultant may attempt to contact the medical source at the VHA medical facility by telephone for this purpose. See the procedure for documenting medical evidence obtained by telephone in DI 22505.030B.
C. MPRO role in developing MER from VHA medical facilities
The MPRO serves as the primary liaison between the adjudicating component and the VHA medical facility. The MPRO works directly with the designated VHA medical facility representative to develop and maintain an effective business process for transfer of VHA records.
D. The SSA-DDS health summary
The SSA-DDS Health Summary compiles the elements of the claimant’s VHA medical facility electronic health record typically required for Social Security disability adjudication.
1. Content of the standard SSA-DDS health summary
The standard summary includes the following, if available:
a. General information
b. Health records
IMPORTANT: Be alert to the possibility that you may need to request supplemental records; see DI 22505.022E.1.e. in this section.
The limits shown indicate the maximum number of occurrences included in the report. Except as noted, the standard report includes the patient’s records from the most recent two years of medical treatment (i.e., two years back from the date last seen at the VHA medical facility).
Outpatient visits (limit 150)
Global Assessment of Functioning (no limit)
Progress notes (limit 40)
Surgery reports (limit 10)
Spinal cord dysfunction information (no limit)
Full report of medical procedures (limit 15)
Radiology and Nuclear Medicine Imaging profile (limit 10)
Cytopathology reports (limit 10)
Electron microscopy reports (limit 10)
Microbiology reports (limit 10)
Surgical pathology reports (limit 10)
Oncology information (no limit)
Chemistry and hematology lab results (limit 20)
Inpatient discharge summaries (limit 4 years or 5 occurrences)
Compensation and pension examinations (limit 4 years or 5 occurrences)
NOTE: VHA medical facilities perform compensation and pension examinations required to adjudicate claims for VA disability benefits.
2. Modified SSA-DDS health summary
The MPRO may request that a VHA medical facility tailor the SSA-DDS Health Summary to better meet the needs of the DDS (i.e., to ensure that content and volume of information sent is sufficient and appropriate).
If a VHA medical facility provides a modified SSA-DDS Health Summary, report content will deviate from the standard summary information listed in DI 22505.022D.1. Refer to local guidelines for report content.
E. Procedure for developing MER from VHA medical facilities
Make every reasonable effort to help the claimant obtain relevant VHA medical records; see DI 22505.001A.2.
Document development efforts in the case development summary worksheet.
1. Initial requests
Send a MER request to each VHA medical facility where the claimant received relevant medical treatment or evaluation.
NOTE: If local experience indicates that a single MER request will produce records from multiple VHA facilities, you may attempt to obtain the records with one MER request.
Include the claimant’s name, date of birth, and the last four digits of the claimant’s social security number.
Consider whether the SSA-DDS Health Summary contains the needed MER. If the VHA medical facility produces a:
standard SSA-DDS Health summary, see DI 22505.022D.1. in this section.
modified SSA-DDS Health summary, refer to local procedures; see DI 22505.022D.2. in this section.
Request the SSA-DDS Health Summary.
Take the following actions if the SSA-DDS Health Summary does not or would not be expected to include all needed MER from the VHA facility:
Carefully target a supplemental MER request;
Include a date or date range and the type of treatment received;
Follow local instructions to alert the VHA medical facility to the nonstandard request; and,
Clearly identify and separately list any additional records needed.
Records from a time prior to that covered by the SSA-DDS Standard Health Summary.
Records of more recent treatment to supplement the SSA-DDS Standard Health Summary already received.
Copies of specific documents (e.g., electrocardiograms, pulmonary function tests, echocardiograms, or audiograms).
Do not request a medical opinion from a VHA medical facility; see DI 22505.007C.
Include a copy of the signed SSA-827 (Authorization to Disclose Information to the Social Security Administration), with each MER request.
NOTE: The VHA medical facility will submit a negative response by ERE if the requested records are not available.
2. Follow up guidelines
Use these guidelines for follow up if the VHA medical facility does not respond to an initial request for MER:
Wait 10 – 20 days after the initial request before you follow up. Allow more time if experience indicates.
Send follow up requests by letter. Do not routinely follow up by telephone.
Allow 10 days, or more if experience indicates, for the VHA medical facility to respond to a follow up request.
Notify the MPRO if the VHA medical facility does not respond to the MER follow-up letter.