Coverage type · Military, veteran or federal employee
Veterans Affairs health care
Two separate tracks. A disagreement with a medical treatment decision goes through a clinical appeal. A disagreement with a health care benefit decision, such as payment, goes through decision review within one year.
On this page 7
- Who has this
- Veterans who get health care from the Department of Veterans Affairs, including care in the community that the Department arranges or pays for.
- Who regulates it
- The Department of Veterans Affairs. Clinical appeals follow Veterans Health Administration Directive 1041(2); decision reviews follow the Veterans Appeals Improvement and Modernization Act of 2017.
- Can your state help?
- No. The appeal steps are federal and run through the Department of Veterans Affairs. No state agency is part of them. Find your state.
How to tell this is your coverage
- Your dispute is about a medical treatment decision by your Veterans Affairs care team, for example whether a medicine or therapy should be prescribed. That is a clinical appeal.
- Your dispute is about a health care benefit decision, such as enrollment or eligibility, payment or reimbursement of community care or emergency care claims, travel reimbursement or family member programs. That is a decision review.
- Whether you qualify to receive care in the community is a clinical appeal matter, not a Board of Veterans' Appeals matter.
The appeal steps, in order
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Medical treatment decision, first appeal
Official name: Clinical appeal to the facility
- Who decides
- The chief of staff of your Veterans Affairs medical facility, or a designee. Send the appeal in writing to the facility's patient advocate, who is a Veterans Affairs employee whose job is to help resolve concerns and help file a clinical appeal.
- Your deadline
- The directive sets no hard filing deadline, and the Department says to send the appeal as soon as you can. If your appeal arrives 60 or more calendar days after the decision, the Department starts with a re-evaluation by the original decision maker before the appeal continues. Check the date on your decision notice, which controls.
- Their deadline
- An appeal about community care eligibility must be decided and communicated within 3 business days of receipt by the patient advocate. All other clinical appeals must be decided within 45 business days.
- What to send
- A written appeal that says which treatment decision you disagree with and why, with a letter from your doctor if you have one. The suggested order is to raise it first with your treatment team, then the provider's supervisor or chief of service, then the patient advocate. A dispute about a benefit decision, such as payment, goes to the review in the third level below instead.
- If you lose, or hear nothing
- If you disagree with the decision, send a second and final clinical appeal.
- The rule
- Veterans Affairs, clinical appeals
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Medical treatment decision, final appeal
Official name: Clinical appeal to the regional network office
- Who decides
- The chief medical officer of your Veterans Integrated Service Network, the regional network office
- Your deadline
- Send it in writing after the facility's decision; the directive sets no hard filing deadline. Check the date on your decision notice, which controls.
- Their deadline
- Within 45 business days, or 60 business days at the network level if an external review is needed. Community care eligibility appeals are decided within 3 business days.
- What to send
- A written second appeal with the facility's decision and anything new that supports your case.
- If you lose, or hear nothing
- This is the final step for a medical treatment decision. A community care eligibility decision cannot be appealed to the Board of Veterans' Appeals.
- The rule
- Veterans Health Administration Directive 1041(2), appeal of clinical decisions
-
Health care benefit decision, decision review
Official name: Higher-Level Review, Supplemental Claim or Board of Veterans' Appeals appeal
- Who decides
- Veterans Affairs for a Higher-Level Review (no new evidence) or a Supplemental Claim (new and relevant evidence); the Board of Veterans' Appeals for a Board appeal.
- Your deadline
- Within one year of the date on the decision notice, ask for a Higher-Level Review (VA Form 20-0996) or appeal to the Board of Veterans' Appeals (VA Form 10182). A Supplemental Claim with new and relevant evidence can be filed at any time, but file it within one year to keep the claim continuously pursued. Check the date on your decision notice, which controls.
- Their deadline
- For the Board, the Board's stated goal on a direct review (no new evidence, no hearing) is a decision within 365 days. You can instead submit new evidence within 90 days of filing, or have a hearing with a Veterans Law Judge (evidence at the hearing and within 90 days after). The decision time for a Higher-Level Review is not confirmed.
- What to send
- The form for the option you choose. A Higher-Level Review takes no new evidence. For a Supplemental Claim, include the new and relevant evidence. The Supplemental Claim form number is not confirmed here, so use the form the Veterans Affairs Supplemental Claim page names. Community care claims have a separate mailing address on the Higher-Level Review page.
- Form
- VA Form 20-0996 (Higher-Level Review)
- If you lose, or hear nothing
- The rules we use do not cover what comes after a Board decision. Read your decision notice and ask free legal aid.
- The rule
- 38 CFR 3.2500, review of decisions
If waiting could harm your health
Deadlines that cause many community care payment denials: the Department of Veterans Affairs must be notified within 72 hours of the start of emergency treatment at a non-Veterans Affairs facility for it to be authorized as community care. A claim for emergency care for a condition not connected to your service must be filed within 90 days (we did not confirm what starts the 90 days, so ask the facility). A claim for unauthorized care related to a service-connected condition must be filed within 2 years. A community care eligibility clinical appeal is decided within 3 business days. The directive behind the 3-day and 45-day deadlines passed its recertification date of 30 September 2025, and a replacement could change them, so confirm on the Veterans Affairs clinical appeals page. Check the date on your notice, which controls.
Free help for this coverage
- Veterans Affairs patient advocate
A Veterans Affairs employee at each medical facility whose job is to help resolve concerns and help file a clinical appeal.
- Veterans Affairs decision reviews
The Department's pages describe each review option, the forms and where to send them.
- Legal aid
Free civil legal help for people with low incomes. A program can advise you on an appeal, but it cannot take every case. Your state page lists legal aid programs for your state.
Who this covers
This page is for veterans who disagree with a decision about their Veterans Affairs health care, or about care in the community that the Department arranged or pays for. Read the Veterans Affairs health appeals guide.
How to tell this is your coverage
First decide which track your dispute is on. A disagreement with a medical treatment decision by your care team is a clinical appeal. A disagreement with a health care benefit decision, such as enrollment, payment of a community care or emergency care claim, or travel reimbursement, goes through decision review.
What does not apply to you
The older reconsideration and appeal rules in sections 17.132 and 17.133 of Title 38 of the Code of Federal Regulations now apply only to legacy claims, meaning decisions made before the modernized system started in 2019. A community care eligibility decision under section 1703(d) or (e) of Title 38 of the United States Code cannot be appealed to the Board of Veterans’ Appeals; it goes through the clinical appeals process. The Department’s Higher-Level Review page lists community care claims among the health benefit decisions that can be reviewed.
Where people go wrong
- Sending a treatment disagreement to the Board. A medical treatment decision goes through a clinical appeal, not decision review.
- Sending a payment denial through a clinical appeal. A payment or reimbursement decision goes through decision review within one year.
- Missing the emergency care notice. The 72-hour notice, the 90-day claim and the 2-year claim are the deadlines that cause many denials. The events that start the 90-day clock were not read in full, so check the rule or ask the facility.
- Assuming the deadlines are fixed. The directive behind the clinical appeal timeframes passed its recertification date, so check the Department’s page for the current version.
Free help is listed above.
Sources
- Veterans Affairs, clinical appeals
- Veterans Affairs, choosing a decision review option
- Veterans Affairs, decision reviews and appeals
- Veterans Health Administration Directive 1041(2), appeal of clinical decisions
- Veterans Affairs, patient advocate
- Veterans Affairs, Higher-Level Review
- Veterans Affairs, Board appeal
- Veterans Affairs, Supplemental Claim
- 38 CFR 3.2500, review of decisions
- 38 CFR 20.202 and 20.203, Board appeals
- 38 U.S.C. 1703, community care
- 38 CFR 17.4020, 17.1004 and 17.126, community care and emergency care deadlines
- 38 CFR 17.132 and 17.133, legacy claims