H.R. 3989 — what changed

“(d) External clinical review of applications

“(1) Using amounts otherwise appropriated to carry out this section, an individual may elect to have an independent contractor described in paragraph (2) perform an external clinical review of any of the following:

changed “(A) The denial by the Secretary of an application by an individual to be a caregiver or family caregiver eligible for benefits the program of comprehensive assistance administered by the Secretary pursuant to this section.

“(B) With respect to such an application that the Secretary has granted, a determination by the Secretary of the level or amount of personal care services that a veteran requires.

“(C) A request by a caregiver or family caregiver for a reconsideration of the level or amount of personal care services that a veteran requires based on changes to the health or abilities of the veteran occurring since the Secretary granted such an application.

changed “(D) The revocation by the Secretary of benefits assistance administered by the Secretary pursuant to this section.

“(2) An independent contractor described in this paragraph is an independent contractor that—

“(A) is awarded a contract by the Secretary to carry out this section pursuant to full and open competition under the Federal Acquisition Regulation;

“(B) has no direct or indirect financial relationship with any non-Department provider of services to caregivers and family caregivers pursuant to this title;

“(C) has not otherwise conducted an external clinical review of benefits administered by the Secretary pursuant to this title other than this section;

“(D) has sufficient training and expertise in medical science and other appropriate health, educational, and vocational training and legal matters to perform the reviews described in paragraph (1); and

“(E) employs a panel of physicians or other appropriate health care professionals who do not provide health care to the individual who makes an election under paragraph (1).

“(3) Each external clinical review conducted pursuant to paragraph (1) shall—

changed “(A) be based on applicable information included in the application for benefits assistance described in such paragraph, including clinical expertise, medical, technical, and scientific evidence;

changed “(B) include an opportunity for both the individual who elects for such review and, to provide the opinions of the individual and extent possible, the veteran for whom care is provided; being provided to offer opinions and supporting data as to the level of care required; and

“(C) include a review of the initial clinical review of such veteran and any other review made by the Secretary.

“(4) In carrying out the external clinical reviews pursuant to paragraph (1), the independent contractor shall, as determined appropriate by the Secretary—

“(A) collect and maintain information required; and

“(B) share such information with the Secretary.

changed “(5) The Secretary shall take into account, but is not bound by, any determination made by the independent contractor pursuant to paragraph (1) shall be final.in determining the final decision with respect to the application for assistance. The Secretary may make a final decision that is contrary to such a determination if the Secretary includes clinically supported documentation with the decision.

changed “(6) The Secretary shall ensure that each external clinical review conducted by the independent contractor pursuant to paragraph (1) is completed and the individual Department is notified in writing of the results of the review by not later than 120 days after the date on which the individual makes the election under such paragraph. Such Not later than 30 days after the delivery of the determination recommended by the independent contractors, the Secretary shall ensure that the veteran and the individual making the election under such paragraph is notified in writing of the final decision of the Secretary. In accordance with paragraph (5), such notification shall include an explanation of the recommended decision, a discussion of the facts and applicable regulations, and an explanation of the clinical rationale for the final decision.

changed “(7) The Secretary shall notify individuals who submit an application to be a caregiver or family caregiver eligible for benefits the program of comprehensive assistance administered by the Secretary pursuant to this section of the ability of the individual to make an election under paragraph (1).

“(8) Nothing in this subsection may be construed to affect claims made by veterans for disability compensation under chapter 11 of this title.”