Sec. 434.0078. CLAIMS ASSISTANCE SERVICES. (a) The commission shall adopt procedures for administering claims assistance services under Section 434.007(a)(5). The procedures shall include:

(1) criteria for determining when a veteran's initial claim is substantially complete and basic eligibility requirements are met as provided by federal law;

(2) a process for expediting a claim based on hardship, including whether the veteran:

(A) is in immediate need;

(B) is terminally ill;

(C) has a verifiable financial hardship; or

(D) has a disability that presents an undue burden;

(3) a procedure for counseling veterans on the potential merits or drawbacks of pursuing a claim;

(4) a process to ensure adequate documentation and development of a claim or appeal, including early client involvement, collection of needed evidence and records, and analysis of actions necessary to pursue and support a claim or appeal;

(5) criteria for evaluating whether a decision of the United States Department of Veterans Affairs contains sufficient cause for filing an appeal;

(6) a requirement that a claims counselor report to the United States Department of Veterans Affairs if the counselor has direct knowledge that a claim contains false or deceptive information; and

(7) a procedure for prioritizing a claim, when appropriate, or providing an alternative source for obtaining claims assistance services when it is not appropriate to prioritize.

(b) The commission shall consult with the United States Department of Veterans Affairs in developing the procedures under Subsection (a) to:

(1) ensure the services provided by the commission do not unnecessarily duplicate services provided through the United States Department of Veterans Affairs;

(2) ensure that the procedures will provide for resolving disputes at the lowest level of the United States Department of Veterans Affairs benefit decision process;

(3) ensure that commission employees are not improperly involved in adjudicating claims; and

(4) establish broad areas of cooperation between the commission and the United States Department of Veterans Affairs to streamline and align the commission's service delivery with United States Department of Veterans Affairs processes, including:

(A) identifying processes to update changes to veterans' cases and power of attorney designation;

(B) cooperating to expedite hardship cases and appeals; and

(C) identifying opportunities for the United States Department of Veterans Affairs to provide the commission with necessary data to assist with tracking the progress and outcomes of claims.

(c) The commission shall regularly evaluate claims assistance services staffing to determine where counselors and special team staff are most needed. The evaluation must include the:

(1) workload of staff;

(2) number of veterans denied claims assistance services; and

(3) quality of claims prepared at each of the claims assistance services offices.

(d) The commission shall regularly evaluate the needs and performance of any special claims assistance resources provided by the legislature, including the state strike force team and the fully developed claims team, and request to adjust staffing for those resources as appropriate.

(e) The commission shall regularly collect detailed information on the outcome of claims and use that information to evaluate and improve claims assistance services. The commission, at a minimum, shall track and evaluate the following information by claims district:

(1) the quality of claims submitted to the state strike force team;

(2) the percentage of claims developed through claims assistance services that are processed as fully developed claims by the United States Department of Veterans Affairs;

(3) the success rate of claims and appeals developed through claims assistance services; and

(4) the average processing time for claims and appeals by the United States Department of Veterans Affairs.

(f) In documenting the success rate of claims and appeals as required by Subsection (e), the commission shall include in a consolidated report each claim, the corresponding decision by the United States Department of Veterans Affairs, and the status and outcome of any appeal.

Added by Acts 2007, 80th Leg., R.S., Ch. 1269 (H.B. 3426), Sec. 7, eff. September 1, 2007.

Amended by:

Acts 2019, 86th Leg., R.S., Ch. 593 (S.B. 601), Sec. 4, eff. September 1, 2019.