Part IV, Subpart i, Chapter 2, Section AExamination Requests Overview

Revised April 20, 2026

IV.i.2.A.1.a#Who May Request an Examination

Development activity personnel have the primary responsibility for requesting examinations. The rating activity may provide guidance as necessary and also has authority to request examinations. In addition, Veterans Service Center Managers (VSCMs), Pension Management Center Managers (PMCMs), or designees may authorize an examination in any case in which they believe it is warranted.Note : When a claim is received that includes one or more automation-eligible contentions, the Department of Veterans Affairs (VA) uses automation tools to draft and submit examination requests for the automation-eligible contention(s) when warranted.

IV.i.2.A.1.b#Definition: Appropriate Examination Facility

An appropriate examination facility is a VA examination facility or contract examination provider that can complete the examination(s) required by the specific claim. Regional offices (ROs) have the flexibility to request an examination from the VA medical center (VAMC) closest to where the claimant lives or receives regular medical treatment and/or the designated contract provider. References: For more information on

• mandatory use of the Examination Request Routing Assistant (ERRA) tool, see M21-1, Part IV, Subpart i, 2.A.1.c, and
• splitting examination requests between VAMCs and contract providers, see M21-1, Part IV, Subpart i, 2.A.2.d.

IV.i.2.A.1.c#Mandatory Use of the ERRA Tool

Claims processors must use the ERRA tool when requesting examinations in support of claims for service-connected (SC) compensation, Veterans Pension, and survivors benefits, absent any noted exception(s). VA resources will be utilized to the fullest extent possible in performing examinations, but the use of contract/vendor resources is authorized whenever a VA examination facility has reached or exceeded maximum capacity. When queried, the ERRA tool will identify the

• 10 VA examination facilities nearest the zip code entered, and
• examination categories that should be routed to a contract examiner, if applicable.

Note: Requests for non-Veterans Health Administration (VHA) examinations scheduled through a designated contractor are limited to the geographic area specified by the contractual agreement between the vendor and the Veterans Benefits Administration (VBA). Exceptions:

• The ERRA tool’s use is not required at Integrated Disability Evaluation System (IDES) or Benefits Delivery at Discharge (BDD) intake sites where existing agreements specify the provider(s) responsible for local IDES or BDD examinations.
• The ERRA tool’s use is not required for examination requests prepared by automation, as these will always be routed to a contract examination provider.
• The ERRA tool’s use is not required for requests involving
  • examination clarification
  • examination addenda
  • corrections to insufficient/inadequate examinations
  • medical opinions in support of claims filed under 38 U.S.C. 1151, or
  • acceptable clinical evidence (ACE) examinations completed by a VHA practitioner assigned to serve the RO.

Reference: For more information on the ERRA tool, see M21-1, Part IV, Subpart i, 2.A.2.c and d.

IV.i.2.A.1.d#Scope of Practice Relative to Examination

The purpose of obtaining a medical examination and/or opinion is discussed in M21-1, Part IV, Subpart i, 1.A. Generally, the VA examination is intended to serve as an evidentiary element that informs the rating activity’s decision-making and facilitates application of the rating schedule for evaluation purposes. The examination appointment is not , however, an appropriate venue for treatment. Certain diagnostic activities may require that the examiner be able to provide treatment or follow-up care and, as such, are considered outside of the scope of VA examination practice. Furthermore, certain disabilities require initial diagnosis via invasive procedural means. Invasive procedures are surgical or exploratory methods that require consideration of anesthesia, infection, shared decision-making between clinician and patient, and informed consent with acknowledgment of known risks; they range broadly in level of severity but include such common diagnostic measures as biopsy, excision, and laparoscopy. Follow procedural guidance found in M21-1, Part IV, Subpart i, 1.B to review for satisfactory evidence of a current disability or symptoms. In situations where evidence of a current diagnosis and treatment is not of record for the examiner to review, do not request an examination to render a diagnosis that requires the Veteran to be sedated and/or undergo an invasive procedure. Performing such a procedure surpasses the VA examination model’s scope of practice.

IV.i.2.A.1.e#Definition: General Medical Examination

The main purpose of a general medical examination is to screen all body systems and either

• document normal findings, or
• identify disabilities that are found or suspected.

Note: The examiner must fully evaluate any disability that is found or suspected according to the applicable disability benefits questionnaires (DBQs). Opinions addressing etiology and relationship to service are not typically provided by general medical examinations. References: For more information on

• general medical examinations, see M21-1, Part IV, Subpart i, 2.A.5, and
• general medical examination DBQs, see the DBQ Switchboard.

IV.i.2.A.1.f#Definition: Specialty Examination

A specialty examination focuses on the disabilities that are specifically at issue in the Veteran’s claim. For example, if a Veteran claims that SC hypertension has worsened and an examination is deemed necessary, use the Hypertension Disability Benefits Questionnaire. Notes:

• Specialty examinations generally do not address disorders that are not at issue in the claim, even if the disorders are found or suspected during the examination.
• Specialty examinations may be (and usually are) performed by non-specialist clinicians, but in unusual cases, or as requested by a Board of Veterans’ Appeals (BVA) remand, it may be necessary for the specialty examination to be performed by a specialist.

IV.i.2.A.1.g#Definition: Specialist Examination

A specialist examination is any examination that is conducted by a clinician who specializes in a particular field. Notes:

• All vision, hearing, dental, and psychiatric examinations must be conducted by a specialist.
• In unusual cases, or as requested by a BVA remand, it may be necessary to request a specialist examination for other types of disabilities.

References: For more information on

• specialist examinations, see M21-1, Part IV, Subpart i, 2.A.6, and
• requesting examinations for BVA remands, see M21-5, Chapter 7, G.4.c.

IV.i.2.A.1.h#Veteran’s Legal Rights at an Examination

A Veteran has no legal right to

• be accompanied by counsel during an examination, or
• record an examination.

IV.i.2.A.1.i#Contract Examination Exclusions

Examinations must not be requested from contract examiners under the circumstances specified in the Contract Exam Exclusions List. Use discretion based on RO expertise and consultation with VA Central Office (CO) when determining whether a contract examination is warranted. Important: When an examination cannot be performed by a contract examiner, include a note in the REMARKS field in the Compensation and Pension Record Interchange (CAPRI) examination request. Example: Veteran has filed a claim for [excluded condition] – cannot submit to VBA contract examination provider.

IV.i.2.A.1.j#Examination Requests for Conditions Affected by Revised Rating Schedule Criteria

When VA issues an amendment to the rating schedule while an initial or increased rating claim is pending, ensure that examination requests (whether initiated through CAPRI or the Veterans Benefits Management System (VBMS)) for conditions affected by the amendment include any appropriate condition-specific historical rating criteria language found in the Supplemental Language Matrix. Claims processors must consider historical rating criteria and associated examination results in order to properly decide claims in such instances. Note: This guidance applies equally if/when a rating claim received after a rating schedule amendment was preceded by an active intent to file (ITF) submitted prior to the amendment date. Reference: For more information on the Supplemental Language Matrix, see M21-1, Part IV, Subpart i, 2.A.10.b.

2Examination Request Tools

This topic contains information about tools used for requesting examinations, including

• overview of examination request tools
• Exam Scheduling Assistant (ESA) tool
• ERRA tool
• interpreting the ERRA tool’s results
• Index of DBQ/Exams by Disability tool, and
• selecting the appropriate application for entering examination requests.

Revised August 22, 2024

IV.i.2.A.2.a#Overview of Examination Request Tools

The examination request tools listed in this topic allow users to

• obtain assistance in determining whether an examination and/or medical opinion is warranted
• identify the examining facility location closest to the Veteran
• identify the DBQs for the claimed disabilities
• build the examination request, and
• submit the examination request to the VHA or contract examination facility.

IV.i.2.A.2.b#ESA Tool

The Exam Scheduling Assistant (ESA) tool allows users to answer a series of questions for each contention to receive guidance regarding whether an examination and/or medical opinion is warranted for the contention. Claims processors are encouraged to use the ESA tool during claims development. Important: While the ESA tool is an aid to assist in determining when examinations and/or medical opinions are needed, claims processors are responsible for following guidance in M21-1, Part IV, Subpart i, 1.B to review evidence for the three elements that must be met to necessitate an examination and/or medical opinion. As provided in 38 U.S.C. 5103A(d) and 38 CFR 3.159(c)(4), an examination or medical opinion is not necessary if the evidence of record is sufficient to make a decision for a claimed contention. References: For more information on

• the ESA tool, see the VBMS Exam Management System (EMS) Toolkit page, and
• reviewing evidence before determining whether an examination or opinion is necessary, see
  • M21-1, Part IV, Subpart i, 1.A.1.c, and
  • M21-1, Part IV, Subpart i, 1.B.1.a.

IV.i.2.A.2.c#ERRA Tool

Examination facilities designated to conduct examinations are found in the ERRA tool. The ERRA tool’s search results include information about the

• application to use for submitting the examination request
• facility routing location
• routing location comments
• examination type comments, and
• approximate distance (from the zip code entered, including driving distance and estimated time).

Important:

• This tool is designed as a guide to assist in the routing of compensation and pension (C&P) examination requests. Its use is mandatory, as discussed in M21-1, Part IV, Subpart i, 2.A.1.c. When routing an examination request to a VHA facility, take into account any
  • claimant preferences, or
  • topography/driving concerns.
• The ERRA tool’s data are refreshed daily. Therefore, it is imperative to check zip codes daily, as the suitability of a claimant’s direction to a VHA or contract examination facility may vary in response to demand and facility availability. Routing location and examination type comments may also be subject to daily updates.

Notes:

• The ERRA tool identifies whether a VHA facility has capacity to complete examinations timely and suggests a contract provider/vendor be used if necessary.
• Any justifiable deviation from the ERRA tool’s recommendations must be explained as a remark in the examination request.

References: For more information on the

• appropriate application for entering examination requests, see M21-1, Part IV, Subpart i, 2.A.2.f, and
• ERRA tool, see the Medical Disability Examination Office Policy and Program Management page.

IV.i.2.A.2.d#Interpreting the ERRA Tool’s Results

Use the table below to interpret the ERRA tool’s results and determine the appropriate examination facility to which an examination request should be routed.

Important: Follow the instructions in the Electronic Health Record Modernization (EHRM) National Process Memorandum when the ERRA tool recommends submitting the examination request to an EHRM VHA facility.

Note: If, after reviewing the ERRA tool’s results, the proper VHA routing location is not clear, VA clinics may be contacted to request clarification. Identify points of contact (POCs) by using the VHA C &P POC List.

References: For more information on

• the ERRA tool’s functionality, see the Medical Disability Examination Office Policy and Program Management page, and
• EHRM, see M21-1, Part III, Subpart ii, 1.A.2.b.

IV.i.2.A.2.e#Index of DBQ/Exams by Disability Tool

The Index of DBQ/Exams by Disability tool allows users to search by a particular word, phrase, or diagnostic code (DC). Input information in the SEARCH CRITERIA text box, and the tool will generate suggested DBQs, DCs, and additional relevant information.

IV.i.2.A.2.f#Selecting the Appropriate Application for Entering Examination Requests

Use the table below to determine which application to use in preparing and submitting an examination

• request, or
• scheduling request.

References: For more information on

• interpreting the ERRA tool’s results, see M21-1, Part IV, Subpart i, 2.A.2.d

• inputting examination requests, see M21-1, Part IV, Subpart i, 2.A.9 and 10

• examination requests in

  • CAPRI, see the CAPRI User Manual, and

  • VBMS, see the VBMS Core User Guide , and

• contract examination exclusions, see M21-1, Part IV, Subpart i, 2.A.1.i.

3DBQs

This topic contains information about DBQs, including

• definition of DBQs, and
• use and acceptance of DBQs for VA examination and opinion purposes.

Revised March 1, 2021

IV.i.2.A.3.a#Definition: DBQs

Disability benefits questionnaires (DBQs) are documents used to

• elicit medical information needed to make decisions on claims, and
• provide a standardized report format for medical examinations and opinions.

DBQs are designed for internal use by both VHA and contract examiners. Most are also approved for public use by private providers. Reference : For more information on DBQs, see the DBQ Switchboard.

IV.i.2.A.3.b#Use and Acceptance of DBQs for VA Examination and Opinion Purposes

Use of DBQs to record the results of VA examinations and medical opinions is required. However, if there is not a DBQ appropriate for a particular type of examination, or examination results or an opinion is submitted in another format, do not return the report as insufficient for rating purposes on that basis alone. In lieu of a DBQ completed by a VA or contract examiner, decision makers can accept the following, provided the findings and conclusions needed to make the necessary regulatory determinations on the issues (as described in 38 CFR 3.326 and 38 CFR 4.2) are documented:

• a DBQ or other medical/opinion report completed by a VA or private health care provider, or
• VA examination/opinion results reported in a legacy/non-DBQ format.

References: For more information on

• examination requirements and sufficiency, see M21-1, Part IV, Subpart i, 3
• returning examination reports as insufficient for rating purposes in
  • general, see M21-1, Part IV, Subpart i, 3.C
  • CAPRI, see the CAPRI User Manual, and
  • VBMS, see the VBMS Core User Guide
• principles for reviewing and weighing evidence, see M21-1, Part V, Subpart ii, 1.A, and
• VA’s authority to develop for all evidence sufficient to render an informed decision, see Douglas v. Shinseki, 23 Vet.App. 19 (2009).

4ACE Examinations

This topic contains information on ACE examinations, including

• examinations based on ACE
• categories of examinations for which the ACE Process is prohibited, and
• examination requests and ACE.

Revised September 24, 2025

IV.i.2.A.4.a#Examinations Based on ACE

In lieu of scheduling an in-person examination, VHA and contract examiners generally (subject to some limitations) have the option to complete a DBQ based on review of existing medical evidence. They may also conduct an interview with the claimant. Examinations based upon medical records and history without an in-person clinical examination or testing are known as ACE examinations or the ACE Process.

IV.i.2.A.4.b#Categories of Examinations for Which the ACE Process Is Prohibited

The ACE Process is not available in the following categories of examinations:

• examinations when necessary electronic medical records are not available for examiner review
• Separation Health Assessments (SHAs) in support of IDES and BDD claims
• general medical examinations
• initial and review traumatic brain injury (TBI) examinations, and
• mental disorder examinations.

Exceptions: The ACE Process may be used to

• resolve requests for clarification of, or addendum to, an SHA where the service member’s previous General Medical – Separation Health Assessment Disability Benefits Questionnaire was completed in person, or
• complete individual specialty and/or specialist DBQs for pre-discharge contentions, provided the
  • service member’s General Medical – Separation Health Assessment Disability Benefits Questionnaire was completed in person, and
  • other exclusion principles discussed in this block are not applicable.

For any contention or examination type that is not prohibited from being completed via the ACE Process, claims processors must indicate in the examination request that the contention is eligible for ACE, as directed in M21-1, Part IV, Subpart i, 2.A.4.c. However, VBA may specifically require an in-person examination in certain cases, such as when requested by a BVA remand.Reference: For more information on the requirement to identify evidence for the examiner’s review, see M21-1, Part IV, Subpart i, 2.A.8.d.

IV.i.2.A.4.c#Examination Requests and ACE

When entering an examination request in CAPRI or VBMS, ensure that the examination request

• specifies that the ACE Process is permitted, or
• clearly states that the ACE Process may not be used, and an in-person examination is required to complete the DBQ.

Note: The DBQ templates include ACE check boxes that contain the rationale for the use of ACE, requiring the clinician to indicate the method used to obtain medical information when using ACE to prepare the DBQ. References: For more information on

• requirements for ACE examinations, see M21-1, Part IV, Subpart i, 3.A.1.m, and
• indicating ACE eligibility when requesting an examination via EMS in VBMS, see the EMS User Guide.

5General Medical Examinations

This topic contains information about general medical examinations, including

• when to request a general medical examination
• when a general medical examination is not necessary
• conducting a general medical examination, and
• citing medical conditions to be examined.

Revised September 24, 2025

IV.i.2.A.5.a#When to Request a General Medical Examination

A general medical examination containing a full report of complaints and functional impairments is the preferred type of examination for compensation claims involving recent discharge from military service. Request a general medical examination if

• an initial claim is received within one year of discharge from any period (original or non-original) of
  • active service, as defined in 38 CFR 3.6(a), or
  • full-time duty performed in the National Guard, as defined in 38 CFR 3.6(c)(3), or
• an ITF is received within one year of such discharge, and a substantially complete application is received within one year of the ITF.

It may also be appropriate to request a general medical examination to obtain evidence in claims for

• individual unemployability (IU)
• service connection (SC) under 38 CFR 3.317, or
• Veterans Pension.

Important:

• When requesting a general medical examination to evaluate an initial compensation claim received within one year of discharge, do not request that the examiner also complete specific, individual DBQs for each claimed disability except in cases where claimed contentions require examination by a specialist, as discussed in M21-1, Part IV, Subpart i, 2.A.6.a. This policy applies to examinations requested from VHA and contract examination providers.
• When an initial claim is received within one year of discharge as described above and an examination is needed for one or more claimed issues under the provisions of 38 CFR 3.317, follow the instructions in M21-1, Part VIII, Subpart ii, 1.B.2. If a Gulf War General Medical Examination Disability Benefits Questionnaire is required, do not also request a General Medical – Compensation Disability Benefits Questionnaire , as this may result in duplication of DBQs completed as part of the general medical examination.

Notes:

• A fully sufficient general medical examination is usually of greater value than a number of uncorrelated specialty examinations.
• If a claim for one or more additional contentions is received within the initial year following discharge, but after a general medical examination has been conducted, do not order an additional general medical examination to evaluate the disability(ies) contended. In this situation, order the appropriate specialty DBQ(s) for the additional contention(s).
• Request a general medical examination for Veterans Pension claims that require a permanent and total (P&T) disability determination when there is insufficient medical evidence to decide the claim.

References: For more information on

• ITF, see
  • 38 CFR 3.155(b), and
  • M21-1, Part II, Subpart iii, 2.A
• specialist examinations, see M21-1, Part IV, Subpart i, 2.A.6
• requesting examinations related to claims for IU, see M21-1, Part VIII, Subpart iv, 3.B.2, and
• when a rating determination of P&T disability for pension purposes is required and when an examination is needed for pension claims, see M21-1, Part IX, Subpart i, 2.2.e-g.

IV.i.2.A.5.b#When a General Medical Examination Is Not Necessary

It is not necessary to request a general medical examination if

• an original claim for compensation is being rated many years after separation from service, or
• a Veterans Pension claim that requires a P&T disability determination contains sufficient medical evidence to decide the claim.

Exception: In claims for IU, SC under 38 CFR 3.317, or Veterans Pension filed more than one year after service, a general medical examination may be appropriate. General medical DBQs exist for compensation, Veterans Pension, and Gulf War claims. Reference: For more information on acceptable medical evidence for pension rating purposes, M21-1, Part IX, Subpart i, 2.2.f.

IV.i.2.A.5.c#Conducting a General Medical Examination

The examiner conducting the general medical examination should confirm the existence of and evaluate

• all disabilities listed in the examination request, and
• any other disabilities the Veteran identifies during the examination.

Notes:

• Opinions addressing etiology and relationship to service are not typically provided by general medical examinations.
• Unclaimed disabilities that are not listed in the examination request, but that are reported or suspected during the examination, must be addressed in the applicable general medical DBQ along with any appropriate additional DBQ(s) when abnormal findings are identified. However, the examiner is not required to complete additional DBQ(s) in conjunction with a general medical examination for subjective complaints reported at the time of examination if objective findings are not noted by the examiner.

References: For more information on

• DBQs used for general medical examinations, see the DBQ Switchboard , and
• soliciting claims for unclaimed, chronic disabilities shown by the evidence, see M21-1, Part V, Subpart ii, 3.A.3.a.

IV.i.2.A.5.d#Citing Medical Conditions to Be Examined

The examination request for a general medical examination should clearly cite the conditions or particular diagnoses that require attention.

6Specialist Examinations

This topic contains information about specialist examinations, including

• examinations that must be performed by specialists
• who may request other types of specialist examinations
• when to request a specialist examination, and
• who determines the choice of examiner.

Revised September 24, 2025

IV.i.2.A.6.a#Examinations That Must Be Performed by Specialists

Some examinations must be performed by specialists. These examination types include

• hearing
• vision
• dental, and
• psychiatric.

Note: In general, do not request a specialist examination for a condition that is not subject to SC for compensation purposes. Example: A claim for SC for astigmatism would not warrant an examination because astigmatism is considered a refractive error and is ineligible for SC.References: For more information on

• conditions that are legally ineligible for SC, see
  • 38 CFR 4.9, and
  • 38 CFR 3.303(c)
• congenital, developmental, or hereditary disorders, see M21-1, Part V, Subpart ii, 2.E
• congenital or developmental defects and refractive error of the eyes, see M21-1, Part V, Subpart iii, 2.A.2
• dental/oral conditions ineligible for SC for compensation purposes, see
  • 38 CFR 3.381(b), and
  • M21-1, Part V, Subpart iii, 14.1.c, and
• the requirement for a disability pattern to be potentially eligible for SC to warrant an examination, see M21-1, Part IV, Subpart i, 1.B.1.b.

IV.i.2.A.6.b#Who May Request Other Types of Specialist Examinations

In certain circumstances, specialist examinations for other conditions can be requested by

• the development or rating activity
• the medical examiner, or
• BVA.

IV.i.2.A.6.c#When to Request a Specialist Examination

Request a specialist examination only if it is considered essential for rating purposes.Example: A specialist examination may be requested

• if an issue is unusually complex
• if there are conflicting opinions or diagnoses that must be reconciled, or
• based on a BVA remand.

Reference : For more information on requesting examinations for BVA remands, see M21-5, Chapter 7, G.4.c.

IV.i.2.A.6.d#Who Determines the Choice of Examiner

The choice of examiners is up to the VA medical facility or contract vendor conducting the examination, unless the BVA remand specifies that the examination must be conducted by a

• Board-certified specialist in … , or
• specialist who is Board qualified.

Some DBQs require a specialist to complete the examination. The DBQ will identify specialist requirements in one of the first paragraphs on the form.Note: In the absence of a BVA remand, ROs may not designate qualification requirements for a specialist examination.

7Medical Opinions

This topic contains information about medical opinions, including

• who may request a medical opinion
• referring claims for complex medical opinion review
• completing medical opinion requests using the VBMS EMS with CAPRI
• procedure for identifying the evidence in a medical opinion request
• maintaining objectivity in medical opinion requests
• medical opinions required for remands
• requesting medical opinions in claims under 38 U.S.C. 1151
• medical opinions and the
  • Hearing Loss and Tinnitus Disability Benefits Questionnaire, and
  • Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire, and
• avoiding asking for legal conclusions in medical opinion requests.

Revised May 27, 2026

IV.i.2.A.7.a#Who May Request a Medical Opinion

Development activity personnel and Military Services Coordinators (MSCs) who have completed training specified by CO are authorized to prepare basic or straightforward medical opinion requests without rating activity review. The VSCM or PMCM will designate categories of opinions that are sufficiently basic or straightforward for preparation by the development activity. However, medical opinion requests of a complex nature, including the following types, must be prepared by the rating activity:

• medical opinions based on stressors involving military sexual trauma
• compensation under 38 U.S.C. 1151
• aggravation (including Allen aggravation)
• diagnostic variation or conflicting medical evidence
• questions of credibility of evidence presented to the examiner, or
• any other matters specified by the VSCM or PMCM, such as
  • rare disorders/rare etiologies, or
  • sensitive or high priority claims.

Exceptions:

• M21-1, Part X, Subpart i, 6.F.2.g, authorizes MSCs to independently prepare medical opinion requests regarding in-service aggravation of pre-service disabilities as they pertain to IDES, BDD, and BDD-excluded claims. If, however, MSCs recognize the need for other “complex” medical opinion types described above, they must refer them for review in accordance with guidance found in M21-1, Part X, Subpart i, 6.F.2.h.
• When a BVA remand or higher-level review (HLR) return directs development for an aggravation opinion (including Allen aggravation), the development activity may prepare and order the medical opinion based on the BVA remand or HLR return instructions. If, however, the development activity recognizes the need for other “complex” medical opinion types described above, the claim must be referred to the rating activity for review as discussed in M21-1, Part IV, Subpart i, 2.A.7.b.

Notes:

• VSCMs or PMCMs may authorize a medical opinion in any case in which they believe it is warranted.
• Generally, any development activity employee or MSC may order an examination using the Hearing Loss and Tinnitus Disability Benefits Questionnaire , which includes certain routine etiology opinions. However, in cases where (1) a separate medical opinion DBQ is required to solicit an opinion not included on the audiological DBQ, or (2) the type of opinion needed is consistent with one of the “complex” exceptions identified above, the opinion request should be prepared by the rating activity.
• Most medical opinions regarding secondary causation are considered of sufficient simplicity to be requested by the development activity without rating oversight. When, however, a Veteran contends entitlement on the basis of Allen aggravation, or a secondary claim is accompanied by competent medical evidence of the contended disability, such that aggravation may be implicated, follow the procedures in M21-1, Part IV, Subpart i, 2.A.7.b, to refer the claim for complex medical opinion review, unless the opinion request is directed by a BVA remand or HLR return, as discussed above.
• When a claim is received that includes one or more automation-eligible contentions, VA uses automation tools to draft and submit medical opinion requests for the automation-eligible contention(s) when warranted.

References: For more information on

• determining when an examination or medical opinion is necessary, see M21-1, Part IV, Subpart i, 1
• medical opinions and the Hearing Loss and Tinnitus Disability Benefits Questionnaire , see M21-1, Part IV, Subpart i, 2.A.7.h
• medical opinion training requirements, see M21-3, Part I, A.3.g, and
• requesting examinations and medical opinions for BVA remands, see M21-5, Chapter 7, G.4.c.

IV.i.2.A.7.b#Referring Claims for Complex Medical Opinion Review

The table below describes the responsibilities of the development and rating activities in ensuring that complex medical opinions are appropriately routed for preparation and entry.

References: For more information on

• special issue indicators, see M21-4, Appendix E, 2, and

• tracked items, see M21-4, Appendix D, 1.

IV.i.2.A.7.c#Completing Medical Opinion Requests Using the VBMS EMS With CAPRI

Use of the VBMS EMS is mandatory in all CAPRI medical opinion requests. When requesting a medical opinion in CAPRI, follow the steps in the table below.

Note : Tracked items will be generated once the user has certified within EMS that the examination request has been submitted in CAPRI.

References: For more information on

• inputting

  • examination requests in CAPRI, see M21-1, Part IV, Subpart i, 2.A.9, and

  • medical opinion requests in CAPRI, see the CAPRI User Manual, and

• using alternate contention names to facilitate appropriate examination request language, see

  • M21-1, Part III, Subpart i, 2.F.2.c, and

  • the Alternate Contention Job Aid.

IV.i.2.A.7.d#Procedure for Identifying the Evidence in a Medical Opinion Request

To identify all pertinent evidence for the examiner to review in connection with the medical opinion requested, in the TABBED EVIDENCE DESCRIPTION field in EMS, provide at a minimum the

• tab label
• document receipt date
• document type, and
• date(s) of treatment, injury, or event.

Example: _Tab A – Pulmonary function test for asthma.__Document Receipt Date – 10/02/2020.__Document Type – CAPRI._Date of Treatment – 07/15/2020. References: For more information on

• EMS, see the
  • VBMS Core User Guide , and
  • EMS User Guide
• requirement to identify relevant evidence for an examiner’s review, see M21-1, Part IV, Subpart i, 2.A.8.d, and
• identification of evidence for examiner review in examination and medical opinion requests prepared by an automated process, see M21-1, Part IV, Subpart i, 2.A.8.e.

IV.i.2.A.7.e#Maintaining Objectivity in Medical Opinion Requests

When requesting medical opinions, claims processors should identify all relevant evidence for the examiner’s review, both favorable and unfavorable. However, maintain objectivity when preparing medical opinion requests.

• Use a neutral and unbiased tone.
• Do not slant the facts.
• Do not communicate that VA prefers one answer or outcome over another.

References: For more information on

• requesting a medical opinion in an impartial manner, see Douglas v. Shinseki, 23 Vet.App. 19 (2009), and
• the attitude of rating officers, see 38 CFR 4.23.

IV.i.2.A.7.f#Medical Opinions Required for Remands

When requesting a medical opinion in compliance with BVA remand instructions, follow guidance in M21-5, Chapter 7, G.4.c.

IV.i.2.A.7.g#Requesting Medical Opinions in Claims Under 38 U.S.C. 1151

When requesting a medical opinion for a claim involving benefits under 38 U.S.C. 1151, submit the request to the appropriate contract examination vendor in all instances , and use existing VBMS EMS medical opinion templates to generate the appropriate language. Ensure the generated request asks the provider only the specific opinion(s) required by the facts of the case. Important: Do not route medical opinion requests of this nature to VHA. Follow-up examination requests involving evaluations of disabilities for which benefits have been established under 38 U.S.C. 1151 may, however, be directed to VHA. Reference: For more information on disability examinations involving claims under 38 U.S.C. 1151, see the DMA C&P Procedure Manual.

IV.i.2.A.7.h#Medical Opinions and the Hearing Loss and Tinnitus DBQ

The DBQ for hearing loss and tinnitus contains specific sections for etiology opinions. However, examiners generally are not expected to provide unsolicited medical opinions, and in some types of hearing loss and tinnitus claims (such as claims for an increased evaluation), an opinion may not be routinely required. In any case involving SC for hearing loss or tinnitus where an etiology opinion is required, follow the medical opinion procedures outlined in M21-1, Part IV, Subpart i, 2.A.7.d. Exception: If tinnitus is not claimed, but reported during the course of the examination, examiners will provide this etiology opinion even when not solicited as long as tinnitus is not already SC. For this reason, when preparing any audiological examination and/or opinion request, include a note/comment informing the examiner whether tinnitus is or is not SC. Important: Do not request a separate medical opinion DBQ unless a medical opinion that is not included on the Hearing Loss and Tinnitus Disability Benefits Questionnaire is needed. References: For more information on

• who may request a medical opinion, see M21-1, Part IV, Subpart i, 2.A.7.a
• the Hearing Loss and Tinnitus Disability Benefits Questionnaire , see the DBQ Switchboard
• requesting audiometric examinations and medical opinions, see M21-1, Part V, Subpart iii, 2.B.1.d, and
• determining sufficiency of a medical opinion for hearing loss, see M21-1, Part IV, Subpart i, 3.B.1.c.

IV.i.2.A.7.i#Medical Opinions and the Initial PTSD DBQ

The Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire elicits from the examiner information relevant to the Veteran’s contended stressor(s), including an assessment of potential relationship to, and adequacy to support, the underlying diagnosis of PTSD. Because this questioning sequence is inherent within the general PTSD examination protocol, do not routinely request a separate medical opinion DBQ unless a medical opinion that is not otherwise satisfied by completion of the Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire is needed. References: For more information on

• examinations and medical opinions in claims for SC for PTSD, see M21-1, Part VIII, Subpart iv, 1.C, and
• the Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire , see the DBQ Switchboard.

IV.i.2.A.7.j#Avoiding Asking for Legal Conclusions in Medical Opinion Requests

Do not request that a medical authority make conclusions of law, as this is a responsibility inherent to the rating activity. To prevent confusion, avoid using the word “opinion” when asking the examiner a question about any issue that does not require a formal medical opinion. Examples:

• Do not request the medical authority to determine if there is "loss of use" of an extremity. Instead, ask for a description of the remaining function of the extremity.
• Do not ask the medical authority to determine if a particular disability is “service-connected” or “SC.” Instead, identify the in-service injury, event, or illness, as well as current disability, and ask the examiner to provide an opinion as to whether or not the current disability was caused by or the result of the identified in-service injury, event, or illness.
• Do not ask the medical authority to provide an opinion as to whether a Veteran is “unemployable” or “entitled to individual unemployability.” Instead, in the REMARKS section of the examination request, ask the examiner to comment on the Veteran’s ability to function in an occupational environment and to describe functional limitations.

Note: The language generated upon selection of the EMPLOYMENT IMPACT ASSESSMENT REQUESTED? field in VBMS is legally sufficient to elicit the information necessary to adjudicate the issue of IU. References: For more information on requesting examinations

• to determine loss of use of an extremity, see M21-1, Part VIII, Subpart iv, 4.A.1.c, and
• in IU claims, see M21-1, Part VIII, Subpart iv, 3.B.2.

8Examiner Review of the Claims Folder

This topic contains information about examiner review of the claims folder, including

• importance of claims folder review
• examinations requiring claims folder review
• requesting examiner review of the claims folder
• requirement to identify relevant evidence for the examiner’s review, and
• identification of evidence for examiner review in examination and medical opinion requests prepared by an automated process.

Revised April 20, 2026

IV.i.2.A.8.a#Importance of Claims Folder Review

Folder review helps VA ensure that the examiner is given the fullest evidentiary picture possible. The claims folder often contains a history of treatment of the disability at issue. In order to provide an adequate basis for the findings and conclusions of an examination, the examiner needs access to that history. Reference: For more information on sending the claims folder in connection with a VA examination or opinion, see VAOPGCPREC 20-1995.

IV.i.2.A.8.b#Examinations Requiring Claims Folder Review

For the reasons discussed in M21-1, Part IV, Subpart i, 2.A.8.a, an examiner’s review of claims folder contents is potentially beneficial and encouraged in all claim types. However, for examinations or medical opinions requested by VBA, the examiner must review the claims folder for the following DBQs or claim types:

• SC under 38 CFR 3.317
• cold injury residuals
• former prisoner of war (FPOW) protocol
• Gulf War general medical
• medical opinions, including etiology opinions in hearing loss and tinnitus claims
• mental health examinations
• TBI examinations
• musculoskeletal examinations involving the
  • ankle
  • back (thoracolumbar spine)
  • elbow/forearm
  • foot, including pes planus
  • hand/finger(s)
  • hip/thigh
  • knee/lower leg
  • neck (cervical spine)
  • shoulder/arm
  • temporomandibular joint, and/or
  • wrist
• BVA remands
• 1151 claims
• ACE
• environmental hazards in Iraq, Afghanistan, and other military installations, and
• IDES claims.

Notes:

• For pension claims, sending the claims folder for review is not required. However, medical records received with the claim relevant to the issue of whether the claimant is currently permanently and totally disabled due to non-service-connected causes must be uploaded into the electronic claims folder (eFolder).
• Privately completed DBQs are not subject to the requirement for claims folder review for the DBQs or claim types listed above. Additionally, medical evidence not in a DBQ format that is deemed adequate for rating purposes in lieu of examination, as discussed in M21-1, Part IV, Subpart i, 2.A.3.b, is not subject to the requirement for claims folder review. This is an internal requirement that applies only to examinations and medical opinions requested by VBA.

References: For more information on

• requesting medical opinions, see M21-1, Part IV, Subpart i, 2.A.7
• requesting examinations in claims for SC under 38 CFR 3.317, see M21-1, Part VIII, Subpart ii, 1.B.2
• ordering initial FPOW protocol examinations, see M21-1, Part VIII, Subpart iv, 2.C.2
• examinations based on ACE, see M21-1, Part IV, Subpart i, 2.A.4
• maintenance of eFolders, see M21-1, Part II, Subpart ii, 2.A
• assessing privately completed DBQs and action to take when a decision cannot be made without additional information that requires an examiner’s claims folder review, see M21-1, Part IV, Subpart i, 3.A.1.e, and
• review of evidence in connection with medical opinions involving speculation, see
  • M21-1, Part IV, Subpart i, 3.A.1.q, and
  • Sharp v. Shulkin, 29 Vet.App. 26 (2017).

IV.i.2.A.8.c#Requesting Examiner Review of the Claims Folder

Examination scheduling requests (ESRs) prepared using VBMS examination management functionality will generate the necessary language indicative of the need for folder review without further user intervention.

IV.i.2.A.8.d#Requirement to Identify Relevant Evidence for the Examiner’s Review

Claims processors must ensure that each piece of relevant evidence in the eFolder is either bookmarked or annotated using the functionality described in the VBMS Core User Guide. Important:

• All relevant evidence (to include service treatment records when their review is relevant to the underlying request), must be scanned into the eFolder prior to requesting any examination. This includes any case for which an examiner may complete an ACE examination.
• If any of the following forms are of record in the eFolder, the most recent form(s) must be annotated prior to submitting an ESR to a contract examination vendor:
  • VA Form 21-0845, Authorization to Disclose Personal Information to a Third Party
  • VA Form 21-22, Appointment of Veterans Service Organization as Claimant’s Representative, and
  • VA Form 21-22a, Appointment of Individual as Claimant’s Representative.

Notes:

• Current functionality allows contract examination vendors to view bookmarks and annotations when the eFolder is automatically transmitted upon submission of an ESR. However, in certain circumstances (including rework requests, sensitive files, or files that require downloading when the eFolder fails to transmit), vendors are unable to physically view the bookmarks and some annotations prescribed in the VBMS Core User Guide and the EMS User Guide. It remains important to apply bookmarks or annotations in all cases as they are significantly beneficial to the underlying process of claim adjudication and provide a means by which evidence relevant to the claim and examination/opinion can be readily and more easily distinguished.
• ESRs submitted by automation fulfill the requirement to identify relevant evidence by directing examiners to the Automated Review Summary Document (ARSD). The ESR will include the ARSD’s document identification number and highlight specific evidence table(s) for the examiner’s review, as necessary.

References: For more information on

• obtaining VA medical records, see M21-1, Part III, Subpart ii, 1.A.2
• timing of the duty to obtain an examination or opinion, see M21-1, Part IV, Subpart i, 1.A.1.d
• the definition of relevant records, see M21-1, Part III, Subpart i, 2.E.1.a
• review of evidence to determine when an examination or medical opinion is necessary, see M21-1, Part IV, Subpart i, 1.B
• procedures for identifying medical opinion evidence, see M21-1, Part IV, Subpart i, 2.A.7.d
• VBMS functionality available to maintain the eFolder, see M21-1, Part II, Subpart ii, 2.A.1.h
• categories of examinations for which the ACE Process is prohibited, see M21-1, Part IV, Subpart i, 2.A.4.b, and
• annotating evidence in VBMS, see the EMS User Guide.

IV.i.2.A.8.e#Identification of Evidence for Examiner Review in Examination and Medical Opinion Requests Prepared by an Automated Process

When an automated process prepares an examination and/or medical opinion request, relevant evidence for the examiner to review is identified on the ARSD. The ESR will include language directing the examiner to the specific table(s) in the ARSD containing relevant evidence for the contention(s) associated with the ESR.Important: In some circumstances, an automated process will leave an examination and/or medical opinion request in draft status because review by a claims processor is required before the ESR is submitted. In these instances, the claims processor should

• determine if any additional
  • evidence was received since automation prepared the draft request that may warrant a change to the ESR
  • contentions not reviewed by automation need to be included on the ESR, and/or
  • medical opinions not included by automation need to be included on the ESR, and
• review the draft for accuracy and edit as necessary prior to submitting the ESR.

Note: If the ARSD does not identify all relevant evidence for examiner review, the claims processor should update the draft ESR to identify only the additional evidence in accordance with guidance in M21-1, Part IV, Subpart i, 2.A.8.d. It is not necessary to tab, annotate, or bookmark documents already identified on the ARSD because the ESR directs the examiner to such relevant evidence.Example: An automated process reviews a claim with two contentions, a request for increased evaluation for SC hypertension and a new claim for SC for gastritis, claimed as due to exposure to jet fuel.

• The automated process uploads an ARSD into the eFolder indicating the outcome for the hypertension issue is Exam Drafted.
• The gastritis issue is listed in the Contentions Not Processed by ADS table with an ineligibility reason of ADS does not currently automate this condition.
• Upon review, the claims processor determines that the gastritis contention warrants an examination with a standard direct SC medical opinion and a toxic exposure risk activity (TERA) medical opinion.

Result: Prior to submitting the ESR, the claims processor

• adds the examination and direct SC and TERA medical opinion requests for the gastritis contention, and
• annotates or bookmarks additional relevant evidence as described in M21-1, Part IV, Subpart i, 2.A.8.d and identifies such evidence on the ESR.

Analysis: Because the gastritis contention was not reviewed by automation but is found to warrant an examination and medical opinions, the claims processor must update the draft ESR accordingly before submitting it.

9Inputting Examination Requests in CAPRI

This topic contains information about inputting examination requests in CAPRI, including

• steps to request an examination in CAPRI
• completing a CAPRI examination request, and
• mandatory entry of requester’s contact information.

Revised September 24, 2025

IV.i.2.A.9.a#Steps to Request an Examination in CAPRI

Follow the steps below when inputting an examination request in CAPRI.

References: For more information on

• certifying submission of a CAPRI examination request, see the
  • VBMS Core User Guide , and
  • EMS User Guide , and
• uploading the CAPRI examination request into the eFolder, see the Uploading VAMC Exam Requests Job Aid.

IV.i.2.A.9.b#Completing a CAPRI Examination Request

Fully complete all fields on the examination request screen in CAPRI, ensuring that those discussed below are appropriately populated.

• The examination location selected should be the appropriate facility identified using the guidance in M21-1, Part IV, Subpart i, 2.A.2.c and d.
• Under LIST OF EXAMS, select all appropriate DBQs. Do not check DBQs for specific body systems if requesting a general medical examination unless the claim also requires the performance of one or more specialist examination(s) discussed in M21-1, Part IV, Subpart i, 2.A.6.a.
• Under the CLAIM TYPE field, select the relevant claim type. Only one selection can be made.
• Under the SPECIAL CONSIDERATIONS field, select any priority processing reason(s) that applies, including
  • AGE OF CLAIM
  • FDC
  • HOMELESS
  • NOT APPLICABLE
  • POW, and/or
  • TERMINAL.
• For the LAST RATING EXAM DATE field, the default entry is N/A. However, where there was a prior examination pertinent to the examination being requested, delete N/A and enter the date of the pertinent prior examination.
• In REMARKS
  • include all generated and manually entered text
  • do not use manual, regulation, or code citations
  • avoid using acronyms or VBA jargon, and
  • if the examinee is rated incompetent, note that fact.

Important: Entering the ITF date is key to correct examination of claims pending at the time of a rating schedule change. This will alert the examiner as to the need to provide historical DBQ information. References: For more information on

• completing a CAPRI examination request, see the CAPRI User Manual
• examinations of non-Veteran claimants, see M21-1, Part IV, Subpart i, 2.E.2.a, and
• the Supplemental Language Matrix, see M21-1, Part IV, Subpart i, 2.A.10.b.

IV.i.2.A.9.c#Mandatory Entry of Requester’s Contact Information

Examination requests submitted through CAPRI must include the primary requester’s contact information, to include, at a minimum, a(n)

• first and last name
• email address, and
• 10-digit telephone number.

Important: ESRs prepared and submitted through VBMS for contract examinations do not require inclusion of the primary requester’s contact information, as any subsequent clarification the contract examination provider/vendor deems necessary will be requested electronically. Note: The telephone number provided must be one that is accessible during any authorized periods of telework the requester may perform.

1. ESRs in VBMS

Introduction — This topic contains information about ESRs in VBMS, including

• entering an ESR
• types of requests requiring supplemental language
• definition of a request for clarification, and
• responding to a request for clarification for vendor examinations.

Change Date — September 24, 2025

IV.i.2.A.10.a#Entering an ESR

As discussed in M21-1, Part IV, Subpart i, 2.A.2.f, and subject to the ERRA tool’s recommendations, requests for contract examinations must be prepared and submitted via VBMS. Follow the steps outlined in the VBMS Core User Guide to prepare an ESR in VBMS. Important:

• Requests for VHA examinations must still be entered in CAPRI.
• As is required with all automated tools, users must ensure that all VBMS system-generated language is legally and procedurally adequate before finalizing an ESR. This includes ensuring that the ADDITIONAL INFORMATION field is completed so as to include information needed by the examiner, but not automatically generated.
• Report any
  • corrected information needed by submitting a trouble ticket, or
  • additional questions or concerns via email to VAVBAWAS/CO/Contract Examination Inquiries.

Notes:

• ESR submission and acceptance in VBMS will automate the creation of one tracked item for each contention identified in the request.
• If unique circumstances exist in a particular case (for example, the Veteran is immobile or unable to drive due to advanced age), these situational factors should be referred in accordance with the Contract Examination Inquiry Guidelines for assistance in determining if, and what, contract examination mitigation may be necessary.

References: For more information on

• types of requests requiring supplemental language, see M21-1, Part IV, Subpart i, 2.A.10.b
• using alternate contention names to facilitate appropriate examination request language, see
  • M21-1, Part III, Subpart i, 2.F.2.c, and
  • the Alternate Contention Job Aid.
• examination suspense dates, see M21-1, Part IV, Subpart i, 2.C.1.a
• contract examination exclusion reasons, see M21-1, Part IV, Subpart i, 2.A.1.i, and
• tracked item suspense and automation relative to examination management, see the
  • VBMS Core User Guide , and
  • EMS User Guide.

IV.i.2.A.10.b#Types of Requests Requiring Supplemental Language

Use the Supplemental Language Matrix to identify the

• claim components or attributes for which ESRs in VBMS must be supplemented, and
• language needed to ensure request adequacy and consistency.

Reference: For more information on entering an ESR in VBMS, see

• M21-1, Part IV, Subpart i, 2.A.10.a
• the VBMS Core User Guide , and
• EMS User Guide.

IV.i.2.A.10.c#Definition: Request for Clarification

In the context of VBMS examination management, a request for clarification is a communication from the examining facility, indicating that additional information about an examination request or individual contention is needed. The request generates either an Exam Request – Request for Clarification or Exam Rework – Request for Clarification tracked item, whichever is applicable. This triggers an NWQ event and electronic routing for review and subsequent action by claims processing personnel. When an examining facility generates a request for clarification, its receipt is reflected by a graphic indicator that appears next to the request in the Exam Scheduling Request Summary table view. Example: Reference: For more information on responding to requests for clarification, see

• M21-1, Part IV, Subpart i, 2.A.10.d, and
• the VBMS Core User Guide.

IV.i.2.A.10.d#Responding to a Request for Clarification for Vendor Examinations

The response to an examining provider’s request for clarification can be provided with a full edit to the previously submitted ESR, or with a claim- or contention-specific narrative response that addresses specific questions posed, depending upon the nature of the information elicited and the processing stage at which the request is received.The following guidelines must be adhered to when responding to requests for clarification from contract examination vendors:

• Responses must be written in a professional manner.
• Responses should be clear and concise regarding any corrective actions taken to resolve the request for clarification.
• All questions posed, information and/or clarification requested, or specific actions indicated must be resolved prior to returning the request for clarification to the contract examination vendor.
• Do not request the contract examination vendor to cancel the examination in the response to a request for clarification.
• Responses must not indicate actions that are contractual in nature. For example, do not make statements indicating that no payment will be rendered for services or informing the contract examination vendor that the ESR will be sent to a different vendor.
• Do not add additional requests, contentions, diagnostics, or requirements that were not included in the original ESR.

Reference: For more information on responding to requests for clarification, see the

• VBMS Core User Guide , and
• EMS User Guide.