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PACT Act Implementation SOP
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Page 1
Public Law (PL) 117-168, Sergeant First Class Heath Robinson
Honoring our Promise to Address Comprehensive Toxics Act of
2022, or the Honoring our PACT Act of 2022 (PACT Act)
Implementation
Standard Operating Procedure (SOP)
In This SOP This SOP contains the following topics:
Topic/Subtopic Topic Name
1 Overview of the PACT Act
2 Toxic Exposure Risk Activity (TERA) Procedures for Non-
Presumptive Claims
3 TERA Healthcare Eligibility Requests
4 Exhibits
-- Version History
Background On August 10, 2022, the President signed Public Law (PL) 117-168, Sergeant
First Class Heath Robinson Honoring our Promise to Address Comprehensive
Toxics Act of 2022, or the Honoring our PACT Act of 2022 (hereafter
referred to as “PACT Act”) establishing substantial legislative changes for the
Department of Veterans Affairs (VA). This historic, multifaceted law:
· expands locations associated with radiation exposure
· expands presumptive conditions associated with herbicide exposure
· expands locations associated with herbicide exposure
· amends the statute involving Persian Gulf War Veterans
· establishes presumptive conditions associated with toxic exposures
· triggers changes to examination requirements when there is toxic exposure
risk activity, and
· provides an avenue for a claimant-elected reevaluation of previously denied
dependency and indemnity compensation (DIC) claims that can result in
retroactive effective dates.
Initial guidance was released to the field on August 10, 2022, followed by
interim guidance on September 9, 2022. With the issuance of this standard
operating procedure (SOP), both documents were rescinded as of January 1,
2023.
References For more information on the PACT Act, see
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· PL 117-168
· Veterans Benefits Administration (VBA) Letter 20-24-06, Updated
Guidance on Processing Claims involving PACT Act
· the Compensation Service PACT Act Information Page, and
· the Pension and Fiduciary Service PACT Act Information Page (including
FAQs).
Procedural Several sections of M21-1, Adjudication Procedures Manual, provide
Precedence procedures for routine handling of toxic exposure cases. Where the
procedures in this SOP, for the purposes of administering the processing of
toxic exposure claims, differ from those of M21-1, the procedures in this SOP
take precedence.
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1. Overview of the PACT Act
Introduction This topic contains an overview of the PACT Act, including:
· applicability
· requirement to identify
- PACT Act-related claims, and
- service-connected death PACT Act-related claims
· PACT Act claim attributes
· claim requirements
· Individual Longitudinal Exposure Record (ILER)
· considering multiple theories of service connection
· effective dates under the PACT Act, and
· decision notice requirements for PACT Act decisions.
Change Date May 15, 2026
Applicability The provisions in this SOP apply to claims pending on or after August 10,
2022, the date PL 117-168 (PACT Act) was signed.
The provisions of this SOP generally apply to both disability compensation
and service-connected death benefits.
Reference: For more information on the definition of a pending claim, see 38
CFR 3.160(c).
Requirement to As noted in guidance in M21-1, Part II, Subpart iii, Chapter 1, Section A,
Identify PACT Topic 2, Block f (M21-1, Part II, Subpart iii, 1.A.2.f), claims must be liberally
Act-Related construed, to include theories of service connection that were not explicitly
Claims and claimed, when doing so would benefit the claimant. When processing claims
Apply Claim based on toxic exposure that is either explicitly claimed or implicitly raised,
Attributes follow the guidelines in M21-4, Appendix E for use of the PACT special issue
and apply it to each relevant contention.
Example: A Veteran files a claim for sleep apnea. The Veteran does not claim
sleep apnea as due to a toxic exposure (there is no explicit claim of exposure.)
There are no symptoms in service.
Result: Sleep apnea is not a presumptive disability. Follow the procedures in
Topic 2, Toxic Exposure Risk Activity (TERA) Procedures for Non-
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Presumptive Claims to rule-out implicit TERA and follow the guidelines in
M21-4, Appendix E to determine if the PACT special issue should be applied.
Notes:
· Apply all other claim attributes required based on the nature of the claim or
disability per existing guidance and when specifically required by the
procedures in this SOP.
· Active duty pre-discharge claims should not be considered under the PACT
Act unless the claimed condition is from a prior period of active duty that
could be associated with the provisions of the PACT Act. If a pre-discharge
claimant has a prior period of qualifying service or is a non-active duty
Integrated Disability Evaluation System (IDES) participant, PACT Act
provisions may apply.
Reference: For complete list of PACT Act locations and presumptive
conditions, see VBA Letter 20-24-06.
Requirement to The guidance below also applies to claims for service-connected death
Identify benefits for survivors :
Service- · Handle implicit claims for service-connected death similarly to a non-
Connected service-connected death claim for inferred DIC. See M21-1, Part XII,
Death PACT Subpart i, 2.A.1.a, for more information.
Act-Related · While the PACT Act only specifically addressed DIC benefits, the
Claims and provisions of the law expanding presumption of service connection will
Apply Claim
Attributes result in additional claimants qualifying for other types of survivor benefits.
· Follow the guidelines in M21-4, Appendix E to determine if the PACT
special issue should be applied.
· Apply all other claim attributes required based on the nature of the claim or
disability per existing guidance and when specifically required by the
procedures in this SOP.
Claim Every claim for disability compensation must be filed on the correct claim
Requirements form for the benefit sought. If the claim was previously denied, the Veteran
must submit a Decision Review Request: Supplemental Claim form to have
the claim considered under the new PACT Act provisions.
Important: Consider the new law as new and relevant evidence for the
purposes of considering a supplemental claim as being complete. This means
a claim based on a new PACT Act provision is a new theory of entitlement,
warranting a merits-based decision.
Reference: For more information on supplemental claims, see
· 38 CFR 3.2501
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· M21-1, Part X, Subpart ii, 2.A, and
· M21-1, Part II, Subpart iii, 2.B.
ILER Follow the guidance for use of Individual Longitudinal Exposure Record
(ILER) found in the ILER Guidance.
Considering Depending on where a Veteran served, multiple provisions of the PACT Act
Multiple could apply to the claim. For example, a claim from a Veteran who served in
Theories of Iraq in 2005 could be considered under the Gulf War Veteran provisions in 38
Service U.S.C. § 1117 (§ 1117) (See M21-1, Part VIII, Subpart ii, 1.A-C), the
Connection presumption of toxic exposure under § 1119 (See M21-1, Part VIII, Subpart
ii, 2.A-C), or the modified exam threshold under § 1168 (See Topic 2, Toxic
Exposure Risk Activity (TERA) Procedures for Non-Presumptive Claims)
depending on the nature of the disability claimed. Claims processors must
follow the guidance in M21-1, Part II, Subpart iii, 1.A.2.f to determine
whether an unclaimed theory of service connection is reasonably raised.
Example 1: A Veteran claims service connection for skin rashes. Military
records show she was deployed to Saudi Arabia in 1991. During her Gulf War
Registry examination in 1993, she mentioned exposure to burn pits and oil
well smoke. With the claim, she submits medical records showing recurrent
treatment over several years for the intermittent skin rashes with no definitive
diagnosis. Service in Saudi Arabia in 1991 qualifies as an area associated
with TERA; consequently, the Veteran is entitled to a medical opinion under
§ 1168 as skin rashes are not necessarily a presumptive disability. An
examination under § 1117 should also be requested as skin rashes are a sign
or symptom of potential undiagnosed illness. In this case, both direct service
connection (38 CFR 3.303) based on TERA and presumptive service
connection for an undiagnosed illness (38 CFR 3.317) are reasonably raised.
Example 2: A Veteran claims service connection for respiratory problems.
Military records and ILER confirm he was deployed to Iraq and Afghanistan
in 2010 and 2012, respectively. VA records show a post-service diagnosis of
chronic bronchitis since 2015, but are not sufficient to establish the current
level of severity. Since the Veteran has qualifying service in a presumptive
exposure location under § 1119 and a known presumptive disability under §
1120, a medical examination to determine severity must be obtained. The
rating considers service connection based on presumption of toxic exposure
under § 1119 only. No other theories of service connection are reasonably
raised.
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Effective Dates In some cases when a claim was pending on the date the PACT Act became
Under the law, August 10, 2022, both a pre-PACT Act and a PACT Act provision will
PACT Act apply to a Veteran’s claim. It is important that claims processors recognize
these situations and assign effective dates in accordance with the provisions
noted in each of the topics below as well as relevant M21-1 provisions.
If awarding a claim based on a newly added or expanded authority under the
PACT Act, apply the provisions of 38 CFR 3.114(a) to the effective date
assigned.
Exception: Claims regarding service-connected death benefits may have an
effective date earlier than August 10, 2022. Refer to M21-1, Part
XII, Subpart i, 3.A.2.c, for more information.
Reference: For more information on assigning an effective date based on a
change in law, see M21-1, Part V, Subpart ii, 4.A.
Decision Notice All decision notices issued under the PACT Act must follow existing
Requirements guidance in M21-1, Part VI, Subpart i, 1.B to generate a decision notice that
for PACT Act complies with the requirements outlined in 38 CFR 3.103(f).
Decisions
When system-generated language does not provide adequate explanation or
cite the correct regulatory or statutory authority, claims processors must use
free text or glossary text to ensure the decision notice is adequate.
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2. TERA Procedures for Non-Presumptive Claims
Introduction This topic contains information on TERA procedures for non-presumptive
claims, including:
· definition of TERA
· provisions of the PACT Act relevant to TERA
· when to apply TERA procedures
· TERA claim attributes
· entitlement to compensation for conditions based on TERA
· identifying a TERA claim
· definition of non-presumptive disability for TERA purposes
· exceptions to ordering TERA examinations
· applying TERA examination exceptions
· TERA and other theories of service connection
· requirement to document all TERA
· procedures for establishing TERA
· determining if location-based TERA applies
· determining the circumstances of the Veteran’s service are consistent with
TERA
· documenting a Veteran’s participation in TERA
· completing the Toxic Exposure Risk Activity Memorandum
· modified examination threshold for TERA claims
· when to request a TERA examination
· TERA opinions and herbicide exceptions
· definition of physical trauma
· evaluating competent medical or scientific evidence for TERA examination
exceptions
· TERA examination
- request procedures, and
- sufficiency
· deciding service connection for disabilities due to TERA
· TERA
- rating decision requirements
- favorable findings, and
· establishing an effective date for TERA claims.
Change Date May 15, 2026
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Definition of The PACT Act defines toxic exposure risk activity (TERA) as any activity
TERA that:
· requires a corresponding entry in an exposure tracking record system, such
as ILER (as defined in § 1119(c)); or
· the Secretary determines qualifies for purposes of this subsection when
taking into account what is reasonably prudent to protect the health of
Veterans.
Notes:
· The definition of TERA is important for the implementation of the modified
threshold examination requirements as discussed in content titled, Modified
Examination Threshold for TERA Claims. The statutory definition is
extremely broad and requires claims processors to consider all evidence of
record when determining if a Veteran was subject to a TERA and regardless
of whether the Veteran specifically claims an exposure(s) as the basis of the
claim.
· There is no required minimum level of exposure or duration of participation
in a TERA to trigger a TERA examination under § 1168.
· Name-only entries and records from contractor or civilian service periods
should not be accepted as participation in a TERA as detailed in the ILER
Guidance.
References: For more information on
· establishing whether an exposure is consistent with the circumstances of a
Veteran’s service, see M21-1, Part VIII, Subpart iii, 9.A and B, and
· what constitutes a non-presumptive disability for TERA purposes, see the
content titled, Definition: Non-Presumptive Disability for TERA Purposes.
Provisions of · New definition: toxic exposure risk activity (TERA) is defined in §
the PACT Act 1710(e)(4). See content titled, Definition of TERA.
Relevant to · New required use of an exposure tracking database when verifying toxic
TERA exposure. Section 302 added a requirement to use an exposure tracking
system, such as ILER during the claim adjudication process.
· Required examinations and medical opinions in non-presumptive exposure
claims. Section 303 creates new § 1168 requiring VA to obtain
examinations and nexus opinions for Veterans who participated in a TERA.
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When to Apply The procedures of this topic apply to any Veteran from any era who
TERA
Procedures · claims or died from a non-presumptive disability, and
· participated in a TERA as defined in the content titled, Definition of TERA.
The table below describes the high-level TERA claims process.
Note: When the Veteran is shown to have a recognized presumptive
disability based on an established presumptive toxic exposure and service
connection can be awarded, do not apply TERA procedures, to include
requesting a TERA nexus opinion. Example: Sinusitis with established fine
particulate matter exposure.
Stage Description
1 Identifying TERA claims.
· Reviewing for explicit and implicit claims.
· Determining when an exception to TERA process applies.
2 Researching and verifying TERA participation.
· Obtaining service records and reviewing ILER.
· Completing the Toxic Exposure Risk Activity Memorandum.
· Applying appropriate claim attributes.
3 Requesting TERA examinations and medical opinions.
· Applying new modified examination threshold.
· Identifying relevant evidence for the examiner.
· Selecting appropriate disability benefits questionnaires (DBQs).
· Using TERA medical opinion template language.
· Ensuring examination provides the appropriate opinion.
4 Rating under direct service connection provisions.
· Discussing TERA and/or a TERA exception in the reasons for
decision.
· Applying the correct effective date.
· Citing TERA as a favorable finding, if applicable.
· Applying relevant TERA special issues in the Veterans Benefits
Management System-Rating (VBMS-R).
TERA Claim In addition to the PACT special issue noted in Topic 1, Overview of the PACT
Attributes Act, claims processors must apply
· the PACT Exam Exclusion – Sec.1168 Circumstance TERA corporate flash,
and
· VBMS-R TERA claim attributes as described in the Utilizing VBMS-R
TERA Special Issues (SIs) Job Aid.
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Note: The PACT Exam Exclusion – Sec.1168 Circumstance TERA corporate
flash must be applied when the Toxic Exposure Risk Activity Memorandum
concedes TERA but determines a circumstance-based exception applies. If
during the processing of a subsequent claim, the exception is found to no
longer apply, for example, new TERA participation is documented in ILER,
remove the flash from the Veteran’s corporate record.
Entitlement to In addition to adding a variety of new presumptive conditions and expanding
Compensation applicable locations for some already existing presumptives, Congress
for Conditions included provisions in the PACT Act to allow Veterans to be considered for
Based on service connection for non-presumptive conditions in certain situations.
TERA Veterans who participated in a TERA while in service and developed a non-
presumptive disease related to that activity may be entitled to receive
compensation benefits under the direct service connection provisions if a
medical opinion provides a nexus of causal link. The PACT Act modifies the
threshold for requesting a disability examination with medical opinion related
to non-presumptive claims for Veterans who participated in a TERA.
Important:
· By introducing the concept of TERA, the PACT Act fundamentally changes
how disability compensation claims processors review and handle claims
primarily by requiring an assessment of the evidence of record regarding
whether the claimant participated in a TERA.
· The PACT Act also fundamentally changes the examination with medical
opinion threshold in non-presumptive disability compensation claims when
the Veteran participated in a TERA. PACT requires a medical opinion
examination when service connection for a condition cannot be granted,
rather than when a decision cannot be made (which could be a grant or
denial).
Note: Unless another theory of service connection applies, such as
presumption, consider claims based on a TERA under the direct service
connection provisions of 38 CFR 3.303 and 3.304.
References: For more information on
· direct service connection, see
- 38 CFR 3.303
- 38 CFR 3.304, and
- M21-1, Part V, Subpart ii, 2.A, and
· service connection for disabilities due to exposure to specific hazards, see
M21-1, Part VIII, Subpart iii, 9.A and B.
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Identifying a The PACT Act requires VA to consider both explicit claims as well as
TERA Claim implicit claims of exposure, unless an exception to the TERA examination
requirements apply as noted below. Therefore, claims processors must review
claims for non-presumptive disabilities, or non-presumptive cause(s) of death,
to determine whether an explicit or implicit TERA claim applies. This
includes reviewing for
· explicit claims of toxic exposure
- the Veteran lists a specific toxic exposure on VA Form 21-526EZ,
Application for Disability Compensation and Related Compensation
Benefits
- the survivor claims the Veteran’s cause of death is due to a toxic exposure
on, or with, a VA Form 21P-534EZ, Application for DIC, Death Pension,
and/or Accrued Benefits (version dated July 2022 or later), or
- lay statements submitted with the claim, and
· implicit claims of exposure where liberally construing the claim raises the
issue even when not specifically claimed, such as
- the Veteran’s service in a location associated with toxic exposure (See
Topic 5 Exhibits and M21-1, Part VIII, Subpart iii, 9)
- the Veteran’s military occupation is associated with a toxic exposure
- ILER or other military records show participation in a TERA
- a documented concession of exposure in a prior claim or the Veteran’s
corporate record contains a claim attribute for toxic exposure, such as the
Toxic Exposure - Sec. 1119 Covered Veteran flash
- medical records contain an allegation of exposure to a toxic substance,
chemical, or airborne hazard, such as a Veterans Health Administration
(VHA) exposure screening
- a survivor submitting a death certificate that lists a primary, or
contributing, cause of death for which a TERA exception does not apply,
and there is reasonable probability that the death may be related to service,
or
- any other relevant evidence of record.
Important:
· Non-presumptive claims must be liberally construed under PACT Act
provisions. The law does not require a Veteran to claim participation in a
TERA for the procedures in this topic to apply.
· These procedures do not apply if another theory of service connection
clearly applies to the claim, such as direct service connection for pre-
discharge claimants, or when an exception for ordering an examination with
medical opinion applies as discussed in the content titled, Exceptions to
Ordering TERA Examinations.
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Example 1: A Veteran claims sleep apnea, which is not a recognized
presumptive disability. A post-service sleep study in the Veteran’s VAMC
records notes a clinical diagnosis of sleep apnea. Military records confirm
service in Iraq in 1991. Because the Veteran served in an area recognized for
toxic exposure because of presumptive exposure to burn pits and other toxins
to include fine particulate matter (BPOT), the claim should be liberally
construed to include an implicit claim of TERA. The claim would be
processed under the TERA direct service connection provisions in this topic.
Example 2: A Veteran claims asthma. Service records show she was deployed
to Afghanistan in 2010. Since asthma is a recognized presumptive disability
under § 1120, and the Veteran served in an area of presumptive BPOT
exposure, assessing whether the Veteran participated in a TERA is not
necessary. The claim would be processed under the presumptive service
connection provisions in M21-1, Part VIII, Subpart ii, 2.A-C.
Definition: Non-presumptive disability for the purposes of TERA refers to conditions for
Non- which service connection cannot be granted on a presumptive basis.
Presumptive
Disability for Reasons may include:
TERA
Purposes · the condition is not listed on any presumptive list
· presumptive exposure is not established
· the condition is not compensable, when required, or
· the condition did not manifest within the required time frame.
Example: A Veteran claims service connection for migraines, a presumptive
disability under 38 CFR 3.309(a) (other organic diseases of the nervous
system). There is evidence of a current disability, but the migraines did not
manifest to a compensable level within one year of separation from active
service, so presumptive service connection under 38 CFR 3.309(a) cannot be
established. The service treatment records are silent for signs or symptoms of
the condition during active duty. Given that there is evidence of a current
disability, and the evidence is not sufficient to grant (rather than decide) the
claim, TERA procedures apply. If research shows participation in a TERA
and no TERA exception applies, then an exam and TERA opinion would be
warranted for the claimed migraines.
Exceptions to § 1168(b) provides that these examination requirements do not apply if the
Ordering Secretary determines there is no indication of an association between the
TERA disability claimed by the Veteran and participation in the TERA.
Examinations
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Claims processors should not order a TERA medical opinion based upon a
TERA if one of the following exceptions applies:
Condition-based Exceptions:
1. Non-presumptive claims based on physical trauma.
2. Mental disorders.
3. The only participation in a TERA that is established is related to herbicide
exposure and the Veteran claims a condition determined to have no
positive association with herbicide exposure.
4. Claims for disabilities that manifested during military service or with an
etiology not associated with toxic exposure.
Circumstance-based Exceptions:
5. The only participation in a TERA that is established is based on an entry
in an exposure tracking record system, such as ILER, that does not
corroborate or correspond to an activity carried out by the Veteran during
active military service that could result in potential exposure to toxic
substances, chemicals, and airborne hazards.
6. The only participation in a TERA that is established is based on an entry
in an exposure tracking record system, such as ILER, that is based on the
Veteran’s report of exposure to toxic substances, chemicals, and airborne
hazards that cannot be substantiated.
Important:
· When applying one of the above exceptions, follow the guidance in the
content titled, Applying TERA Examination Exceptions.
· When a TERA exception applies, ensure the rating decision follows the
guidelines outlined in TERA Rating Decision Requirements.
References: For more information on
· TERA exceptions, see the TERA Exception Job Aid, and
· when to complete the Toxic Exposure Risk Activity Memorandum, see the
Toxic Exposure Risk Activity Memorandum Job Aid.
Applying Use the table below to determine the appropriate development actions when a
TERA TERA exception applies.
Examination
Exceptions Important: In all claims where a TERA examination exception applies, add
the following VBMS note prior to sending the claim to the rating activity:
Met 1168 Exclusion Criteria.
If applying ... Then ...
a condition-based exception do not
based on
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· physical trauma, or · conduct a full review for TERA based on
· mental disorders the condition claimed, or
· order a disability examination based upon a
TERA unless the Veteran submits
competent medical or scientific evidence of
an association between the disability and
the in-service TERA.
condition-based exception · do
based on no positive - conduct a full review for non-herbicide
association with herbicide TERA
exposure - complete the Toxic Exposure Risk
Activity Memorandum
§ using the embedded TERA MEMO
functionality in VBMS, and
§ answering Question 1 based on the
evidence of record, and
- add a note to the free text entry box under
Question 1 specifying that herbicide
development was not completed because
the Veteran's claimed condition is a
condition determined to have no positive
association with herbicide exposure, and
· do not
- refer the claim to centralized processing
for research of herbicide exposure
- order a disability examination based upon
a TERA unless
§ a non-herbicide TERA is shown, or
§ the Veteran submits competent medical
or scientific evidence of an association
between the disability and the in-service
TERA.
condition-based exception do not
for disabilities that
manifested during military · conduct a full review for TERA based on
service or with an etiology the condition claimed
not associated with toxic · complete the Toxic Exposure Risk Activity
exposure Memorandum, or
· order a disability examination based upon a
TERA.
a circumstance-based · do
exception - conduct a full review of the record for
TERA
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- complete the Toxic Exposure Risk
Activity Memorandum using the
embedded TERA MEMO functionality in
VBMS
- concede participation in a TERA
- apply the PACT Exam Exclusion –
Sec.1168 Circumstance TERA corporate
flash, and
· do not order a TERA-related examination
and medical opinion unless the Veteran
submits competent medical or scientific
evidence of an association between the
disability and the in-service TERA.
TERA and In cases where a non-TERA direct medical opinion came back negative and a
Other Theories TERA opinion had not been requested concurrently, whether or not a TERA
of Service opinion is needed is dependent on the facts of the case and the reason behind
Connection the negative opinion. For example, the opinion may have been negative due to
no diagnosis; if so, TERA procedures would not be applicable since there is
no evidence of a current disability. In a case where the Veteran has a chronic
disability which the examiner opined is less likely than not associated with an
in-service event, disease, or injury, TERA procedures may apply.
Use the table below to determine if a TERA medical opinion is needed when
another theory of service connection is being considered.
If the ... And ... Then a TERA opinion is ...
direct or secondary medical there is no diagnosis not needed.
opinion is negative
the rationale attributes not needed.
the disability to a non-
TERA etiology
unrelated to service
the rationale needed, if TERA
· concludes the participation is shown.
disability is not due to
the non-TERA in- Important: Identify the prior
service event or negative medical opinion as
secondary to the SC evidence for the examiner’s
disability, but review.
· does not attribute the
condition to a specific
etiology
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claim does not meet no TERA participation not needed.
presumptive service is shown
connection provisions
Note: This finding must
Reference: See content be documented on the
titled, Definition: Non- Toxic Exposure Risk
Presumptive Disability for Activity Memorandum.
TERA Purposes. TERA participation is needed.
shown
Note: When examination results were previously received by VBA and it’s
subsequently determined that a TERA medical opinion is needed, ensure the
new examination request is routed to the same vendor that completed the
original. If the correct vendor is not populated in the VBMS Examination
Management System (EMS) when submitting the examination request, the
claims processor should use the “View Alternate Destinations” option and
select the original vendor. In the REASON block, include “TERA Language
Required.” These requests should not be submitted as Rework.
Requirement to Under § 1168, VA is required to provide the Veteran a nexus examination
Document All with medical opinion when the Veteran claims a non-presumptive disability
TERA and records show participation in TERA. The law also requires when
providing this opinion that the examiner address
· the total potential exposure through all applicable military deployments of
the Veteran, and
· the synergistic, combined effect of all toxic exposure risk activities of the
Veteran.
To aid the examiner in reviewing the claims file and providing the opinion,
claims processors must document all TERAs in accordance with the
procedures below.
Procedures for If the Veteran submits a substantially complete claim for a non-presumptive
Establishing disability that cannot be granted on some other basis, follow the procedures in
TERA the table below to establish and document the Veteran’s participation in
TERA.
Important: During the TERA claims process, all claims processors are
responsible for ensuring relevant claim attributes are assigned or removed in
accordance with PACT and TERA claim attributes guidance.
Step Action
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1 Review the claim in accordance with the Toxic Exposure Risk Activity
Memorandum Job Aid. Is a Toxic Exposure Risk Activity Memorandum
necessary?
· If yes,
- ensure all military records, to include personnel records if they are not
already of record, have been requested and obtained, and
- go to the next step.
· If no, refer the claim for a decision and take no further action in this table.
2 Follow the steps outlined in the Toxic Exposure Risk Activity Memorandum
Job Aid to complete the Toxic Exposure Risk Activity Memorandum. Is
there evidence of TERA participation warranting an opinion under 38 U.S.C.
§ 1168?
· If yes,
- ensure all evidence used to support TERA is uploaded to the eFolder and
documented in accordance with the guidance in the content titled,
Documenting a Veteran’s Participation in TERA, and
- go to the next step..
· If no,
- complete all applicable fields on the Toxic Exposure Risk Activity
Memorandum
- upload the memorandum
- disregard the remaining step in this table, and
- refer the claim for a decision.
Important:
· If a circumstance-based TERA exception applies, claims processors must
affix the PACT Exam Exclusion – Sec.1168 Circumstance TERA corporate
flash.
· Do not submit research requests of this nature to the Military Records
Research Center (MRRC) unless the M21-1 or other authoritative source
requires it for the specific exposure type (e.g., herbicide exposure).
3 Follow the procedures in the content titled, TERA Examination Request
Procedures.
Determining If Whether explicitly claimed or not, TERA participation should be recognized
Location-Based if the Veteran served in a location associated with
TERA Applies
· a presumption of exposure to a toxic substance (See Topic 5, Exhibits)
· mustard gas exposure as listed in M21-1, Part VIII, Subpart iii, 3.A.5.b, or
· a toxic exposure event as noted in M21-1, Part VIII, Subpart iii, 9.A.1.b.
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Exception: As noted in M21-1, Part VIII, Subpart iii, 8.A.3.b, if the only
service at Camp Lejeune was with the National Guard or the Reserve while
on active duty for training or inactive duty for training, the service does not
qualify as active service. In these cases, do not consider the Camp Lejeune
service as evidence of TERA participation.
Follow the steps in the table below to determine if location-based TERA
applies.
Step Action
1 Review Veteran’s file for evidence of established service in a
location associated with toxic exposure.
2 Review current service records and ILER for an indication of
service in a qualifying location.
3 Ensure entire personnel file is obtained and added to claims
folder or unavailability of records is appropriately documented.
4 Once all service records are obtained, determine if service in a
qualifying location is shown.
· If yes, complete the remaining steps in the content titled,
Procedures for Establishing TERA.
· If no, go to next step.
5 Is potential service in a qualifying location explicitly raised by
the Veteran or reasonably raised by the evidence of record?
· If yes, complete remaining development steps specific to that
location, to include referral to a centralized processing site, if
required.
· If no, complete the remaining steps in the content titled,
Procedures for Establishing TERA.
Example 1: Veteran’s personnel records show he served on a ship
during the Vietnam era, but there is no evidence of land-based
service in a herbicide location. Potential nautical service in a
herbicide location is reasonably raised. The claim should be
referred to centralized processing for research of nautical service
unless the claimed disability is a condition determined to have no
positive association with herbicide exposure as discussed in M21-
1, Part VIII, Subpart i, 1.B.1.g.
Example 2: Veteran’s personnel file shows duty stations in
Germany and United States only. Potential location-based
exposure is not reasonably raised.
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Note: If the Veteran had qualifying active duty service at Camp Lejeune
during the presumptive period, follow the guidance in M21-1, Part VIII,
Subpart iii, 8.A to complete all required development procedures prior to
routing the claim for centralized processing.
Determining When determining if the circumstances of a Veteran’s service are consistent
the with participation in TERA, follow the guidance in
Circumstances · M21-1, Part VIII, Subpart iii, 9.B for specific environmental or military
of the Veteran’s occupational hazards
Service Are · M21-1, Part VIII, Subpart iii, 5.A for chemical, biological, radiological,
Consistent nuclear, and explosives testing participation, and
With TERA
· M21-1, Part VIII, Subpart iii, 6.A for participation in the Shipboard Hazards
and Defense Project.
This includes researching military records, ILER, and alternative sources of
evidence, to include military exposure information available on VHA’s
Military Exposures site.
In addition, follow existing M21-1 guidance regarding military occupational
specialty (MOS)-related toxic exposure, such as
· military occupational hazards in M21-1, Part VIII, Subpart iii, 9.B.3, and
· asbestos exposure and MOS in M21-1, Part VIII, Subpart iii, 7.C.1.b.
Recognize participation in TERA if it is consistent with the places, types, and
circumstances of the Veteran’s service consistent with 38 CFR 3.303(a).
Important: Vaccines and medications in general are not considered
participation in a TERA because there is no scientific or medical evidence
that supports the conclusion that vaccines and medications administered to
Service Members have resulted in long-term adverse health effects. In cases
where the Veteran claims a disability specifically due to a vaccine or
medication received in service, consider the claim based on the facts and
circumstances of the case to include any acute health effects experienced by
the Service Member. However, an examination under the provisions of §
1168 (TERA) should not be invoked.
Example 1: A Veteran files a claim for a non-presumptive cancer. There is
not a record for the Veteran in ILER. The Veteran’s Post-Deployment Health
Assessment in his STRs show reports of exposure to Perfluoroalkyl and
Polyfluoroalkyl Substances (PFAS) in drinking water during his deployment
to Germany. Exposure to PFAS is TERA consistent with the circumstances of
the Veteran’s service.
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Example 2: Veteran files a claim for a non-presumptive skin disability but
does not explicitly claim toxic exposure. Medical records contain results of a
toxic exposure screening at a VHA facility and note the Veteran reports being
exposed to industrial solvents. The Veteran’s records in ILER lists industrial
solvents in the Exposures Pathway tab. Exposure to industrial solvents is
TERA consistent with the circumstances of the Veteran’s service.
Documenting a Veterans may qualify for TERA participation on more than one basis, such as
Veteran’s location-based presumptive exposure and exposure via military occupation-
Participation in related activities. Claims processors must document all qualifying TERA in
TERA order to ensure the examiner can provide the required medical opinion.
Document the Veteran’s participation in all TERAs by
· completing a Toxic Exposure Risk Activity Memorandum using the TERA
embedded MEMO functionality in VBMS
· ensuring the evidence used to support the determination of TERA
participation is uploaded to the Veteran’s eFolder, and
· editing the subject line of the relevant document(s) used to verify
participation using the following format: TERA, pg. [number(s)].
Example:
Notes:
· While the TERA process applies at the contention level, only one Toxic
Exposure Risk Activity Memorandum is required for a claim.
· The provisions of this SOP generally apply to both disability compensation
and service-connected death benefits.
Reference: For more information on editing document properties, see
· the VBMS User Guide, and
· M21-1, Part II, Subpart ii, 2.A.1.e.
Completing the The Toxic Exposure Risk Activity Memorandum will be included in the
Toxic Exposure eFolder and will provide the justification for ordering or not ordering the
Risk Activity examination/medical opinion required in § 1168. It will also serve as a
Memorandum concise summary of exposure information for the medical examiner.
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When completing the Toxic Exposure Risk Activity Memorandum,
· follow the guidance in the Toxic Exposure Risk Activity Memorandum Job
Aid, and
· use the embedded TERA MEMO functionality in VBMS to complete the
memorandum.
In some cases where a memorandum has already been completed, TERA
participation must be researched and a new Toxic Exposure Risk Activity
Memorandum completed. Complete a new updated Toxic Exposure Risk
Activity Memorandum when required by the Toxic Exposure Risk Activity
Memorandum Job Aid and:
· new evidence shows TERA participation that is not documented on an
existing Toxic Exposure Risk Activity Memorandum
· the Veteran explicitly alleges TERA participation that was not previously
researched
· the only TERA participation is documented on a Modified TERA
Memorandum for Health Care Purposes
· one of the following §1168 exceptions applied in a prior claim:
- a herbicide exposure exception, or
- a circumstance-based exception, or
· the previously completed memorandum was not generated using the
embedded TERA MEMO functionality in VBMS on or after November 3,
2024.
Note: The herbicide and circumstance-based examination exceptions are
related to evidence as it existed in ILER at the time the claim was processed.
ILER is subject to continual updates and evidentiary additions. While ILER
would not generally include herbicide exposure information, it could
establish other TERA participation. Therefore, if a Veteran files a
subsequent claim with evidence of a disability, and a condition-based
exception does not apply, the TERA procedures must be followed, and a
new Toxic Exposure Risk Activity Memorandum must be completed to
determine if the previous exception still applies to the current claim.
References: For more information on the
· embedded TERA MEMO functionality, see the VBMS Core User Guide,
and
· binding nature of TERA decisions, see the Interim Guidance-TERA and
CUE.
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Modified § 1168(a) directs that VA will provide an examination and medical opinion
Examination when
Threshold for
TERA Claims · the Veteran
- submits a claim for compensation and
- has evidence of a disability, and
- has evidence of participation in a TERA, and
· such evidence is not sufficient to establish service connection for the
disability, and
· a TERA exception does not apply.
Note: The statutory language in § 1168 modifies the existing § 5103A
threshold in the above situations. As such, in scenarios where claims
processors previously would not have requested an examination based on
insufficient evidence and such claim would result in a denial, if such claim is
related to a TERA, VA now is required to request an examination and
medical opinion before deciding the claim.
When to After establishing that the Veteran participated in a TERA and there is
Request a evidence of a disability, then claims processors must determine whether the
TERA Veteran’s claim meets the minimal threshold for ordering the examination
Examination and medical opinion as discussed in the content titled, Modified Examination
Threshold for TERA Claims.
Notes:
· Request a medical opinion for a survivor claim when
- processing a service-connected death claim based on a non-presumptive
disability, and
- the evidence shows the Veteran participated in a TERA.
· The language of new § 1168(a) requires VA to obtain an examination and
opinion “if a veteran submits to the Secretary a claim for compensation.” A
survivor submitting a claim for DIC is distinct from a Veteran submitting a
claim for compensation, and thus would not fall under the purview of the
new section. See Delarosa v. Peake, 515 F.3d 1319, 1321-22 (Fed. Cir.
2008) (noting that the requirement to provide medical examinations for
compensation claims in § 5103A(d) does not apply to DIC claims).
However, VA may still be required to provide an opinion in relation to a
DIC claim pursuant to § 5103A(a). For more information regarding
requesting an opinion in relation to a DIC claim, please see M21-1 Part XII,
Subpart i, 1.B.1.h.
Reference: For more information on evidence of a current disability or
symptom, see M21-1, Part IV, Subpart i, 1.B.1.b.
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TERA If the herbicide TERA exception applies for a claimed disability, claims
Opinions and processors must still fully research whether the Veteran also participated in
Herbicide another TERA. In these cases, if the Toxic Exposure Risk Activity
Exceptions Memorandum reveals there is evidence of a different TERA (other than
herbicides), a TERA medical opinion is required. Enter the following
language when requesting the TERA medical opinions for conditions
determined to have no positive association with herbicide exposure based on
TERAs other than herbicides:
Although the Veteran served in [herbicide location] and exposure to
herbicides is conceded, only consider the TERA(s) of [non-herbicide
TERAs] as [disability] has been determined by the Secretary to have
no positive association with herbicide exposure.
Reference: For more information on the TERA herbicide exceptions, see
· M21-1, Part VIII, Subpart i, 1.B.1.g, and
· the TERA Exception Job Aid.
Definition: VBA defines physical trauma as a serious injury to the body. Three main
Physical types of physical trauma are as follows:
Trauma
· Blunt force trauma—when an object or force strikes the body, often
causing concussions, deep cuts, or broken bones
· Trauma due to repetitive use—when repeated stress to the body’s soft
tissue structures, including muscles, tendons, and nerves, results in
repetitive strain injuries, and
· Penetrating trauma—when an object pierces the skin or body, usually
creating an open wound
Exceptions:
· Hearing loss is not considered a physical trauma under this exception.
· Penetrating traumas with toxic embedded fragments do not fall under this
exception. An embedded fragment is a piece of metal or other material (also
referred to as shrapnel) that stays in the body after injury.
Example: The Veteran served from 1994 to 2014. Service included tours of
duty in Kuwait, Israel, Iraq, and Bahrain. He is diagnosed with mild hearing
loss in 2020. Pure tone threshold loss of 50 decibels is shown at the 4000
hertz level bilaterally. Service records show normal hearing upon entering and
separating from service. The Veteran files a claim for service connection for
hearing loss in November 2022. He claims that his hearing loss is the result of
exposure to toxic substances in service. Should the Veteran receive an
examination/opinion?
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Result: Yes. Participation in a TERA is established so toxic exposure is
presumed pursuant to § 1119. Although acoustic trauma and noise exposure
are the common etiologies of hearing loss, the disability does not fall under a
physical trauma as it is not consistent with blunt force or penetrating trauma,
or trauma due to repetitive use. Therefore, since participation in a TERA is
demonstrated and the hearing loss, which is rated under diagnostic code (DC)
6100, does not fall within the physical trauma exception under § 1168(b), an
examination/opinion should be provided as there is a potential indication of
an association between the disability and toxic exposure.
Evaluating When determining if there is competent medical or scientific evidence to
Competent overcome an exception to the TERA examination, follow the guidelines in
Medical or M21-1, Part V, Subpart ii, 1.A to evaluate the credibility and competence of
Scientific the evidence. If after weighing the evidence, it is determined to have
Evidence for sufficient probative value, the claims processor should follow the procedures
TERA in the content titled, TERA Examination Request Procedures to order an
Examination examination with medical opinion for the claimed disability.
Exceptions
Reference: For more information on determining if an examination is
necessary, see M21-1, Part IV, Subpart i, 1.A.1.c.
TERA Follow the procedures below when requesting an examination with medical
Examination opinion based on TERA as required by Step 10 in the content titled,
Request Procedures for Establishing TERA.
Procedures
Step Action
1 · Ensure all evidence supporting exposures is uploaded to the
eFolder, including the completed Toxic Exposure Risk Activity
Memorandum and ILER Individual Exposure Summary, if
applicable, and
· identify the relevant evidence for the examiner’s review per
M21-1 Part IV, Subpart i, 2.A.7.d.
2 Select all appropriate DBQs based on the nature of the
disability(ies) claimed, and the medical opinion DBQ for each
applicable contention.
3 In the “Is there a Medical Opinion Needed?” drop down menu in
the VBMS EMS, select TOXIC EXPOSURE.
4 Input the required fields.
Notes:
· The contention will be system generated.
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· Input the toxic exposure risk activity(ies) as documented on the
Toxic Exposure Risk Activity Memorandum.
5 In the examination request in the ADDITIONAL
INFORMATION field, provide the examiner with the following:
· established TERA(s)
· whether the information is documented in ILER/personnel
pages/DD Form 214, Certificate of Uniformed Service (DD
214)/Veteran statement, and
· free text/other, if needed.
TERA Under § 1168, examinations based on TERA require the examiner to provide
Examination an opinion that considers the total potential exposure through all applicable
Sufficiency military deployments of the Veteran and the synergistic, combined effect of
all toxic exposure risk activities of the Veteran.
If an examination fails to provide or to sufficiently explain and support the
required opinion, follow the procedures in M21-1, Part IV, Subpart i, 3.C to
obtain clarification of the examination.
Deciding When deciding a claim for service connection for a disability due to TERA
Service during service, the rating activity should
Connection for
Disabilities Due · determine whether or not service records demonstrate the Veteran
to TERA participated in a TERA during service, and
· determine whether
- a condition-based or circumstance-based TERA examination exception
applied, or
- the evidence establishes a nexus between the TERA and the claimed
disease.
Notes:
· Apply the direct service connection provisions when deciding claims based
on this provision of the PACT Act.
· As always, resolve reasonable doubt under 38 CFR 3.102 in the claimant’s
favor.
Reference: For more information on direct service connection, see
· 38 CFR 3.303
· 38 CFR 3.304, and
· M21-1, Part V, Subpart ii, 2.A.
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TERA Rating Follow existing guidance in M21-1, Part V, Subpart iv, 1.A to generate a
Decision rating decision that explains the basis of any decision under the PACT Act. In
Requirements addition to system-generated text, decision makers should use glossary
fragments created based on the new law, when applicable.
If awarding or denying a claim under the provisions of TERA, apply the
following guidelines:
· cite the relevant statute(s) that applies to the claim, such as, but not limited
to, § 1168, 38 CFR 3.303, etc.
· list the TERA as a favorable finding, if applicable
· in all denials (for explicit and implicit claims) where a TERA examination
exception applied, the rating narrative must discuss
- the specific condition-based or circumstance-based exception, and
- whether there was evidence rebutting the exception, and
· affix the appropriate TERA special issue(s) as discussed in the Utilizing
VBMS-R TERA Special Issues (SIs) Job Aid.
Important: When a TERA examination exception applies and the PACT
Exam Exclusion – Sec.1168 is selected, VBMS-R will generate narrative text
discussing the exception as well as the absence of competent medical or
scientific evidence.
· When a new circumstance-based exception applies, decisionmakers must
include the TERA_exceptions_ILER fragment in the rating decision
narrative and remove any irrelevant system-generated language, as needed.
· If the claim includes medical or scientific evidence attempting to rebut the
exception, but the examination threshold is still not met, the system-
generated text must be edited to explain why the evidence was not sufficient
to overcome the exception.
References: For more information on
· available VBMS-R glossary fragments, see TERA Glossary Text for VBMS-
R, and
· implicit TERA claims, see the content titled Identifying a TERA Claim.
TERA When denying service connection, the rating decision must include the TERA
Favorable favorable finding when TERA participation is shown.
Findings
Important: If TERA participation is shown on a Toxic Exposure Risk Activity
Memorandum, include the favorable finding even when a condition-based or
a circumstance-based TERA exception applies.
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Example: Participation in a toxic exposure risk activity is conceded. TERA
was conceded based on an entry in an exposure tracking record system.
Reference: For more information on documenting favorable findings, see
M21-1, Part V, Subpart iv, 1.A.5.h.
Establishing an The PACT Act was signed into law on August 10, 2022, so any grant based
Effective Date on the new examination threshold under § 1168 cannot precede this date. The
for TERA effective date provisions under § 5110 and 38 CFR 3.400 should be
Claims followed. Effective date provisions due to a change of law under 38 CFR
3.114 also apply.
Reference: For more information on establishing an effective date, see M21-
1, Part V, Subpart ii, 4.A.
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3. TERA Healthcare Eligibility Requests
Introduction This topic contains information about TERA healthcare eligibility requests
from VHA, including:
· background
· applicability
· claims establishment
· unidentified mail, and
· subsequent claims.
Change Date July 17, 2024
Background Section 103(a) of the PACT Act amended 38 U.S.C. § 1710(e)(1) to establish
eligibility for hospital care, medical services, and nursing home care for
toxic-exposed Veterans. If VHA cannot confirm the Veteran participated in a
TERA through VBMS system indicators or through an ILER search, VHA
will request VBA assistance.
VHA uses VA Form 10-7131, Exchange of Beneficiary Information and
Request for Administrative and Adjudicative Action, to request VBA perform
TERA research and provide a formal TERA determination. The TERA
finding may qualify the Veteran for hospital care, medical services, and
nursing home care or for higher priority group enrollment through VHA.
A positive TERA finding for healthcare eligibility will be documented on a
new form, the Modified TERA Memorandum for Health Care Purposes. Only
one documented TERA finding is needed for healthcare eligibility under
Section 103. This differs from the Toxic Exposure Risk Activity Memorandum
used during the disability benefits claims process, which requires the claims
processor to review and document all qualifying TERA participation.
Applicability The PACT provisions for healthcare eligibility requests apply to VA Forms
10-7131 worked by VBA on or after March 5, 2024.
Claims VHA healthcare eligibility determinations for TERA are processed under EP
Establishment 290 using the claim label Healthcare Eligibility - 7131 Review
(290HE7131R) to ensure that the cases are routed to the Benefits Eligibility
Support Teams (BEST) locations.
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When a VA Form 10-7131 is received from VHA in the mail portal, there
may be instances when the appropriate EP and claim label will need to be
established. If the 10-7131 is requesting any healthcare eligibility request,
follow the actions below.
Step Action
1 Create an EP 290 and assign the 290HE7131R - Healthcare
Eligibility - 7131 Review claim label.
2 In the SEGMENTED LANE field, assign to Non-Rating
(National).
3 Select the SUPPRESS ACKNOWLEDGEMENT LETTER
checkbox.
4 · Enter a contention of 7131 healthcare eligibility review
· select Administrative Issue in the CLASSIFICATION field, and
· add all applicable special issue(s)
Important: Any 10-7131 referencing TERA should have the PACT special
issue applied. Continue to follow current guidance and apply all appropriate
corporate flash(es) and special issues.
References: For more information on
· processing TERA healthcare requests, see the PACT Act Section 103 SOP
Addendum, and
· flashes and special issues, see
- M21-4, Appendix E
· M21-1 Part II, Subpart ii, 3.
Unidentified When processing mail, continue to follow guidance in M21-1, Part II, Subpart
Mail i, 1.A.1.c and M21-1 Part II, Subpart i, 2.C.5 when processing unidentifiable
mail.
Note: During the TERA healthcare determination process, to include
unidentifiable mail, VBA will not perform development to the Veteran. All
communication to the Veteran is conducted by VHA.
Subsequent TERA participation that is only documented on a completed Modified TERA
Claims Memorandum for Health Care Purposes is not sufficient for disabilities
compensation claims processing, as only one documented TERA is needed to
support the TERA finding for VHA healthcare eligibility purposes.
Consequently, if a subsequent claim for benefits is filed and that claim raises
the issue of TERA participation, claims processors must follow the TERA
procedures, to include completion of the Toxic Exposure Risk Activity
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Memorandum, when warranted, as detailed in the Toxic Exposure Risk
Activity Memorandum Job Aid.
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4. Exhibits
Change Date February 6, 2023
Locations The table below lists the locations currently associated with a presumptive
Associated exposure to a specific toxic substance, chemical, or airborne hazard.
With
Presumptive
Exposure
Location-Based Exposures Reference for Presumption of
Exposure
Service in locations associated with · 38 CFR 3.307(a)(6)
exposure to certain herbicide agents - Vietnam in-country
- C-123
· § 1116
- Thailand
- Laos
- Cambodia at Mimot or Krek,
Kampong Cham Province
- Guam
- American Samoa
- Johnston Atoll
· § 1116A (BWN RVN), and
· § 1116B (Korean DMZ)
Service in locations associated with 38 CFR 3.307(a)(7)
exposure to contaminants in the water
supply at Camp Lejeune
Service in locations associated with 38 CFR 3.309(d)
radiation-risk activity § 1112
Note: DoD is the source of
information concerning the Veteran’s
participation in radiation-risk activity.
Service in Southwest Asia theater of § 1117
operations or other § 1117 location
Service in locations associated with · 38 CFR 3.320 (current)
exposure to fine particulate · § 1119 (new PACT Act locations)
matter/burn pits
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Version History
Version History The table below outlines changes to SOP content.
Note: Simple updates and additions of general references will not be itemized.
Version History
Version Date Page(s) Purpose
TP 12/05/2022 -- Training Purposes Only
1 01/01/2023 4 and 13 Added a note regarding pre-discharge claims.
1 01/01/2023 5, 8, 18, Updated language regarding the TERA examination
19, and 23 threshold to improve clarity and readability.
1 01/01/2023 8-9 Corrected numbering of the table steps.
1 01/01/2023 19 Replaced discussion of TERA examination threshold
with cross reference to relevant content within SOP.
1 01/01/2023 -- Added a note that the exceptions to presumptive service
connection under 38 CFR 3.320(b) still apply.
2 02/06/2023 11 Clarified TERA example to include post-service
evidence of the claimed disability.
2 02/06/2023 11-12 Added a definition of non-presumptive disability for
TERA purposes.
2 02/06/2023 12-14 Clarified the TERA exceptions guidance.
2 02/06/2023 14-15 Added guidance on TERA and other theories of service
connection.
2 02/06/2023 15-17 Added a new step to the TERA procedures to review for
competent lay or medical evidence of the claimed
disability and to document use of ILER.
2 02/06/2023 20 Added guidance on vaccinations/medications and
TERA.
2 02/06/2023 23 Updated TERA examination procedures to account for
new EMS functionality.
2 02/06/2023 37 Updated guidance on the automated herbicide flash.
2 02/06/2023 37 and 40 Updated guidance for when additional military records
should be requested in herbicide claims.
2 02/06/2023 -- Updated guidance on the automated § 1117 flash.
2 02/06/2023 -- Updated guidance on the automated § 1119 flash.
2 02/06/2023 -- Removed reference to the Rare Respiratory Cancer Fact
Sheet as all Fact Sheets have been discontinued.
2 02/06/2023 -- Updated procedures for standalone service-connected
burials regardless of the date of the Veteran’s death.
2 02/06/2023 -- Clarified that substitute claimants are not precluded
from raising a new theory of entitlement in support of a
DIC claim that was pending at the time of the original
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claimant’s death. Additionally, updated that a substitute
claimant cannot elect a DIC reevaluation of a previously
denied DIC claim, if the original claimant had not made
such an election prior to the claimant’s death.
2 02/06/2023 -- Added guidance to the ‘Service-Connected Death
Benefit Effective Dates’ to clarify that any retroactivity
prior to 8-10-22, on initial DIC claims and any claim
that continuously pursues an initial claim (i.e., a
supplemental claim filed on VA Form 0995), has
limitations only to the hypertension and MGUS
conditions as provided within section 404.
2 02/06/2023 -- Removed Gulf War Service Areas table and updated all
hyperlinks to direct to the Gulf War Service Areas Job
Aid on the PACT page.
3 04/10/2023 3 Clarity edit regarding how to identify a PACT claim.
3 04/10/2023 10 Removed reference to the specific field on VA Form 21-
526EZ where toxic exposure can be claimed, as the
Veteran’s statement of toxic exposure should be
accepted anywhere it appears on the form.
3 04/10/2023 15 and 19 Clarified the requirement to obtain personnel records in
TERA claims.
3 04/10/2023 16 Added a note regarding TERA rating requirements
when a TERA exception applies.
3 04/10/2023 21-22 Added VBMS attribute guidelines to be used when
uploading the Toxic Exposure Risk Activity
Memorandum.
3 04/10/2023 23 Added TERA medical opinion language to be used
when a TERA exception for herbicide exposure applies.
3 04/10/2023 24 Updated TERA examination procedures to account for
new EMS functionality.
3 04/10/2023 26 Clarified that the requirement to discuss TERA
examination requirements applies to both implicit and
explicit claims.
3 04/10/2023 -- Removed guidance on PACT radiation claims
provisions as this guidance is now available in the M21-
1.
3 04/10/2023 31 Added a reminder to apply the regulatory diagnostic
threshold for hypertension when considering
presumptive service connection.
3 04/10/2023 34 Updated guidance on how to add or remove the
automated Agent Orange corporate flash.
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3 04/10/2023 -- Corrected an erroneous reference to presumptive BPOT
exposure and updated guidance on correcting the
automated 1117 flash.
3 04/10/2023 -- Updated undiagnosed illness and MUCMI examination
procedures to account for new EMS functionality.
3 04/10/2023 -- Updated guidance on correcting the automated 1119
flash.
3 04/10/2023 -- Updated guidance on when HLRs must be returned and
when they can be granted/denied.
4 09/08/2023 3-5 Clarified instructions for identifying PACT-related
claims and applying the PACT special issue.
4 09/08/2023 10-11 Clarified instructions for applying TERA claim
attributes.
4 09/08/2023 12 Updated guidelines for identifying TERA-related death
claims.
4 09/08/2023 21-22 Added guidance regarding Camp Lejeune and TERA
participation.
4 09/08/2023 23 Updated VBMS attributes used for the Toxic Exposure
Risk Activity Memorandum.
4 09/08/2023 24 Updated guidelines for requesting TERA-related death
opinions.
4 09/08/2023 28 Clarified when a rating decision must include discussion
of a TERA examination exception.
4 09/08/2023 31 Added a note that herbicide procedures apply to certain
death claims.
4 09/08/2023 33 Updated guidance regarding Thailand nautical service.
4 09/08/2023 -- Updated automated §1117 flash information.
4 09/08/2023 -- Added guidelines for considering BPOT exposure in
death claims.
4 09/08/2023 -- Updated automated §1119 flash information.
4 09/08/2023 -- Updated death claims establishment guidance.
4 09/08/2023 -- Updated procedures for processing death claims.
4 09/08/2023 -- Added new guidance on processing non-service-
connected death claims potentially related to the PACT
Act.
4 09/08/2023 -- Added a note regarding Survivors Pension effective
dates.
5 07/17/2024 9 Added a note about when TERA applies.
5 07/17/2024 10 Updated TERA claim procedures overview, including a
new note about when not to apply TERA procedures.
5 07/17/2024 10 Updated claim attribute guidance.
5 07/17/2024 13-14 Updated TERA exceptions guidance.
5 07/17/2024 14-15 Added new guidance on development actions to take
when a TERA examination exception applies.
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5 07/17/2024 17 Aligned TERA procedures with updated TERA
exceptions and TERA memorandum job aids.
5 07/17/2024 21 Added guidance about when to complete a new TERA
memorandum.
5 07/17/2024 22 Added TERA exceptions to the examination threshold
guidance.
5 07/17/2024 25 Added TERA exceptions to the factors to consider when
deciding TERA claims.
5 07/17/2024 26 Updated TERA rating decision requirements.
5 07/17/2024 26 Added guidance on TERA favorable findings.
5 07/17/2024 35-38 Updated herbicide claim procedures to integrate Nehmer
review of all claims, which was previously addressed in
a note after the table.
5 07/17/2024 42 Updated herbicide effective date guidance.
5 07/17/2024 -- Updated guidance on correcting the automated 1117
flash.
5 07/17/2024 -- Removed Gulf War examination procedures, which are
now in the M21-1.
5 07/17/2024 -- Updated guidance on correcting the automated 1119
flash.
5 07/17/2024 -- Removed lymphomatic cancer from the list of
recognized BPOT presumptive disabilities.
5 07/17/2024 -- Deleted duplicative note about potential DIC
retroactivity.
5 07/17/2024 -- Replaced Processing Supplemental Claims Requesting a
Reevaluation of a Previously Denied DIC Claim content
with a note added to Processing DIC Claims for
Reevaluation of a Previously Denied DIC Claim Related
to the PACT Act. The new note clarifies procedures for
accepting VA Form 20-0995 as an election under the
PACT Act for reevaluations of a previously denied DIC
claim.
5 07/17/2024 -- Added special issue guidance for death ratings.
5 07/17/2024 -- Clarified HLR examples and guidance regarding TERA
development requirements and HLR returns.
5 07/17/2024 -- Added new Topic 8 with all new guidance on TERA
healthcare eligibility requests.
6 11/04/2024 31-32 Update covered service in Thailand for entitlement to
spina bifida benefits under 38 U.S.C. § 1822.
7 06/13/2025 26 Updated guidance on the TERA exception rating
narrative requirements to account for future system
enhancements.
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7 06/13/2025 9, 14-15, Updates made to broad pronouns for compliance with
40, 48 executive orders that have been issued by the current
Administration.
7 06/13/2025 -- Removed Topic 4, Presumptive Service Connection of
Undiagnosed Illnesses and Medically Unexplained
Chronic Multi-Symptom Illnesses (MUCMIs) for
Persian Gulf Veterans, as this guidance is now available
in the M21-1.
7 06/13/2025 -- Removed Topic 5, Presumptive Service Connection
Based on Exposure to Burn Pits and Other Toxins,
Including Fine Particulate Matter (BPOT), as this
guidance is now available in the M21-1.
7 06/13/2025 -- Removed Topic 6, Service Connected Death Benefits
under the PACT Act, as this guidance is captured in
either the M21-1 or the Pension & Fiduciary Service
(P&F) PACT Act — Frequently Asked Questions
(FAQs) document.
7 06/13/2025 -- Removed Topic 7, Higher-Level Reviews (HLRs) and
Legacy Appeals Under the PACT Act, as guidance can
be found outlined in this SOP and the M21-1.
8 09/15/2025 -- Removed Topics 3.1 and 3.2, which covered
presumptive herbicide exposure, as this guidance is now
available in the M21-1.
9 05/15/2026 3 Updated guidance on scope of claim to align with M21-
1 updates.
9 05/15/2026 14, 18 Updated guidance for actions to take when a herbicide
exception applies.
9 05/15/2026 14, 15, 20, Added the requirement to complete the TERA
21 Memorandum using the embedded VBMS functionality.
9 05/15/2026 27 Removed outdated effective date guidance.
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