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M21-1, Part III, Subpart v, Chapter 6, Section A – Information Exchange Between Department of Veterans Affairs (VA) Regional Offices (ROs) and Medical Facilities

Overview


In This Section

This section contains the following topics:
Topic
Topic Name
1
2
3

1.  Methods of Information Exchange


Introduction

This topic contains information on the methods ROs and VA medical facilities use to exchange information, including

Change Date

December 3, 2018

III.v.6.A.1.a.Definition: Hospitalization

Hospitalization, as it is used in this chapter, generally refers to inpatient care or treatment that a Veteran receives in a
  • Department of Veterans Affairs (VA) hospital or medical facility
  • VA domiciliary
  • VA nursing home, or
  • private facility under VA contract.
Note:  Where specifically stated elsewhere in this chapter, hospital care may be excluded from the term “hospitalization” for adjustment of benefits for Veterans receiving Veteran’s pension after January 31, 1990.

III.v.6.A.1.b.  Methods of Exchanging Information

VA medical facilities and regional offices (ROs) use the following methods to exchange information:
Important:  ROs must not rely on e-mailed or faxed transmission of a VA Form 10-7131 in order to obtain relevant VA medical records that are not electronically accessible through CAPRI or the Advanced Web Image Viewer.  Instead, claims processors must request the records using the electronic VA Form 10-7131functionality available in CAPRI.
References:  For more information on

III.v.6.A.1.c. Use of VA Form 10-7131

Historically, VA medical facilities and ROs have used VA Form 10-7131 to exchange information or request administrative and adjudicative action relating to a Veteran’s status when he/she is applying for or receiving VA medical care.
The deployment of CAPRI substantially reduced the need to use paper forms for communication between ROs and VA medical facilities.  However, VA Form 10-7131 is still used in some situations because VA medical facilities cannot initiate electronic requests to ROs.

III.v.6.A.1.d. Use of VA Form 10-7132

Historically, VA medical facilities have used VA Form 10-7132 to notify ROs of changes in a patient’s status.  Although the deployment of CAPRI has substantially reduced the need for use of this form, personnel at VA medical facilities still occasionally use it.
Note:  Some VA medical facilities do not track contract nursing home cases electronically and may still use VA Form 10-7132 to notify ROs about changes in the status of Veterans residing in contract nursing homes.

III.v.6.A.1.e.  Accessing Reports of Hospital and Nursing Home Admissions

The table below
  • lists the reports ROs must run from CAPRI, and
  • describes when ROs must run the reports.
Report Name
When to Run the Report
Actions to Take
Admission Report for SC Veteran
daily or weekly
Special Report for A&A/Pension
on or about the first day of each month
Re-Admission Report
on or about the first day of each month
Discharge Report
on or about the first day of each month
Contract Nursing Home (CNH) Report of Admissions/Discharges
on or about the first day of each month
Note:  To access these reports, log into CAPRI but do not attempt to locate a specific Veteran.  Instead, select
  • File from the tool bar in the top, left-hand corner of the screen, and
  • Reports from the drop-down box.

III.v.6.A.1.f.Protection of Information Accessed Through CAPRI

Records accessed through CAPRI contain individually identifiable, highly sensitive health information that is protected by Federal statutes, including
Veterans Benefits Administration (VBA) personnel may access the records on a need-to-know basis only and disclose health information for business purposes only, as authorized by these statutes.

III.v.6.A.1.g.Administration of CAPRI User Accounts

The Office of Information and Technology administers CAPRI user accounts for RO employees.  ROs may request access to CAPRI for their employees by submitting VA Form 20-8824-CAPRI, User Request for CAPRI Access, through their local Information Security Officer (ISO).
Before gaining access, each employee must
  • complete VBA and Veterans Health Administration (VHA) security/privacy training, and
  • acknowledge receipt of and adherence to the CAPRI Rules of Behavior.
Notes:
  • Misuse of CAPRI, such as accessing medical records for purposes other than VA business, may result in disciplinary action and criminal prosecution.
  • Contact the local ISO for more information on CAPRI security/privacy requirements and prevention of unauthorized disclosure of VHA records.

2.  Initial Actions Upon Receipt of Notice From a VA Medical Facility of a Veteran’s Hospitalization at VA Expense


Introduction

This topic contains information on the initial actions to take upon receipt of notice from a VA medical facility of a Veteran’s hospitalization at VA expense, including

Change Date

December 3, 2018

III.v.6.A.2.a.  HAC Responsibilities

Each RO must designate a hospital adjustment coordinator (HAC) and alternate to ensure appropriate action is taken on notices of hospitalization.
The HAC is specifically responsible for
  • generating the reports discussed in M21-1, Part III, Subpart v, 6.A.1.efrom the VA medical facilities within the jurisdiction of the HAC’s RO
  • referring the reports to the coach of the RO’s Intake Processing Center
  • forwarding reports that involve Veterans with claims folders under the jurisdiction of another RO to that RO’s HAC, and
  • maintaining a log of the reports that shows
    • each type of report generated
    • the date each report was generated
    • the period covered by each report
    • the date any reports involving Veterans with claims folders under the jurisdiction of another RO were forwarded to that RO’s HAC, and
    • any problems experienced in the handling of the reports.
Note:  RO HACs no longer forward notices of hospitalization of Veterans in receipt of pension to their counterparts at the pension management centers (PMCs).
Reference:  For more information on PMCs obtaining hospitalization reports for Veterans in receipt of pension, see M21-1, Part V, Subpart iv, 2.1.g.

III.v.6.A.2.b.Determining Whether an Award Adjustment Is Necessary

The table below
  • describes situations under which an award adjustment may be necessary based on receipt of notice from a VA medical facility of a Veteran’s hospitalization at VA expense, and
  • provides hyperlinks to references with instructions for addressing each situation.
If the Veteran is …
Then see …
receiving additional benefits for aid and attendance (A&A)
  • receiving pension, and
  • has no dependents
still hospitalized for treatment of a service-connected (SC) disability that is currently evaluated at less than 100 percent
Notes:
  • “Notice,” for the purpose of this topic, includes CAPRI reports that HACs are responsible for running to identify Veterans whose awards might require adjustment because of hospitalization at VA expense.
  • Upon receipt of notice, first review the corporate record through Share to determine whether an adjustment of the Veteran’s award is necessary. Review the claims folder only if information required to determine whether an award adjustment is necessary cannot be obtained through Share.
References:  For more information about

III.v.6.A.2.c.Selecting and Storing Hospital Records

Use the Report Builder feature in CAPRI to select only those hospital records that are relevant in determining whether an award adjustment is necessary.
After selecting the records, follow the instructions in M21-1, Part III, Subpart ii, 4.G.2.b for transmitting/uploading them into the corresponding Veteran’s electronic claims folder.

III.v.6.A.2.d.Notices of Hospitalization Containing Erroneous Data

After receiving notice from a VA medical facility of a Veteran’s hospitalization, notify that medical facility if
  • the admission diagnosis is a disability for which VA has denied or severed service connection, or
  • the notice contains erroneous eligibility coding.
Note:  Provide the notification via e-mail or fax so the medical facility can take action to correct data in the Veterans Health Information Systems and Technology Architecture (VISTA).

III.v.6.A.2.e.Requesting Documents/ Reports Under the 7131 REQUEST Tab in CAPRI

Oftentimes, the medical information required to process a claim or adjust a Veteran’s award based on hospitalization at VA expense is available and instantaneously retrievable under the CLINICAL DOCUMENTS tab in CAPRI.
When such medical information is unavailable in CAPRI, users must request it under the 7131 REQUEST tab.
The table below lists reports/documents available under the 7131 REQUEST tab and the circumstances under which users might request them.
If …
Then request …
adjustment of a Veteran’s award is necessary because the Veteran was hospitalized and is receiving
  • pension and has no dependents, or
  • additional benefits for A&A
Notice of Discharge.
a VA medical facility notifies an RO that a Veteran was hospitalized, and
  • the admission diagnosis is a(n)
    • SC disability, or
    • disability that an SC disability may have caused
  • the admission diagnosis is unclear and the Veteran has an SC disability
  • a claim for compensation or pension is pending, or
  • the Veteran has a service-connected disability that is subject to improvement (a diary for a future examination exists)
Note:  A hospital summary is also necessary, according toM21-1, Part III, Subpart v, 6.C.2.a, if VA awards additional benefits for A&A based on a Veteran’s nursing home status.
Hospital Summary.
a hospital report covering certain disabilities is needed immediately
Note: Enter the specific disabilities at issue in the ADDITIONAL REMARKS or COMMENTS section.
Other/Exam.
  • a claim is pending and it appears the claimant
    • is terminally ill
    • is experiencing financial hardship, or
    • will be hospitalized for a long period of time
  • a hospital report of record is inadequate for rating purposes and, in the opinion of the rating activity, the hospital clinical records folder might contain the information required to render a decision, or
  • a hospital report is required after a specific number of days.  (This generally occurs when a Veteran is totally disabled or when permanency for pension purposes has not been established and a hospital report is needed in 90 or 180 days.)
Note:  Other situations may arise that require a request for a Special Report. These include situations in which an RO must retrieve
  • an autopsy report, or
  • medical evidence or information in connection with a Board of Veteran’s Appeals remand.
Special Report.
a Veteran’s competency is at issue and the evidence of record indicates he/she is being treated for a disability other than a mental condition
Note:  Information about a Veteran’s competency is normally included in hospital reports when treatment is for a mental condition.
Competency Report.
medical information is needed soon after a Veteran’s admission for long-term treatment of a disability such as
  • a psychiatric disability, or
  • tuberculosis
Admission Report.
a Veteran has been admitted to a contract nursing home (CNH) at VA expense
CNH Report of Admissions/ Discharges.
Important:  As is noted in M21-1, Part III, Subpart v, 6.A.1.b, ROs must not rely on e-mailed or faxed transmission of VA Form 10-7131 in order to obtain relevant VA medical records that are not electronically accessible.
References:  For more information on

3.  Unsolicited Reports from VA Medical Facilities and the MFH Program


Introduction

This topic contains information about unsolicited reports and the MFH program, including

Change Date

March 20, 2019

III.v.6.A.3.a.  Unsolicited Reports That ROs Might Receive From VA Medical Facilities

The Chief, Medical Administration Specialist (MAS) at a VA medical facility may send unsolicited reports to an RO under the situations described in the table below.
If …
Then the MAS will send the RO of jurisdiction (ROJ) …
staff at the medical facility believe a Veteran might be entitled to additional benefits for A&A or because the Veteran is housebound
Note:  The MAS might send supplemental reports regarding the Veteran’s medical condition to the ROJ.
  • staff at the medical facility believe a Veteran might be incompetent, and
  • the Veteran has a claim for disability benefits pending or is receiving compensation, pension, or retirement pay as a competent Veteran
a report regarding the Veteran’s competency.
staff at the medical facility believe a Veteran rated incompetent for VA purposes might becompetent
a report regarding the Veteran’s competency.
  • treatment of a Veteran’s SC disability ends after the medical facility provides the ROJ with a 21-day certificate, but
  • the Veteran remains hospitalized for a non-service-connecteddisability
an interim hospital report showing termination of treatment for the SC disability.
Reference:  For more information about 21-day certificates, see M21-1, Part III, Subpart v, 6.D.

III.v.6.A.3.b.  General Information About the MFH Program

The Medical Foster Home (MFH) Program is a non-institutional alternative to nursing home care for Veterans that are unable to safely live alone due to chronic or terminal illness.
Note:  Eligible Veterans must bear the cost of residing at an MFH.  However, the cost is less than the amount traditional nursing homes charge.
Reference:  For more information about MFHs, see

III.v.6.A.3.c.  Eligibility Requirements for Referral to an MFH

To be eligible for referral to an MFH, a Veteran must require the level of care that a nursing home provides.  This includes
  • the inability to live independently due to functional, cognitive, and/or psychosocial impairment, and
  • the existence of complex medical conditions that require care from a VA home health care team.

III.v.6.A.3.d.  VAMC Responsibilities

Each VA medical center (VAMC) that participates in the MFH Program is responsible for designating an MFH Coordinator.  These coordinators are responsible for
  • identifying Veterans that meet the eligibility requirements for referral to an MFH
  • assisting eligible Veterans in completing an application for VA disability benefits (compensation and/or pension)
  • ensuring the VAMC examines eligible Veterans and completes a VA Form 21-2680 for each of them
  • contacting the MFH Coordinator at the ROJ when a Veteran is ready to be admitted to an MFH and asking whether the RO needs any additional information or evidence to process the Veteran’s claim, and
  • faxing the following to the MFH Coordinator of the ROJ for each eligible Veteran:
    • application for VA disability benefits
    • completed VA Form 21-2680, and
    • pertinent medical records.

III.v.6.A.3.e.  RO Responsibilities

ROs are responsible for designating an MFH Coordinator and alternate coordinator.  Following receipt of a claim that is based on a Veteran’s referral to an MFH, these coordinators are responsible for
  • undertaking development to obtain any documentation (such as forms, applications, or medical evidence) that is necessary to decide the claim
  • monitoring the progress of the claim throughout the claim process and taking any action necessary to prevent unnecessary delays, and
  • notifying the VAMC MFH Coordinator that submitted the claim of the decision the RO ultimately makes on the claim.
Notes:
  • Compensation Service maintains a list of RO MFH Coordinators on its intranet site athttp://vbaw.vba.va.gov/bl/21/staff/mfhcoordinators.htm.  When an RO designates a new coordinator, it must notify Compensation Service of the change by sending an e-mail to VAVBAWAS/CO/212A.
  • In order to effectively track claims that are based on a Veteran’s referral to an MFH, RO MFH Coordinators must utilize the Medical Foster Homespecial issue indicator when placing the claims under end product control.
  • In many cases, claims that an RO MFH Coordinator receives from a VAMC MFH Coordinator will be ready for a decision without further development other than accessing VA treatment records through CAPRI.
  • If a Veteran is otherwise entitled to pension, an RO may administratively (without a rating decision) grant entitlement to special monthly pension based on the Veteran’s referral to an MFH.
  • An RO MFH Coordinator must issue Section 5103 notice to a Veteran and work with the VAMC MFH Coordinator to obtain the associated notice response if
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