Overview
In This Section |
This section contains the following topics:
|
1. Determining Eligibility for Medical Care
Introduction |
This topic contains information on determining eligibility for medical care, including
|
Change Date |
August 20, 2018
|
III.v.7.A.1.a.Methods of Information Exchange Between VBA and VHA |
Requests for information and reports exchanged between the Veterans Benefits Administration (VBA) and the Veterans Health Administration (VHA) may be provided through
Requests for information from the medical facilities to the regional offices (ROs) may be necessary when the
This chapter relates primarily to the use of VA Form 10-7131 when CAPRI or other forms of communication, such as telephone contact, are not used for exchange of information.
Reference: For information on CAPRI, see the CAPRI User Guide.
|
III.v.7.A.1.d.Types of Requests Sent on VA Form 10-7131 |
Refer to the table below for information on
Reference: For more information on information exchange between ROs and medical facilities, see M21-1, Part III, Subpart v, 6.A.
|
III.v.7.A.1.e. Types of Requests Sent on VA Form 20-0986 |
VHA-initiated requests for medical benefits for former service members discharged under other-than-honorable (OTH) conditions are sent on VA Form 20-0986. The form was released in January 2018.
Important:
Reference: For more information on VHA-initiated requests for medical benefits when there is an OTH discharge, see M21-1, Part III, Subpart v, 7.A.7.
|
2. Requests Requiring Claims Folder Review Only
Introduction |
This topic contains information on processing requests for information received from medical facilities that require claims folder review only, including
|
Change Date |
June 1, 2017
|
III.v.7.A.2.a.Receipt of VA Form 10-7131 |
The medical facility will check the specific boxes in Part I of VA Form 10-7131 to indicate the information required.
|
III.v.7.A.2.b.Processing Requests Requiring Claims Folder Review Only |
When a request for information received on VA Form 10-7131 only requires review of the claims folder, follow the steps in the table below to respond to the medical facility with the requested information.
|
3. Requests Requiring Action by the Authorization Activity
Introduction |
This topic contains information on requests received from VHA facilities that require action by the authorization activity, including
|
Change Date |
August 20, 2018
|
III.v.7.A.3.a.Requests Requiring an Administrative Decision |
Requests involving authorization action generally require an administrative decision so that the originating VHA facility can determine health care eligibility when the
References: For more information on
|
III.v.7.A.3.b.Processing Requests Requiring Action by the Authorization Activity |
Follow the steps in the table below when processing a VHA facility’s request that requires authorization action.
References: For more information on
|
4. Requests Requiring Action by the Rating Activity
Introduction |
This topic contains information on requests from VHA facilities that require action by the rating activity, including
|
Change Date |
March 11, 2019
|
III.v.7.A.4.a.Request for a Determination of SC |
A VHA facility may request that an RO make a determination on the issue of SC for a particular condition for treatment purposes only. This request may be received on VA Form 10-7131.
A copy of VA Form 10-10m, Medical Certificate, along with any other medical evidence available, will routinely be attached to the VA Form 10-7131.
A request for a determination of SC for active psychosis under 38 U.S.C. 1702 is an example of a request received from the medical facility on VA Form 10-7131.
Reference: For more information on SC for psychosis under 38 U.S.C. 1702, see M21-1, Part IX, Subpart ii, 2.5.
|
III.v.7.A.4.b.Processing Requests Requiring Action by the Rating Activity |
When a VHA facility request requires the rating activity to determine eligibility for SC for treatment purposes, follow the steps in the table below.
References: For more information on
|
5. Requests for Outpatient Medical Benefits
Introduction |
This topic contains information on requests for outpatient medical benefits including |
Change Date |
March 11, 2019 |
III.v.7.A.5.a.Eligibility for Outpatient Medical Services |
Veterans who are enrolled in the VA healthcare system are eligible for outpatient medical services as defined in 38 CFR 17.38.
Veterans are assigned to one of eight enrollment priority groups at the time of enrollment. The priority group designation determines whether a co-payment will be required for outpatient services.
|
III.v.7.A.5.b.Eligibility Based on the Level of Disability |
A Veteran with a single SC disability or a combination of disabilities that render him/her at least 50-percent disabled is
Note: This includes a disability rating of a 50 or 100 percent under 38 CFR 4.28.
|
III.v.7.A.5.c.Providing Notification of Eligibility to the Veteran |
Following the initial processing of a rating establishing the Veteran’s level of disability, send the Veteran
|
III.v.7.A.5.d.Processing Eligibility Requests |
When a VHA facility submits VA Form 10-7131 requesting information for eligibility of a Veteran under 38 U.S.C. 1710, complete the Remarks section of Part II by listing any and all SC and non-service-connected (NSC) disabilities and their assigned evaluations. |
6. Eligibility for Medical Treatment Tentatively Approved on Prima Facie Evidence
Introduction |
This topic contains information on making a tentative determination of eligibility for medical treatment based on prima facie evidence, including |
Change Date |
July 21, 2015 |
III.v.7.A.6.a.Requirements for Determining Prima Facie Eligibility |
VHA facilities are authorized to determine prima facie eligibility upon which treatment may be initially authorized if
|
III.v.7.A.6.b.Notifying the SOJ of an Initial Determination of Prima Facie Eligibility |
If treatment based on prima facie eligibility is initially authorized by VHA, then VHA
|
III.v.7.A.6.c.Processing VA Form 10-7131 |
Follow the steps in the table below upon receipt of a VA Form 10-7131 communicating authorization of treatment for certain conditions based on prima facie eligibility.
|
7. VHA-Initiated Requests for Medical Benefits for Former Service Members Discharged Under OTH Conditions
Introduction |
This topic contains information on requests for medical benefits for former service members discharged under OTH conditions, including
|
Change Date |
March 11, 2019 |
III.v.7.A.7.a.Requirements for Eligibility for Health Care |
Health care benefits are generally extended to Veterans who meet the minimum active duty service requirements and were discharged or released under conditions other than dishonorable.
Medical facilities may request information from ROs when a COD determination is required for health care eligibility purposes.
|
III.v.7.A.7.b. Initiation of VA Form 20-0986 by a VHA Facility |
Upon receipt of an application for treatment from a former service member with an OTH discharge, the VHA facility initiates a VA Form 20-0986 advising the SOJ that an eligibility determination is needed.
|
III.v.7.A.7.c. EP Control Over Eligibility Determination Requests |
Use an EP 290 – Character of Discharge to control any incoming VHA request for an eligibility determination regarding COD.
Important: If VHA’s request contains the language Mental Health Initiative (MHI) – Eligibility Determination Needed. Please determine Chapter 17 entitlement,
Notes:
|
III.v.7.A.7.d. Actions to Take Upon Receipt of an Eligibility Determination Request |
When a VHA facility initiates a request for an eligibility determination regarding COD, follow the steps in the table below.
Exception: If the eligibility determination request pertains to a former service member’s potential access to emergency mental health care, follow processing instructions in M21-1, Part III, Subpart v, 7.A.7.e.
References: For more information on
|
III.v.7.A.7.e. Actions Specific to Special Eligibility Determination Requests Involving Access to Emergency Mental Health Care |
When a VHA facility initiates a request for an eligibility determination regarding COD, and the request contains the MHI language referenced in M21-1, Part III, Subpart v, 7.A.7.c, consider it sought in support of affording the former service member access to emergency mental health care, and prioritize action accordingly.
Note: Application of the Emergency Care corporate flash mandated in M21-1, Part III, Subpart v, 7.A.7.c prompts National Work Queue reassignment to one of several designated processing stations. Eligibility determination requests involving access to emergency mental health care are centrally processed by the Nashville and Winston-Salem ROs.
Follow the steps in the table below to respond to an eligibility determination request of this type.
Note: If a former service member in need of emergency mental health care submits a completed application claiming disability compensation for the underlying mental condition(s) before the issue of COD is resolved, any decision concerning SC for treatment purposes for the mental condition(s) will be decided under the pending EP 290.
|
8. Requests for A&A and Housebound Medical Benefits
Introduction |
This topic contains information on requests for A&A and housebound medical benefits, including |
Change Date |
April 12, 2007 |
III.v.7.A.8.a.Eligibility for Medical Services Under 38 U.S.C. 1712 (d) |
Under 38 U.S.C. 1712(d), Veterans receiving additional compensation or increased pension for A&A or housebound benefits are entitled to medical services, including
|
III.v.7.A.8.b.Providing Notification of Eligibility to Veterans |
Notify a Veteran of medical care eligibility and application information when A&A or housebound benefits are awarded. The information is provided on VA Form 21-8764, Disability Compensation Award Attachment, or VA Form 21-8768, Disability Pension Award Attachment. |
III.v.7.A.8.c.Processing Eligibility Requests |
Follow the steps in the table below when an eligibility request is received for medical services under 38 U.S.C 1712(d).
|
9. Eligibility for Outpatient Medications for A&A Cases in Which Income Is Excessive
Introduction |
This topic contains information on eligibility for outpatient medications for A&A cases in which income is excessive, including |
Change Date |
April 12, 2007 |
III.v.7.A.9.a.Income Limitation for Eligibility for Medications |
Per 38 U.S.C. 1712(d), VA continues to furnish outpatient medications to Veterans entitled to A&A, including those reduced under 38 CFR 3.552(b)(1), whose income exceeds the applicable limit by no more than $1,000. |
III.v.7.A.9.b.Cases Involving the Termination of Pension Awards |
If a pension award to a Veteran entitled to A&A (code 1 or 2) is terminated because of excess income, message code 652, A&A Term—[Year] Income Over Limit by $_____, is issued for routing to the pension management center. |
III.v.7.A.9.c.Processing Message Code 652 |
To process message code 652, follow the steps in the table below.
|
III.v.7.A.9.d.Establishing Continued Entitlement to Medications |
Establish continued entitlement to outpatient medications annually in those pension cases in which the current year income did not exceed the limit by more than $1,000.
Individual requests from the medical facility for income information for the next calendar year are received on VA Form 10-7131 during the last three months of the current year.
|
III.v.7.A.9.e.Requesting Income Information From the Veteran |
Check the claims folder to determine if there is current data sufficient to permit furnishing income information for the next year.
If the claims folder does not already contain sufficient income data for the next year,
|
III.v.7.A.9.f.Completing the Remarks Section of VA Form 10-7131 |
Upon receipt of the desired information, or at the end of 30 days, enter the response in the Remarks, section, Part II, of VA Form 10-7131.
Use the table below to determine what to enter into Remarks when income information is received or not received from the Veteran.
|
10. Medical Treatment for Veterans Showing a Positive Tuberculin Reaction
Introduction |
This topic contains information on medical treatment for Veterans showing a positive tuberculin reaction, including |
Change Date |
April 12, 2007 |
III.v.7.A.10.a.Chemotherapy Program Adopted by the Service Departments |
Individuals who receive tuberculin tests sometimes show a change from negative to positive without any other evidence of a tuberculosis infection.
The military service departments have adopted a program of chemotherapy for personnel who had a negative tuberculin test on entrance into service, but who were found to have converted to positive during service.
|
III.v.7.A.10.b.Policy on Chemotherapy Treatments |
Chemotherapy prescribed for personnel testing positive for tuberculin reaction is to be continued over a 12-month period to reduce the possibility of subsequently acquiring tuberculosis.
Important: A positive tuberculin reaction without any other evidence of a tuberculosis infection is not a disease or disability and is not a reason for discharge from service.
|
III.v.7.A.10.c.Chemotherapy for Discharged Personnel |
At the request of the military service departments, VA medical facilities provide continued chemotherapy for the remainder of the 12-month period to discharged personnel who tested positive for tuberculosis during service.
After treatment, the medical facility forwards VA Form 10-7131 to the SOJ with the following legend:
Medical care being authorized for positive reaction to tuberculin test on basis of prima facie evidence of eligibility.
|
III.v.7.A.10.d.Processing VA Form 10-7131 |
Follow the steps in the table below when you receive VA Form 10-7131 is received for discharged personnel testing positive for tuberculosis.
|
11. Eligibility Requirements for Veterans Treated With NRI
Introduction |
This topic contains information on eligibility requirements for Veterans treated with NRI under 38 U.S.C. 1720E, including
|
Change Date |
July 21, 2015 |
III.v.7.A.11.a.Definition: NRI |
Nasopharyngeal Radium Irradiation (NRI) is a technique developed in the 1920s that used radium to treat hearing loss caused by repeated ear infections. This technique was also used for treating other conditions including
|
III.v.7.A.11.b.Background on NRI Use in the Military |
Because NRI was effective in treating otitis media, military physicians used NRI to treat aerotitis media (barotrauma) in submariners, aviators, and divers due to enlarged tissue in the throat combined with rapid pressure changes. |
III.v.7.A.11.c.Policy on Services Provided to Veterans |
VA is authorized to provide Veterans with a medical examination, hospital care, medical services, and treatment for any cancers of the head or neck found to be associated with the Veteran’s receipt of NRI treatment during active service.
Reference: For more information on NRI, see 38 U.S.C. 1720E.
|
III.v.7.A.11.d.Eligibility Requirements for Medical Care |
To be eligible for VA medical care under this provision of law, the Veteran must have
Notes:
|
III.v.7.A.11.e.Types of Examinations and Care Offered |
Veterans with head or neck complaints or who are concerned about the possible adverse effects of their NRI treatments will be offered the opportunity to receive an Ionizing Radiation Registry examination.
Examination by an ear, nose, and throat specialist and additional studies, such as biopsies, will be performed if clinically indicated.
|
III.v.7.A.11.f.Provision of Other Services for Veterans Receiving Medical Care Due to NRI Treatment |
Provision of other services for Veterans receiving medical care due to NRI treatment is dependent on eligibility, as determined by the medical facility. |
III.v.7.A.11.g.Verification of Eligibility |
If the VA medical facility cannot verify eligibility for treatment on the basis of the information of record, a request for verification of eligibility may be sent to the SOJ. |
III.v.7.A.11.h.Processing the Eligibility Request |
When a request for verification for NRI treatment is received,
|
12. Eligibility Requests for Polish and Czechoslovakian Armed Forces
Introduction |
This topic contains information on eligibility requests for the Polish and Czechoslovakian Armed Forces, including |
Change Date |
July 21, 2015 |
III.v.7.A.12.a.Statutory Basis for Eligibility |
Public Law (PL) 94-491 amended 38 U.S.C. 109 by establishing eligibility for medical services for certain members of the Polish and Czechoslovakian Armed Forces who served during World War I or II.
Reference: For more information, see 38 U.S.C. 109(c).
|
III.v.7.A.12.b.Rating Jurisdiction |
The Wilmington RO has sole rating jurisdiction for Veterans of the Polish and Czechoslovakian Armed Forces. |
III.v.7.A.12.c.Information Forwarded When Rating Action Is Required |
If the claim is identified as a PL 94-491 case and rating action is required, the Wilmington VA medical center, Medical Administration Service, is responsible for developing the claim and will refer the following items to the Wilmington RO:
Note: In these cases, no VA claim number is assigned.
Reference: For more information on rating disabilities under the provisions of 38 U.S.C. 109(c), see M21-1, Part IX, Subpart ii, 2.10.
|
III.v.7.A.12.d.Establishing Controls |
Maintain temporary control pending completion of rating action by using an alphabetical holding file under the claimant’s last name. |
Historical_M21-1III_v_7_SecA_11-30-17.docx | May 16, 2019 | 92 KB |
03-10-16_Key-Changes_M21-1III_v_7_SecA.docx | May 16, 2019 | 68 KB |
03-10-16_Key-Changes_M21-1III_v_7_SecA-1.docx | May 16, 2019 | 68 KB |
Historical_M21-1III_v_7_SecA_8-20-18.docx | May 16, 2019 | 87 KB |
Change-July-21-2015-Transmittal-Sheet-M21-1III_v_7_SecA_TS.docx | May 16, 2019 | 43 KB |
11-17-16_Key-Changes_M21-1III_v_7_SecA.docx | May 16, 2019 | 79 KB |
11-30-17_Key-Changes_M21-1III_v_7_SecA.docx | May 16, 2019 | 97 KB |
3-11-19_Key-Changes_M21-1III_v_7_SecA.docx | May 16, 2019 | 71 KB |
in Chapter 7 Eligibility for Department of Veterans Affairs (VA) Medical and Dental Treatment, Part III General Claims Process, Subpart v General Authorization Issues and Claimant Notification
Related Articles