M21-1 Manual / Part XIII, Subpart i, Chapter 3, Section A
General Information on Eligibility for Medical Services
M21-1, Part XIII, Subpart i, Chapter 3, Section A
Overview
In This Section | | This section contains the following topics: | Topic | Topic Name |
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| 1 | Determining Eligibility for Medical Care | | 2 | Requests Requiring Claims Folder Review Only | | 3 | Requests Requiring Action by the Authorization Activity | | 4 | Requests Requiring Action by the Rating Activity | | 5 | Requests for Outpatient Medical Benefits | | 6 | Eligibility for Medical Treatment Tentatively Approved on Prima Facie Evidence |
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1.Determining Eligibility for Medical Care
Introduction | | This topic contains information on determining eligibility for medical care, including - methods of information exchange between the Veterans Benefits Administration (VBA) and the Veterans Health Administration (VHA)
- determination of eligibility for medical treatment
- regulations governing eligibility for medical treatment
- types of requests sent on VA Form 10-7131, Exchange of Beneficiary Information and Request for Administrative and Adjudicative Action, and
- types of requests sent on VA Form 20-0986, Eligibility Determination for Character of Discharge (COD) Request Form.
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XIII.i.3.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 It may be necessary for medical facilities to request information from regional offices (ROs) when the - Veteran is not entered into the AMIE/CAPRI system as a patient
- medical facility is unable to access the Veteran's corporate record, or
- medical facility cannot ascertain required information from its inquiry into the Veteran's corporate record.
This chapter relates primarily to the use of VA Form 10-7131when 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 Manual. |
XIII.i.3.A.1.b. Determination of Eligibility for Medical Treatment | | When a Veteran applies for medical treatment, the medical facility determines the Veteran’s eligibility and enrollment category for hospital, nursing home, domiciliary, medical, and dental care. However, in certain cases such as those described in this section, the medical facility may require information from the RO in order to make a determination regarding eligibility for care. |
XIII.i.3.A.1.c. Regulations Governing Eligibility for Medical Treatment | | The table below lists regulations governing a Veteran’s eligibility for hospital, nursing home, domiciliary, medical, and dental care. |
XIII.i.3.A.1.d. Types of Requests Sent on VA Form 10-7131 | | Refer to the table below for information on - the types of requests that may be sent on VA Form 10-7131, and
- where to find more information on the particular type of request.
| Upon receipt of a VA Form 10-7131 that involves a request that ... | See ... |
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| requires claims folder review only | M21-1, Part XIII, Subpart i, 3.A.2. | | requires action by the authorization activity | M21-1, Part XIII, Subpart i, 3.A.3. | | requires action by the rating activity | M21-1, Part XIII, Subpart i, 3.A.4. | | pertains to eligibility for outpatient medical benefits under 38 U.S.C. 1710 | - M21-1, Part XIII, Subpart i, 3.A.5, and
- M21-1, Part XIII, Subpart i, 3.A.6.
| pertains to - requests for aid and attendance (A&A) and housebound medical benefits provided under 38 U.S.C. 1712(d), or
- medications for A&A cases in which income is excessive under 38 U.S.C. 1712(d)
| M21-1, Part XIII, Subpart i, 3.D. | | pertains to treatment for a positive tuberculin reaction | M21-1, Part XIII, Subpart i, 3.E. | | pertains to Veterans treated with nasopharyngeal radium irradiation (NRI) under 38 U.S.C. 1720E | M21-1, Part XIII, Subpart i, 3.F. | | requires a determination of service connection (SC) for purposes of 38 U.S.C. 109(c) for the Polish and Czechoslovakian Armed Forces | M21-1, Part XIII, Subpart i, 3.G. |
Note: Requests for documentation of service in the offshore waters of the Republic of Vietnam (RVN) fall under authorization determinations. Reference: For more information on information exchange between ROs and medical facilities, see M21-1, Part X, Subpart iii, 1.A. |
XIII.i.3.A.1.e. Types of Requests Sent on VA Form 20-0986 | | VHA usesVA Form 20-0986 to request determinations regarding a former service member’s eligibility for medical benefits when the former service member was discharged under other-than-honorable (OTH) conditions. The form was released in January 2018. Important: Reference: For more information on VHA requests for eligibility determinations for service members with an OTH discharge, see M21-1, Part XIII, Subpart i, 3.B. |
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 - receipt of VA Form 10-7131, and
- processing requests requiring claims folder review only.
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XIII.i.3.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. |
XIII.i.3.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. | Step | Action |
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| 1 | For each item requested in Part I, respond by entering the requested information in Part IIof VA Form 10-7131. Note: All information may be legibly handwritten. | | 2 | Mark any non-applicable items as N/A. | | 3 | If information about monetary benefits is requested, and the Veteran receives military retired pay (MRP), complete Part II, Items 5 and 5A (Retirement Pay-By Whom Paid), to show the amount and source of the MRP. Example: $121–Army | | 4 | Make an appropriate entry in the Remarks section to advise the VHA facility of any of the following conditions that affect eligibility for hospitalization or treatment: - the Veteran has no period of honorable service
- the Veteran has forfeited rights to benefits, or
- the Veteran’s only service was in the Commonwealth Army of the Philippines, Special Philippine Scouts, or recognized Guerrilla Service.
Note: If the Veteran’s only service was in the Commonwealth Army of the Philippines, Special Philippine Scouts, or recognized guerrilla service, - medical care is restricted to care provided by the Philippine government, or
- the Department of Veterans Affairs (VA) may furnish hospital and nursing home care and medical services for treatment of service-connected (SC) disabilities only if the Veteran resides in the US.
| | 5 | Upon completion of the requested claims folder review, - return the original form to the medical facility
- file the duplicate form in the claims folder, or upload a copy of the form into the Veteran's electronic claims folder (eFolder), if one is present, and
- clear an end product (EP) 400.
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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 - requests requiring an administrative decision
- requests for documentation of service in the offshore waters of the RVN, and
- processing requests requiring action by the authorization activity.
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Change Date | | October 8, 2020 |
XIII.i.3.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 - Veteran has an OTH discharge, or
- evidence shows circumstances that require a line-of-duty (LOD) determination.
References: For more information on - requests requiring action by the rating activity, see M21-1, Part XIII, Subpart i, 3.A.4, and
- VHA requests for eligibility determinations for former service members discharged under OTH conditions, see M21-1, Part XIII, Subpart i, 3.B.
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XIII.i.3.A.3.b. Requests for Documentation of Service in Offshore Waters of the RVN | | VHA uses VA Form 10-7131to request that VBA provide documentation that an individual had qualifying service in the offshore waters of the RVN during the Vietnam Era as defined by Public Law (PL) 116-23. Such service may make the individual eligible for higher priority care through VHA. These cases are worked under EP 290 using the special issue Blue Water Agent Orange to ensure that the cases are routed to the centralized processing teams. Claims processors there will - perform necessary development
- prepare an evidence-based determination on whether to concede qualifying service
- upload the determination to the eFolder, and
- complete and return Section II of VA Form 10-7131.
Important: These requests are not seeking SC for treatment purposes or a COD determination. Do not require the Veteran to complete an application for VA compensation or other benefits. References: For more information on - centralized processing of herbicide claims, see M21-1, Part VIII, Subpart i, 1.A.1, and
- processing VHA requests for documentation of service in the offshore waters of the Republic of Vietnam, see M21-1, Part XIII, Subpart i, 3.A.3.c.
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XIII.i.3.A.3.c. 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. | Step | Action |
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| 1 | Complete the development required to make the requested authorization determination. | | 2 | Prepare - a formal administrative decision when required (such as for COD or LOD), or
- an evidence-based determination of whether to concede that the individual had qualifying service in the offshore waters of the RVN as defined by PL 116-23.
| | 3 | Provide the requested information or determination by completing, as applicable | | 4 | - Return the form via e-mail to the originating VHA facility using the e-mail address noted on the form, and
- upload a copy of the completed form to the appropriate eFolder.
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References: For more information on - centralized processing of herbicide claims, see M21-1, Part VIII, Subpart i, 1.A.1
- requests for documentation of service in the offshore waters of the RVN, see M21-1, Part XIII, Subpart i, 3.A.3.b
- administrative decisions, see M21-1, Part X, Subpart v, 1.C
- COD determinations, see M21-1, Part X, Subpart iv, 1.A and B
- COD determinations and health care eligibility, see M21-1, Part X, Subpart iv, 1.B.1
- VHA requests for eligibility determinations for former service members discharged under OTH conditions, see M21-1, Part XIII, Subpart i, 3.B, and
- LOD determinations, see M21-1, Part X, Subpart iv, 1.C.
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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 - RO role in eligibility determinations for medical care
- processing a request requiring action by the rating activity, and
- taking rating action for medical care purposes.
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XIII.i.3.A.4.a. Request for a Determination of SC | | When a Veteran applies for medical treatment under 38 U.S.C. 1710, the VHA medical facility determines the Veteran’s eligibility and enrollment category. However, the medical facility may require information from the RO in order to make its determination. What action to take after a VHA request is received will depend on the nature of the request. The request will advise what information or determination by VBA is required. Notes: - 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.
References: For more information on - respective roles in determinations of eligibility for medical treatment, see M21-1, Part XIII, Subpart i, 3.A.1.b
- action to take depending on the nature of the VHA request, see M21-1, Part XIII, Subpart 1, 3.A.1.d, and
- ratings for the purpose of treatment under 38 U.S.C. 1702, see, M21-1, Part XIII, Subpart i, 3.C.
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XIII.i.3.A.4.b. Processing a Request 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. | Step | Action |
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| 1 | Is a rating decision for the condition already of record? - If yes, process the request as a request requiring claims folder review only as outlined in M21-1, Part XIII, Subpart i, 3.A.2.
- If no, go to the next step.
| | 2 | Request that the claimant submit an application and refer to the table below to determine the appropriate subsequent action. | If an application … | Then … |
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| is received within 30 days | - send Section 5103 notice to the claimant, if required
- perform the necessary development, and
- upon completion of development, go to the next step.
| | is not received within 30 days | - notify the claimant that VA cannot consider SC without an application
- return VA Form 10-7131 to the originator, and
- take no further action.
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Important: Do not generate a rating decision for the purpose of medical care eligibility in the absence of contentions from the Veteran. VA must make an effort to obtain contentions by requesting an application from the Veteran. Note: Ensure that the request for an application informs the Veteran of the option of submitting a claim electronically. Reference: For more information on determining whether the issuance of Section 5103 notice is necessary, see M21-1, Part III, Subpart i, 2.B. | | 3 | Take rating action as described in M21-1, Part XIII, Subpart i, 3.A.4.c. | | 4 | When the rating decision is completed, | | 5 | Return VA Form 10-7131 to the originator. | | 6 | Promulgate the rating decision and send notification to the claimant. |
Reference: For more information on requests for medical outpatient benefits, see M21-1, Part XIII, Subpart i, 3.A.5. |
XIII.i.3.A.4.c. Taking Rating Action for Medical Care Purposes | | Process requests requiring rating action using the table in M21-1, Part XIII, Subpart i, 3.A.4.b. Important: Individuals who are barred from receiving payment for SC compensation because of a discharge under other than honorable conditions can still receive medical care benefits for a disability incurred or aggravated in the LOD during active military naval or air service as provided by 38 CFR 3.360, and M21-1, Part X, Subpart iv, 1.B.1. In making determinations of SC for medical care eligibility purposes in such a case, use the same criteria that are applicable to determinations of service incurrence and LOD when there is no COD bar. Note: When entering a decision in the Veterans Benefits Management System - Rating allowing SC for treatment purposes, do not enter a disability percentage. The generated text notes that SC is granted for treatment purpose only under 38 U.S.C. Chapter 17, and compensation is not payable for the condition. The effective date field is disabled. Do not attempt to assign an effective date. References: For more information on - the definitional requirements of Veteran status including COD, see M21-1, Part III, Subpart i, 1.A.1.a
- statutory bars to benefits and COD, see M21-1, Part X, Subpart iv, 1.A
- COD determinations and healthcare, M21-1, Part X, Subpart iv, 1.B.1
- checking for COD, see M21-1, Part III, Subpart i, 1.A.2.f, and
- administrative decisions, including on COD, see M21-1, Part X, Subpart v, 1.C.
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5. Requests for Outpatient Medical Benefits
Introduction | | This topic contains information on requests for outpatient medical benefits including - eligibility
- for outpatient medical services, and
- based on the level of disability
- providing notification of eligibility to the Veteran, and
- processing eligibility requests.
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Change Date | | October 8, 2020 |
XIII.i.3.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. |
XIII.i.3.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 - assigned to Priority Group 1, and
- eligible for outpatient treatment for all disabilities with no co-payment requirement.
Note: This includes a disability rating of a 50 or 100 percent under 38 CFR 4.28. |
XIII.i.3.A.5.c. Providing Notification of Eligibility to the Veteran | | Following the initial processing of a rating decision establishing the Veteran’s level of disability, send the Veteran - a notice of eligibility, and
- instructions for applying for treatment.
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XIII.i.3.A.5.d. Processing Eligibility Requests | | When a VHA facility submits VA Form 10-7131requesting information for eligibility of a Veteran under 38 U.S.C. 1710, complete the Remarks section of Part IIby listing any and all SC and non-service-connected (NSC) disabilities and their assigned evaluations. Important: When VHA uses VA Form 10-7131 to make a request limited to documentation of service in the offshore waters of the RVN, as defined in PL 116-23, process the request as specified in M21-1, Part XIII, Subpart i, 3.A.3.b and c. |
6. Eligibility for Medical Treatment Tentatively Approved on Prima Facie Evidence
Introduction | | This topic contains information on tentative determinations of eligibility for medical treatment based on prima facie evidence, including - requirements for determining prima facie eligibility
- station of jurisdiction (SOJ) notification of an initial determination of prima facie eligibility, and
- processing notice of an initial determination of prima facie eligibility.
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XIII.i.3.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 - the Veteran was discharged or released with an honorable or general discharge after active service of
- six or more months, if the enlistment date was prior to September 8, 1980, or
- 24 or more months, if the enlistment date was September 8, 1980, or later.
- application is made within six months from the date of discharge or release, and
- the application of sound medical judgment warrants a tentative conclusion that the condition originated in, or was aggravated during, service.
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XIII.i.3.A.6.b. SOJ Notification of an Initial Determination of Prima Facie Eligibility | | If treatment based on prima facie eligibility is initially authorized by VHA, then VHA |
XIII.i.3.A.6.c. Processing Notice of an Initial Determination of Prima Facie Eligibility | | Follow the steps in the table below upon receipt of a VA Form 10-7131communicating authorization of treatment for certain conditions based on prima facie eligibility. | Step | Action |
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| 1 | Perform necessary development for service treatment records (STRs). | | 2 | Refer the case to the rating activity for determination of SC for the condition(s) at issue. | | 3 | Return the completed VA Form 10-7131 by following guidance in M21-1, Part XIII, Subpart i, 3.A.4.b. |
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Source: VA M21-1 Adjudication Procedures Manual, M21-1, Part XIII, Subpart i, Chapter 3, Section A (U.S. government work, reproduced for reference). Browse all sections →