M21-1 Manual  /  Part XIII, Subpart i, Chapter 4, Section B

Processing Dental Claims

M21-1, Part XIII, Subpart i, Chapter 4, Section B

Overview

In This Section

 This section contains the following topics:
TopicTopic Name
1 Receipt and Processing of VA Form 10-7131, Exchange of Beneficiary Information and Request for Administrative and Adjudicative Action
2 Completing VA Form 10-7131 for Missing Teeth
3 Referring Dental Disability Claims to the Rating Activity
4 Processing VA Form 10-7131 for Former Prisoners of War (FPOWs) and Totally Disabled Service-Connected (SC) Veterans
5 Disposition of VA Form 10-7131 Requests and Handling Legacy Notices of Disagreement (NODs) and Appeals


1. Receipt and Processing of VA Form 10-7131

Introduction

 This topic contains information on procedures for processing VA Form 10-7131 for outpatient dental treatment, including
  • handling requests for dental treatment
  • responsibility of the treating Veterans Health Administration (VHA) facility to initiate VA Form 10-7131
  • responsibility of the treating VHA facility to complete development in dental claims
  • procedures for processing VA Form 10-7131 for dental eligibility
  • verification of former prisoner of war (FPOW) status for dental eligibility
  • determining the character of discharge for dental eligibility, and
  • procedures for review and development following receipt of VA Form 10-7131.

Change Date

 July 20, 2016

XIII.i.4.B.1.a. Handling Requests for Dental Treatment

 As is discussed in M21-1, Part V, Subpart iii, 14.1.b, the Veterans Benefits Administration is responsible for developing and deciding claims for service connection (SC) of dental and oral disabilities. If, however, a Veteran submits a benefit application containing a request for dental treatment(with or without claiming a specific disability), do not
  • refer the request to the rating activity, or
  • send a copy of the application to the nearest Veterans Health Administration (VHA) facility.
Instead, use the Veterans Benefits Management System (VBMS) (or other appropriate claims-processing system) to generate a subsequent development letter, informing the Veteran of the following: We recently received your request for dental treatment. In order to initiate a determination regarding your eligibility to dental treatment services, you may
  • visit the enrollment office at your nearest VA healthcare facility, or
  • call the VA Health Eligibility and Enrollment line at 1-855-488-8440.
Notes:
  • Do not include dental treatment as a contention in VBMS.
  • If the request for dental treatment eligibility is free-standing, unaccompanied by a concurrent claim for compensation and/or pension benefits,
    • change any pending end product (EP) control to a 400, and
    • clear such EP control following preparation and finalization of the letter discussed in this block.
References: For more information on

XIII.i.4.B.1.b. Responsibility of the Treating VHA Facility to Initiate VA Form 10-7131

 The treating Department of Veterans Affairs (VA) facility initiates VA Form 10-7131 if it cannot determine eligibility and the dental treatment claim may involve
  • Class I dental treatment
  • Class II dental treatment, including
    • II(a)
    • II(c), or
  • Class IV dental treatment.
Generally, this determination is made promptly upon receipt of an outpatient treatment claim and prior to a VA) examination. Reference: For a description of dental classes, see M21-1, Part XIII, Subpart i, 4.A.

XIII.i.4.B.1.c. Responsibility of the Treating VHA Facility to Complete Development in Dental Claims

 The treating facility personnel also complete any development required to establish dates and places of treatment. The following documents are provided by the treating facility, except in referrals of Class II(c) or Class IV cases: Note: Claims for missing teeth should not be referred for adjudication unless exercise of professional judgment alone cannot establish entitlement after VA examination. In such cases, a copy of the VA examination should be submitted with VA Form 10-7131, with the annotation, Claim for missing teeth under 38 CFR 17.161(f), in the Remarks section of Part I, Item 6 of the form.

XIII.i.4.B.1.d. Procedures for Processing VA Form 10-7131 for Dental Eligibility

 The basic procedures for processing VA Form 10-7131 for dental outpatient treatment are the same as those provided in M21-1, Part XIII, Subpart i, 3.A.

XIII.i.4.B.1.e. Verification of FPOW Status for Dental Eligibility

 When the request involves verification of former prisoner of war (FPOW) status or total service-connected (SC) disabilities, the request appears in the Remarks section of Part I, Item 6 of VA Form 10-7131 as follows: Information on verification of the Veteran’s FPOW status or total SC disabilities should appear in the claims folder. Verification of FPOW status should be requested if not available in the claims folder. References: For more information on

XIII.i.4.B.1.f. Determining the Character of Discharge for Dental Eligibility

 When a request involves determining the character of the Veteran’s discharge, follow the procedures in

XIII.i.4.B.1.g. Procedures for Review and Development Following Receipt of VA Form 10-7131

 Follow the steps in the table below when a request for adjudication of a dental claim is received on VA Form 10-7131.
StepAction
1 Review the request to ensure the claim is based on one or more of the dental outpatient classifications discussed in M21-1, Part XIII, Subpart i, 4.A.
2 Determine if the dental claim is for one or more of the following circumstances:
  • treatment of an SC compensable dental disability or condition
  • an SC noncompensable dental condition or disability resulting from combat wounds or service trauma
  • treatment of a Veteran with FPOW status
  • treatment based on the Veteran’s combined schedular evaluation of 100 percent or eligibility to the rate of 100 percent on the basis of individual unemployability (IU), or
  • the Veteran had teeth extracted while in military service (per 38 CFR 17.162 and 38 CFR 3.381), provided that
    • the claim is made within 180 days of discharge or release from active duty, or within 180 days after date of correction of a disqualifying discharge or release
    • service did not consist entirely of active or inactive duty for training, and
    • exercise of professional judgment alone cannot establish entitlement.
Note: “Schedular evaluation of 100 percent” means that the Veteran’s SC disabilities combine to an evaluation of 100 percent based on the application of schedular rating criteria. This does not apply to cases in which the evaluation of 100 percent is granted on a temporary basis due to surgical or hospitalized treatment for an SC disability under 38 CFR 4.28, 4.29, or 4.30. Reference: For more information on the circumstances for which the Veterans Service Center (VSC) is responsible for making dental treatment determinations, see 38 CFR 3.381.
3 Does the claim meet one or more of the circumstances outlined in Step 2?
  • If yes, go to Step 4.
  • If no, return VA Form 10-7131 to the medical facility with Part II, Item 10, Remarks, annotated to state, Improper referral because [________]. Authorization action is not required.
4 If service dental records for the alleged treatment are Reference: For information on completing VA Form 10-7131 for missing teeth, see M21-1, Part XIII, Subpart 1, 4.B.2.

2. Completing VA Form 10-7131 for Missing Teeth

Introduction

 This topic contains information on completing VA Form 10-7131 for missing teeth, including
  • responsibility of authorization personnel in claims for missing teeth, and
  • procedures for completing VA Form 10-7131 when reviewing service dental records.

Change Date

 April 12, 2007

XIII.i.4.B.2.a. Responsibility of Authorization Personnel in Claims for Missing Teeth

 If service dental records are received in a claim under 38 CFR 17.161 for missing teeth, authorization personnel have the primary responsibility for
  • reviewing the service dental records, and
  • furnishing a prompt response to the request.

XIII.i.4.B.2.b. Procedures for Completing VA Form 10-7131 When Reviewing Service Dental Records

 Use the table below to take the appropriate actions when completing VA Form 10-7131 based on the evidence contained in the service dental records.
If service dental records contain …Then …
a panoramic x-ray taken at induction
  • a complete dental examination taken at induction, and
  • the induction dental examination is definite
 annotate VA Form 10-7131, Part II, Item 10, Remarks, to show whether or not any teeth were missing at induction. Example: Teeth #5 and #12 missing at induction. Reference: For various tooth numbering methods, see M21-1, Part XIII, Subpart i, 4.C.
  • a complete dental examination taken at induction, and
  • the notation on the induction dental examination is indefinite, such as
    • acceptable
    • undisqualifying, or
    • not examined
  • if the Veteran was examined within 60 days after induction, accept the first examination after induction as an induction examination, or
  • if the Veteran was not examined within 60 days after induction, annotate VA Form 10-7131, Part II, Item 10, Remarks,as to why a statement of missing teeth cannot be provided.
records of dental treatment
  • review the records for indication of extractions, and
  • annotate VA Form 10-7131, Part II, Item 10, Remarks, to show, by number, any teeth extracted in service.
Note: If a tooth is identified as missing at induction, but treatment records show its extraction, show the tooth as extracted in service, and do not show it as missing at induction.


3. Referring Dental Disability Claims to the Rating Activity

Introduction

 This topic contains information on referring dental disability claims to the rating activity, including
  • referral of VA Form 10-7131 to the rating activity for dental treatment claims, and
  • using photostatic copies of Naval dental examinations.

Change Date

 May 11, 2015

XIII.i.4.B.3.a. Referral of VA Form 10-7131 to the Rating Activity for Dental Treatment Claims

 In addition to the normal referral for rating required when a claim for a compensable dental disability is filed on a prescribed form, rating action is also required for the proper disposition of VA Form 10-7131 on a claim for dental treatment for Reference: For more information on ratings for dental treatment, see M21-1, Part XIII, Subpart i, 4.C.

XIII.i.4.B.3.b. Using Photostatic Copies of Naval Dental Examinations

 If the Veteran served prior to 1953, photostatic copies of Naval dental examinations are generally not usable for rating purposes since red and blue markings were used on the originals. These markings cannot be distinguished from each other on photocopies. In these cases, do not refer the claims folder to the rating activity until the originals are obtained. Reference: For more information on Naval dental records, see M21-1, Part XIII, Subpart i, 4.C.

4. Processing VA Form 10-7131 for FPOWs and Totally Disabled SC Veterans

Change Date

 May 11, 2015

XIII.i.4.B.4.a. Procedure for Processing VA Form 10-7131 for Dental Eligibility for FPOWs and Totally Disabled SC Veterans

 When processing VA Form 10-7131, follow the procedure in the table below for claims filed under 38 U.S.C. 1712(a)(1)(F) and (G) for FPOWs and totally disabled SC Veterans.
If ...Then ...
records establish that a Veteran was an FPOW for any length of time add the annotation, FPOW service verified, to the Remarks section of Part II, Item 10.
a rating decision establishes the existence of an SC disability or SC disabilities with combined schedular evaluation of
  • 100 percent, or
  • eligibility to 100-percent rate based on IU
add the annotation, Veteran 100-percent service-connected, to the Remarks section of Part II, Item 10. Note: Permanency of total SC disabilities is not required, but the 100-percent evaluation cannot be granted on a temporary basis due to surgical or hospitalized treatment for an SC disability under 38 CFR 4.28, 4.29, or 4.30.
  • notice was furnished that the Veteran did not meet eligibility requirements, and
  • it is later established by rating or service department determination that the Veteran now meets those requirements
annotate the Remarks section of Part II, Item 10, to indicate the reason for eligibility.

5. Disposition of VA Form 10-7131 Requests and Handling Legacy NODs and Appeals

Introduction

 This topic contains information on disposition of VA Form 10-7131 requests and handing legacy NODs and appeals, including
  • disposition of a VA Form 10-7131 after a dental rating decision
  • handling a legacy NOD when dental eligibility is at issue, and
  • certifying a legacy appeal to the Board of Veterans Appeals (BVA) when dental eligibility is at issue.

Change Date

 February 25, 2019

XIII.i.4.B.5.a. Disposition of VA Form 10-7131 Request After a Dental Rating Decision

 After a dental rating decision has been made, submit a copy of the dental rating with the VA Form 10-7131 request to the originating office. Important: Do not furnish notice of the decision directly to the Veteran. The Chief Dental Officer notifies the claimant of the final decision. Note: The rating decision should be prepared in accordance with the VBMS-Rating User Guide. The historic manually prepared rating, VA Form 21-546b, is obsolete and should not be used.

XIII.i.4.B.5.b. Handling a Legacy NOD When Dental Eligibility Is at Issue

 If a legacy notice of disagreement (NOD) is received in response to a dental rating decision, the VSC is responsible for preparing a statement of the case if SC is at issue, including discussion of such issues as
  • service trauma
  • FPOW status
  • combat wounds, or
  • compensable evaluation.
Reference: For more information about legacy NODs, see M21-5, Chapter 7, Section B.

XIII.i.4.B.5.c. Certifying a Legacy Appeal to BVA When Dental
Eligibility Is at Issue

 Follow the steps in the table below when certification of a legacy appeal to the Board of Veterans Appeals (BVA) is in order.
StepAction
1 Are there dental treatment or examination records in the claims folder?
  • If yes, forward the dental treatment records with the claims folder for appellate consideration to BVA in all claims for SC for dental disabilities.
  • If no, send a statement to that effect to BVA along with the claims folder.
2 Along with the records forwarded for appellate consideration, include the
  • application for dental treatment, and
  • determination denying the benefits or additional benefit sought in the legacy appeal.
Reference: For more information on BVA, see M21-5, Chapter 7, Section G.

Source: VA M21-1 Adjudication Procedures Manual, M21-1, Part XIII, Subpart i, Chapter 4, Section B (U.S. government work, reproduced for reference). Browse all sections →