General Information on Eligibility for Medical Services

Overview

In This Section

This section contains the following topics:

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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.

Change Date

June 1, 2021

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

• the Automated Medical Information Exchange (AMIE) or Compensation and Pension Records Interchange (CAPRI) system
• telephone contact
• VA Form 20-0986, Eligibility Determination for Character of Discharge (COD) Request Form, or
• VA Form 10-7131, Exchange of Beneficiary Information and Request for Administrative and Adjudicative Action.

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 10-7131 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 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.

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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.

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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 uses VA 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:

• Requests submitted on VA Form 10-7131 prior to the release of VA Form 20-0986 will still be processed by the RO.
• If a request is submitted on VA Form 10-7131 after the January 2018 release of VA Form 20-0986, contact the sender and request submission of the correct form.

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.

Change Date

June 1, 2017

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.

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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.

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.

XIII.i.3.A.3.b. Requests for Documentation of Service in Offshore Waters of the RVN

VHA uses VA Form 10-7131 to 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.

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.

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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.

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.

Change Date

June 1, 2021

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.

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.

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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.

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.

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.

XIII.i.3.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.

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.

Change Date

July 21, 2015

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.

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

• prepares a VA Form 10-7131 and annotates the form to show Medical care being authorized for [condition] on prima facie evidence of eligibility, and
• forwards the completed form along with a copy of the VA examination, hospital report, or outpatient treatment report, as applicable, to the station of jurisdiction (SOJ).

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 10-7131 communicating authorization of treatment for certain conditions based on prima facie eligibility.

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