Processing Dental Claims

Overview

In This Section

This section contains the following topics:

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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

• the responsibility of the treating VHA facility to initiate VA Form 10-7131, Exchange of Beneficiary Information and Request for Administrative and Adjudicative Action, see M21-1, Part XIII, Subpart i, 4.B.1.b, and
• when to refer a VA Form 10-7131 initiated by VHA to the rating activity, see M21-1, Part XIII, Subpart i, 4.B.3.

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:

• VA Form 10-7131
• a copy of VA Form 10-10, Application for Medical Benefits, and
• copies of any additional statements showing dates and places of treatment.

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:

• Dental Eligibility – FPOW, 38 U.S.C. 1712(a)(1)(F), or
• Dental Eligibility – Total Disability, 38 U.S.C. 1712(a)(1)(G).

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

• processing VA Form 10-7131 for FPOWs, see M21-1, Part XIII, Subpart i, 4.B.4
• FPOW status, see M21-1, Part VIII, Subpart iv, 2.A
• developing for evidence of FPOW status, see M21-1, Part VIII, Subpart iv, 2.C, and
• developing for FPOW service records, see M21-1, Part VIII, Subpart iv, 2.B.

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

• M21-1, Part XIII, Subpart i, 3.A, and
• M21-1, Part X, Subpart iv, 1.B.

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.

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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.

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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

• SC noncompensable dental disabilities or conditions resulting from combat wounds or service trauma (Class II(a))
• SC noncompensable dental disabilities if the Veteran was an FPOW (Class II(c))
• SC noncompensable dental disabilities if additional pathology developed for conditions noted upon entry
• after 180 days of active service, and
• application was received within 180 days of separation from active service (Class II), or
• dental treatment under 38 CFR 17.161 for teeth extracted in service if service records do not identify teeth missing at induction or as extracted in service, when application was received within 180 days of separation from active service (Class II).

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.

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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.

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Reference: For more information on BVA, see M21-5, Chapter 7, Section G.