**Veterans Benefits Administration M21-1, Part IV**

**Department of Veterans Affairs Change 213**

# Washington, DC 20420 January 11, 2005

Veterans Benefits Manual M21-1, Part IV, "Authorization Procedures," is
changed as follows:

**Pages 18-i through 18-ii:** Remove these pages and substitute pages
18-i through 18-ii attached.

**Pages 18-I-1 through 18-I-4:** Remove these pages and substitute pages
18-I-1 through 18-I-4 attached.

Paragraphs 18.02a and 18.04e are revised to update the term Adjudication
to Veterans Service Center. These are miscellaneous editorial
corrections to the chapter.

Paragraph 18.03 is revised to include the necessary report to be
obtained when a contract nursing home (CNH) payee has been hospitalized
at VA expense.

**Pages 18-A-1 through 18-A-2:** Remove these pages and substitute pages
18-A-1 through 18-A-2 attached.

Addendum A is revised to show the guidelines for generating the CNH
report.

By Direction of the Under Secretary for Benefits

Renée Szybala, Director

> Compensation and Pension Service

Distribution: RPC: 2068

FD: EX: ASO and AR (included in RPC 2068)

LOCAL REPRODUCTION AUTHORIZED

**CHAPTER 18. AUTOMATED MEDICAL INFORMATION EXCHANGE (AMIE) SYSTEM**

**AND BENEFICIARIES INSTITUTIONALIZED AT VA EXPENSE**

**CONTENTS**

PARAGRAPH PAGE

**SUBCHAPTER I. EXCHANGE OF INFORMATION**

18.01 General\--Exchange of Information between Medical Centers,
Outpatient

Clinics, and Regional Offices 18-I-l

2.  Action by the Veterans Service Center upon Receipt of an Admission
    Notice or Specialized

> AMIE Report 18-I-1

18.03 Reports Which May Be Requested 18-I-2

18.04 Action by the Veterans Service Center when VA Form 10-7131 is a
Request for a Net Worth

> Decision (Means Test) 18-I-3

18.05 Reports Submitted by VA Medical Centers or Domiciliaries without

Requests from the Veterans Service Center 18-I-5

18.06 Notification to Institutions of Changes in Status 18-I-5

**SUBCHAPTER II. AMIE MAIN MENU AND OPTIONS**

18.07 AMIE Regional Office Main Menu 18-II-l

18.08 Options Related to 7131 Information Requests 18-II-2

18.09 Inquiry Options Available through the AMIE System 18-II-2

18.10 Options Which Generate Specialized Reports 18-II-3

18.11 Discharge Notifications and Issuance of 21-Day Certificates
18-II-6

18.12 Option for Auditing DHCP Data Base 18-II-7

18.13 Electronic Mail System 18-II-7

18.14 C&P Examination Program (2507) 18-II-7

**SUBCHAPTER III. ADJUSTMENTS UNDER 38 CFR 3.551 AND 3.556**

18.15 General 18-III-1

18.16 Reduction Due to Initial Admission 18-III-2

18.17 Action on Readmission 18-III-4

18.18 Authorized Absences and Non-Bed Care Status 18-III-5

18.19 Adjustment Due to Existence of Dependents 18-III-6

18.20 Restoration on Discharge (38 CFR 3.556) 18-III-8

**SUBCHAPTER IV. ADJUSTMENT OF AWARDS INVOLVING AID AND ATTENDANCE
ALLOWANCE**

18.21 Reduction of Aid and Attendance during Hospitalization 18-IV-1

18.22 Determination of Need for Hospital Summary 18-IV-2

18.23 Grant or Termination of Entitlement to Aid and Attendance during
Hospitalization 18-IV-2

18.24 Adjustment of Aid and Attendance Benefits on Departure or
Discharge

from or Return to Institution 18-IV-3

18.25 Expedited Aid and Attendance or Housebound Determinations for

Nonservice-Connected Chronic Invalids Hospitalized at VA Expense 18-IV-4

**SUBCHAPTER V. AWARD ADJUSTMENTS BASED ON HOSPITALIZATION IN EXCESS**

**OF 21 DAYS AND ON TEMPORARY SURGICAL RATINGS**

18.26 Obtaining 21-Day Certificate when Veteran Is Hospitalized in
Excess of 21 Days 18-V-1

18.27 Initial Award Adjustment 18-V-1

18.28 Action on Receipt of Notification of Discharge, Termination

of Treatment or Authorized Absence 18-V-2

18.29 Action on Receipt of Final Hospital Summary 18-V-3

**SUBCHAPTER VI. INSTITUTIONAL AWARDS SPECIFIC TO INCOMPETENT VETERANS**

18.30 Notices Relating to Incompetent Veterans Admitted to a VA

Institution or Non-VA Institution as a VA Beneficiary 18-VI-1

18.31 Preparation of Institutional Awards 18-VI-1

18.32 Awards to Dependents 18-VI-3

18.33 FDIB and PFOP Accounts 18-VI-4

18.34 Adjustment of Institutional Awards during Non-Bed Care 18-VI-6

18.35 Action when Discharge from Institution Is Planned 18-VI-7

18.36 Discontinuance of Institutional Awards 18-VI-8

**SUBCHAPTER VII. PROCEDURES RELATIVE TO \$1,500 ESTATE LIMITATION**

18.37 Control Procedure for Purposes of \$1,500 Estate Limitation
18-VII-1

18.38 Exchange of Asset Information between VA Medical Center and
Regional Office 18-VII-2

18.39 Determination of Value of Estate for 38 CFR 3.557 Purposes
18-VII-2

18.40 Action when Value of Estate Equals or Exceeds \$1,500 18-VII-3

18.41 Awards for Cost of Maintenance and Apportionment to Dependent
Parents 18-VII-5

18.42 Resumption\--Incompetents \$1,500 Estate Cases 18-VII-6

18.43 Payment of Lump Sum\--38 CFR 3.558(c) 18-VII-7

18.44 Care and Maintenance Award after Veteran\'s Death 18-VII-7

**SUBCHAPTER VIII. AMIE C&P EXAMINATION PROGRAM**

18.45 Electronically Transmitted Examinations 18-VIII-1

18.46 Automated Examination Program Workflow 18-VIII-1

18.47 Option 17\--Regional Office C&P Menu 18-VIII-1

18.48 Requesting C&P Examinations 18-VIII-2

18.49 Changing C&P Requests 18-VIII-3

18.50 Inquiring about C&P Exam Requests 18-VIII-3

18.51 Edit Patient Address Information 18-VIII-4

18.52 Regional Office Reports 18-VIII-4

18.53 Examination Reports 18-VIII-4

18.54 AMIS 290 Report for RO\--Option 4 18-VIII-5

18.55 Exam Check List 18-VIII-5

**ADDENDA**

A AMIE REPORT TIMETABLE 18-A-1

B MAS MOVEMENT/TRANSACTION TYPES AND DESCRIPTION 18-A-3

C EXAMPLE\--BENEFICIARY INFORMATION STATUS INQUIRY (OPTION 3) 18-A-6

D EXAMPLE\--PENDING FORM 7131 REQUESTS REPORT (OPTION 14) 18-A-7

E SPECIALIZED REPORTS 18-A-8

F REGIONAL OFFICE 7132 MENU (OPTION 16) 18-A-10

G EXAMPLE\--AMIE C&P EXAM WORKSHEET 18-A-11

H EXAMINATION BULLETINS 18-A-14

I EXAMPLE\--INQUIRY FOR C&P REQUESTS 18-A-15

J EXAMPLE\--PENDING 2507 EXAMS REPORT 18-A-18

K AMIS 290 REPORT FOR RO 18-A-19

**CHAPTER 18. AUTOMATED MEDICAL INFORMATION EXCHANGE (AMIE) SYSTEM**

**AND BENEFICIARIES INSTITUTIONALIZED AT VA EXPENSE**

**SUBCHAPTER I. EXCHANGE OF INFORMATION**

18.01 GENERAL\--EXCHANGE OF INFORMATION BETWEEN MEDICAL CENTERS,
OUTPATIENT CLINICS, AND REGIONAL OFFICES

a\. **VA Form 10-7131.** Historically, VA Form 10-7131, Exchange of
Beneficiary Information and Request for Administrative and Adjudicative
Action, was used by VA medical centers, outpatient clinics, and by
regional offices for the exchange of information or to request
administrative and adjudicative action relating to a veteran\'s status
when he or she is applying for or receiving hospitalization, domiciliary
care, nursing home care or other medical services. The AMIE system has
substantially reduced the need to use this form. Because regional
offices are not linked electronically to ALL medical centers and because
medical centers cannot initiate electronic requests to regional offices,
this form is still useful.

b\. **VA Form 10-7132.** Historically, VA Form 10-7132, Status Change,
was used by VA medical centers to furnish regional offices with patient
status change information. Although need for this form has also been
substantially reduced, medical center personnel still use it to provide
regional office personnel with information regarding veterans in private
nursing homes under VA contract. Some medical centers do not track
contract nursing home cases electronically.

c\. **AMIE.** Software for the AMIE system is loaded into the
Decentralized Hospital Computer Program (DHCP) at each medical facility
and allows for electronic transfer of data between the regional office
and medical centers servicing the same area. The AMIE system consists of
two programs: the 7131/7132 Program and the Compensation and Pension
(C&P) Program.

\(l\) **7131/7132 Program.** The AMIE 7131/7132 Program provides
exchange capabilities, inquiry capabilities, and the ability to generate
specialized reports for veterans receiving certain VA benefits. The
systematic completion of reports in accordance with predetermined
timetables assures that those cases requiring adjustment are identified
timely.

\(2\) **C&P Program.** The C&P Program automates the examination
process. Examination requests are generated by the regional office and
sent directly to the DHCP at a medical center. The local medical center
electronically schedules, tracks, enters and validates results, and
transmits completed examination requests back to the regional office.

**18.02 ACTION BY THE VETERANS SERVICE CENTER UPON RECEIPT OF AN
ADMISSION NOTICE OR SPECIALIZED AMIE REPORT**

a\. **Initial Determinations by the Veterans Service Center.** On
receipt of an admission notice or specialized AMIE report, review
information in the Benefits Delivery Network (BDN) to determine what
actions and reports, if any, are required. Pull the claims folder only
if needed information cannot be obtained from BDN. During the review,
consider the following:

\(1\) Is the veteran incompetent and is the award subject to reduction
under 38 CFR 3.557? See subchapter VII.

\(2\) Is award subject to A&A reduction under 38 CFR 3.552? See
subchapter IV.

\(3\) Is award subject to reduction under 38 CFR 3.551? See subchapter
III.

\(4\) Is treatment for a service-connected disability and is the
disability evaluated at less than 100 percent? See subchapter V.

\(5\) Is any hospital report required under paragraph 18.03 below?
Observe the following guidelines in requesting hospital reports:

\(a\) Request only those hospital reports which are absolutely essential
in the consideration of a claim.

\(b\) When requesting an \"EXAM OF COND LISTED\" or a \"SPECIAL
REPORT,\" be sure to furnish in

\"Remarks\" the exact information required.

\(c\) Do not request interim summaries.

b\. **Erroneous Information in DHCP.** If the admission diagnosis shows
a disability for which service connection has been severed or denied or
if a report shows erroneous eligibility coding, promptly notify the
medical facility, via mailman or FAX, so that action can be taken to
correct data in the DHCP.

**18.03 REPORTS WHICH MAY BE REQUESTED**

a\. **\"NOTICE OF DISCHARGE.\"** Request a notice of discharge under any
of the following circumstances:

\(1\) Whenever a veteran, having neither a dependent spouse nor child,
is institutionalized and it is determined that an adjustment under the
provisions of 38 CFR 3.551 is warranted.

\(2\) Whenever a veteran, receiving an additional allowance of pension
or compensation for A&A, is institutionalized and it is determined that
reduction under 38 CFR 3.552 is warranted.

\(3\) Whenever an incompetent veteran is subject to 38 CFR 3.557
discontinuance and benefits are being paid or have been discontinued
because the veteran\'s estate is over \$1,500. See subparagraph h below.

b\. **\"HOSPITAL SUMMARY.\"** Request a hospital summary when:

\(1\) The admission diagnosis shows a service-connected disability or a
secondary condition that may have been caused by a service-connected
condition or if the veteran has a service-connected disability and the
admission diagnosis is unclear.

\(2\) The veteran is in receipt of A&A and a future examination is
scheduled due to the existence of conditions subject to improvement. See
paragraph 18.22.

\(3\) A claim for pension or compensation is pending.

\(4\) A future examination has been scheduled.

c\. **\"CERTIFICATE (21 DAY).\"** Request a 21-day certificate if the
admission diagnosis shows a service-connected disability and the
disability is currently rated at less than 100 percent.

d\. **\"EXAM OF COND LISTED IN REMARKS.\"** Request this report when an
immediate hospital report

covering certain conditions is necessary. Enter conditions for which the
examination is requested in the \"Remarks\" section.

e\. **\"SPECIAL REPORT.\"** Enter the reason for the request in
\"Remarks,\" including the specific disability, anatomical system or
part of the body for which the report is desired. Request a \"Special
Report\" under any of the following circumstances:

\(1\) A claim is pending and it appears that the veteran is suffering
from a terminal illness, a hardship exists or a lengthy period of
hospitalization is indicated.

\(2\) A hospital report received is inadequate for rating purposes and,
in the opinion of the rating board, the hospital clinical records folder
would contain specific data adequate for rating the claim.

\(3\) When a hospital report is required in a specific number of days.
Generally, this will occur when a veteran is totally disabled but
permanency for pension purposes has not been established and a hospital
report is desired in 90 or 180 days.

\(4\) Where a special report not otherwise covered herein is required
(e.g., an autopsy report).

f\. **\"COMPETENCY REPORT.\"** Competency information is normally
included in hospital reports when treatment is for a mental condition.
Request a competency report, when required, and facts indicate that the
veteran is being treated for other than a mental condition.

g\. **\"VA FORM 21-2680.\"** Request this report when a claim for
regular A&A or Housebound benefits is filed and an immediate report is
necessary.

h\. **\"ASSET INFORMATION.\"** Request asset information when an
incompetent veteran without a spouse or child has a running compensation
or pension award. If a competency report is requested and the claims
folder reveals assets, show those assets and estimated value in
\"Remarks.\" If there are no known assets, in \"Remarks\" insert the
statement, \"No assets shown.\"

i\. **\"ADMISSION REPORT.\"** Request an admission report only if
information is needed soon after an admission for long term treatment
such as for a psychiatric disability or tuberculosis.

j\. **\"OPT TREATMENT RPT (DATE RANGE).\"** A report of treatment
furnished at an outpatient activity may be requested.

k\. **"CONTRACT NURSING HOME (CNH) REPORT."** Request this report when a
veteran has been hospitalized in a contract nursing home at VA expense.
To properly adjust contract nursing home (CNH) payee benefits, ROs must
obtain the "Report of Admissions/Discharges for CNH" in addition to the
normal "Report of Admissions and Discharges." The required information
to make the necessary adjustment can be obtained from both reports.

**18.04 ACTION BY THE VETERANS SERVICE CENTER WHEN VA FORM 10-7131 IS A
REQUEST FOR A NET WORTH DECISION (MEANS TEST)**

Effective July 1, 1986, Public Law 99-272 established an income test and
an income plus net worth test for determining eligibility for treatment
for a nonservice-connected disability.

a\. **Entitlement.** If a veteran\'s income plus net worth exceeds
applicable limits, the veteran is entitled to treatment for a
nonservice-connected disability only if he or she agrees to pay an
amount not to exceed the hospital Medicare deductible. The treating
healthcare facility will make income determinations. The regional office
will make net worth determinations.

b\. **Use of VA Form 10-7131.** The treating healthcare facility will
use VA Form 10-7131 to request that the regional office make a net worth
determination for veterans without service-connected disabilities who
are not otherwise exempted (e.g., former POW\'s). Authorization will
determine whether or not net worth is a bar to hospital or nursing home
care without copayment.

c\. **Determination by Treating Healthcare Facility**

\(1\) If the treating medical facility determines that the veteran\'s
income exceeds applicable limits, the veteran must agree to pay
applicable copayments for VA care. These cases are not referred to the
regional office.

\(2\) Notwithstanding the veteran\'s income, the veteran may not be
eligible for treatment if his/her net worth is such that it is
reasonable that some part of his/her estate be consumed for maintenance.
Authorization will make any required net worth determination based on
the criteria of 38 CFR 3.275.

d\. **Development by Treating Medical Facility**

\(1\) The treating medical facility will develop the information needed
to make a net worth decision and maintain copies of required forms in
the veteran\'s medical folder. Only in a limited number of cases, such
as those involving farm property or small businesses, should the
regional office be required to assist in developing evidence for the net
worth decision.

\(2\) The treating medical facility will ask the veteran to complete VA
Form 10-10F, Financial Worksheet, and VA Form 21-8049, Request for
Details of Expenses. If the veteran is a rancher, farmer, or small
business owner, VA Form 21-4165, Pension Claim Questionnaire for Farm
Income, or VA Form 21-4185, Report of Income From Property or Business,
will be requested. The medical facility will send copies of these
completed forms and VA Form 10-7131 to the regional office. Part I, item
6, of VA Form 10-7131 will be annotated, \"Net Worth Determination for
Medical Care.\"

e\. **Net Worth Determination by the Veterans Service Center**

\(1\) Upon receipt of a request for a net worth determination,
authorization will make the determination. See paragraphs 16.04 and
16.39.

\(2\) The veteran\'s net worth includes the net worth of the veteran\'s
spouse and any dependent children.

\(3\) If properly referred, complete VA Form 21-5427, Corpus of Estate
Determination, and indicate in item 13 whether \"NET WORTH IS A BAR\" or
\"NET WORTH IS NOT A BAR.\" Return VA Form 10-7131, copies of all forms,
and VA Form 21-5427 to the treating healthcare facility.

\(4\) When computing the income of farmers, ranchers or small business
owners, deduct the expenses shown on VA Form 21-4165 or 21-4185. When
determining if some part of the veteran\'s estate should be used to pay
for medical care, consider if the property can readily be converted into
cash at no substantial sacrifice.

\(5\) Do not make a net worth determination if development is
insufficient to make a decision or if income alone is excessive. Do not
establish a claims folder for these claimants. Return the claim to the
healthcare facility of jurisdiction for action.

\(6\) If net worth is a bar, maintain a copy of the decision along with
supporting evidence in a holding file for one year. This information
will be used to process any appeal received on an unfavorable net worth
determination. It is optional whether or not copies of favorable net
worth decisions are maintained. Dispose of this holding file under RCS
VB-1, part 1, after one year.

f\. **Notice of Determination**

\(1\) If the net worth decision is unfavorable, inform the veteran that
net worth is a bar to medical care without participatory payment. The
letter must include procedural and appellate rights.

\(2\) Send a copy of this letter, copies of all supporting evidence, and
the completed VA Form 21-5427 to the treating healthcare facility.

\(3\) Unless evidence of record indicates the veteran\'s income or net
worth has changed significantly, a favorable net worth determination is
valid for one year.

**ADDENDUM A**

**[AMIE REPORT TIMETABLE]{.underline}**

**[PERIOD]{.underline}**

**[REPORT FREQ COVERED ACTION]{.underline}**

**Service-Connected Admissions** Daily No earlier than 4 Screen across
BDN

(Option 6) or Weekly days prior

If admitted for SCD,

request 21-day cert.,

discharge report and

hospital summary.

Establish EP 320

control as needed.

**Incompetency Admissions** 1st Day of Prior Month If hospitalized at

(Option 8) Each Month end of month, screen

across BDN.

Request asset info

as required.

Request discharge

report.

Establish EP 135

control as needed.

**A&A Admissions** 1st Day of Month preceding ONE Screen across BDN

(Option 11) Each Month full calendar month and/or c-file to

(Review for 3.552(b)(l) (e.g., on 8/1/93 run verify that reduction

and 3.552(b)(2) 6/l - 6/30/93) is required.

adjustments.)

Send predetermination

notification as appropriate.

Request notice of discharge

as required.

PCLR EP 135.Establish EP 600 control.

**Pension Adm. (Sect. 306)** 1st Day of Month preceding TWO Screen
across BDN.

(Option 11) Each Month full calendar months

(Review for 3.551(c)(l) (e.g., on 8/1/93 run Send predetermination

adjustments.) 5/l - 5/31/93) notification as appropriate.

Request notice of

discharge as required.

PCLR EP 135.

Establish EP 600 control

**Pension Adm. (Old Law)** 1st Day of Month preceding SIX

(Option 11) Each Month full calendar months Same as pension above.

(Review for 3.551(b)(1) (e.g., on 8/1/93 run

adjustments.) 1/1 - 1/31/93)

**Dischg. Rpt. (Improved Pens.)** 1st Day of Month preceding 3 Same as
pension

(Option 7) Each Month full calendar months above.

(Review for 3.551(e)(l) (e.g., on 8/1/93 run

adjustments.) 4/1 - 4/30/93)

## Contract Nursing Home (CNH) Same as Same as pension Same as pension above.

**Admissions/Discharges** pension above. above.

**NOTE: Request ALL discharge types which constitute domiciliary or
nursing home care by VA.**

**Readmission Report** 1st Day of The preceding month Screen across BDN
to

(Option 12) Each Month determine if a reduction

(Review for 3.552(b)(3), was made within the last

3.551(b)(3), 3.551(c)(2), 6 months which would

and 3.551(e)(2) adjustments.) require adjustment.

Send predetermination

notification as appropriate.

Request notice of

discharge as required.

PCLR EP 135.

Establish EP 600 control.

##