The Veterans’ Health Care Eligibility Reform Act of 1996 required that VA establish an enrollment system to help manage its health care delivery system. VHA’s HEC is the business owner of the Enrollment System— the official system of record for verifying veterans’ eligibility for health care benefits and maintaining enrollment information. To enroll for health care benefits, veterans submit an application to either HEC or a VAMC. Application information includes demographic, military service, financial, and insurance information. A veteran may apply online, by mail, by fax, by phone, or in person. Once a veteran submits an application, there are three key steps for processing the application: intake of application, verification of eligibility, and enrollment determination. There may be an additional processing step—resolving a pending application—if enrollment staff need additional information to determine eligibility. According to VHA policy, staff are required to process applications within 5 business days of receipt. Figure 1 provides an overview of the enrollment process, as of June 2017. Intake of application. If a veteran applies in person, or faxes or mails an application to a VAMC, local enrollment staff enter the application information into the VAMC’s Veterans Health Information Systems and Technology Architecture (VistA) system. If a veteran applies in person, by phone, or faxes or mails an application to HEC, HEC enrollment staff enter application information into the Enrollment System. A veteran may also apply online, and the application information is directly transmitted into the Enrollment System. Historically, VAMCs have received more than 90 percent of enrollment applications for processing. Verification of eligibility. After the intake of an application, VAMC and HEC staff attempt to verify whether veterans meet eligibility requirements based on their military service and, if applicable, financial information. VAMC staff attempt to verify military service by reviewing supporting documentation provided by veterans (e.g., military discharge or separation papers). If veterans do not provide any documentation of military service, staff will try to verify this information through military service databases. For application information that HEC staff have entered into the Enrollment System or for those applications that have been submitted online with information transmitted directly to the Enrollment System, the system assesses eligibility based on the information entered. Both VistA and the Enrollment System automatically assess whether a veteran’s self-reported income meets VHA income thresholds for eligibility, as applicable. VAMC staff are required to ensure that application information is accurately entered into VistA. Application information that is entered into local VistA systems is transmitted nightly into the Enrollment System. Enrollment determination. The Enrollment System makes all enrollment determinations, including those for applications processed at VAMCs. Specifically, the Enrollment System determines whether veterans are enrolled, rejected, or ineligible for health care benefits. Veterans who are enrolled or rejected are placed in a category based on type of eligibility—called a priority group—established to manage the provision of care. For example, priority group 1 consists of veterans who are rated 50 percent or greater based on service-connected disabilities. Priority group 5 consists of veterans who are eligible because their incomes are at or below VHA’s eligibility thresholds; and priority group 8g consists of non-service connected veterans whose incomes are above the thresholds, and thus are rejected for health care benefits. HEC sends a letter and a personalized handbook to each veteran once it has made an enrollment determination with the decision and a description of benefits, if applicable. Resolving pending applications. If VAMC or HEC enrollment staff cannot verify veterans’ eligibility for making an enrollment determination, the application is categorized as pending. To resolve a pending application, VAMC or HEC staff are to contact the veteran to obtain the missing information (e.g., military service or financial information). VAMC and HEC staff share responsibility for resolving pending applications. For instance, HEC staff may send a pending application for VAMC staff to help process. VAMC staff may also contact HEC staff for assistance in collecting missing information because, for example, according to officials, HEC has greater access to military service databases. VHA enrollment staff, both from HEC and VAMCs, frequently did not process enrollment applications in accordance with VHA’s timeliness standards and made incorrect enrollment determinations. VHA, through HEC, is assessing efforts to improve its enrollment processes. Prior studies show that VHA enrollment staff, whether from HEC or VAMCs, frequently did not process enrollment applications within 5 business days in accordance with VHA timeliness standards. Specifically, a June 2016 VHA audit found that HEC staff did not process 143 of 253 applications reviewed (57 percent) within VHA’s timeliness standard. The audit found that this occurred, in part, because HEC enrollment staff were not prioritizing workload to focus on processing applications that were approaching the timeliness standard. In response to an audit recommendation, HEC officials said they have begun prioritizing workload to help meet the timeliness standard. A VHA Chief Business Office analysis showed that VAMCs also did not consistently process online applications within 5 business days. According to the analysis, only 35 percent of online applications were processed by VAMCs within 5 business days in fiscal year 2012 and 65 percent through the first 7 months of fiscal year 2016. VAMC officials we contacted said because there is no mechanism for veterans to provide supporting military service records, such as discharge papers, with their online applications, VAMC staff need to obtain the information by querying available military service databases or following up with the veterans, which may cause delays in processing. Several VAMC officials said that HEC should implement automated controls that do not allow veterans to submit online applications without attaching supporting documents that include information needed for making enrollment determinations. Additionally, the overall time needed to process enrollment applications may increase when staff need to place applications in a pending status. In its September 2015 report, VA’s Office of Inspector General found that, as of September 2014, the Enrollment System contained nearly 870,000 pending applications, many of which had been pending for more than 5 years. According to the report, 72 percent of those applications were pending because additional financial information was needed from veterans. In response to the report, in 2016, HEC and VAMCs undertook outreach efforts, such as attempting to contact all veterans with pending applications via phone and letters. According to HEC officials, as of May 2017, they were able to resolve about 30 percent of the applications (about 255,000 applications). This included enrolling approximately 88,000 veterans, as well as removing from pending status applications for which HEC officials said veterans were no longer living. HEC officials and VAMC staff in our review said they experienced problems resolving pending applications because they were generally several years old and lacked accurate contact information. HEC officials stated they would continue to work on resolving them, but if staff cannot obtain the information within 365 days, the applications’ status will change from pending to closed at that time. Based on our discussions with enrollment staff, we found that none of the VAMCs in our review had a specific policy or procedure for how to resolve pending applications. Officials indicated that they had not received any national procedure or guidance from VHA, nor had they developed local procedures. According to federal internal control standards, management should design control activities, such as policies and procedures, to achieve objectives and respond to risk. In the absence of a standard procedure for VAMCs to use to resolve pending applications, veterans are at risk for experiencing unnecessary delays while waiting for their applications to be processed. For the six VAMCs in our review, we found that, as of March and April 2017, VAMC enrollment staff had not resolved 31 (55 percent) of the 56 pending applications included in our random, nongeneralizable sample of pending applications. (See table 1.) Specifically we found that for 22 (71 percent) of the 31 unresolved applications there was no evidence that VAMC enrollment staff had attempted to contact the veterans to obtain missing military service or financial information, and that 18 of these 22 applications had been in a pending status for 3 months or longer at the time of our review. VAMC officials told us they were not aware that some of the unresolved were in a pending status prior to our review. For the remaining 9 applications, we found VAMC enrollment staff attempted to contact the veterans, but were unable to resolve the application, for example, due to the lack of response from the veteran or lack of valid contact information. These 9 applications had been in a pending status between 2 and 5 months at the time of our review. For the 25 applications that enrollment staff resolved, we found that staff enrolled the veterans for 19, and for the other 6, staff determined the veterans were ineligible or rejected for enrollment. We also found the time it took staff to make an enrollment determination varied widely—ranging from 3 to 119 days. (See table 2.) Officials from five of the six VAMCs told us that based on our review they recognized the need to improve their processes. For example, officials from two VAMCs indicated that they were going to develop a standard operating procedure for identifying pending applications, following up with veterans to obtain missing information, and documenting actions such as the dates that enrollment staff called veterans or mailed letters to resolve outstanding issues. VHA’s Compliance and Internal Control Program Office conducted two audits (in April and August 2016), which found that VHA enrollment staff, including those from HEC and VAMCs, frequently made incorrect enrollment determinations. In some cases, veterans were rejected for health care benefits when those veterans should have been enrolled, and in other cases veterans were enrolled when they were ineligible for benefits, according to these audits.