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Use Of Telephone, E-mail And Fax For Claims Development


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WARMS - What's New? http://www.warms.vba.va.gov/whatsnew.html

Veterans Benefits Administration M21-1, Part III

Department of Veterans Affairs Change 135

Washington, DC 20420 November 10, 2005

Veterans Benefits Manual M21-1, Part III, “Authorization and Clerical Procedures,” is changed as follows:

Pages 11-III-1 and 11-III-2: Remove these pages and substitute pages 11-III-1 and 11-III-2 attached.

Paragraph 11.17c is amended to clarify that the telephone call must be properly documented, even if the information is advantageous to the beneficiary.

Paragraph 11.18a is revised to show that award action may not be taken on oral information or statements, unless all the requirements cited in this paragraph are met.

Paragraph 11.18a(3)6 is added to show that before ending the call, the VSR should explain to the beneficiary that a notification letter of our decision will be sent, based on the information obtained during the call.

Paragraph 11.18b is revised to show that regardless of whether the information obtained during the call will favorably or adversely affect the award, it should be documented.

Minor editorial corrections were made to the subchapter.

By Direction of the Under Secretary for Benefits

Renée L. Szybala, Director

Compensation and Pension Service

Distribution: RPC: 2068

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

November 10, 2005 M21-1, Part III

Change 135

SUBCHAPTER III. USE OF TELEPHONE, E-MAIL AND FAX FOR CLAIMS DEVELOPMENT

11.17 GENERAL

a. Regional offices should make full use of telephones, e-mail and fax machines as an integral part of claims development procedures for compensation, pension, and burial claims.

b. Issues Suitable for Telephone, E-Mail and Fax Development:

(1) Social Security numbers of dependents, including the Social Security Number Verification Match;

(2) Correct mailing address(es);

(3) Date(s) of birth;

(4) Reserve or National Guard unit information (e.g., address);

(5) Information concerning retired, severance or readjustment pay;

(6) Names and addresses of physicians or medical record numbers;

(7) Employment information (current or past);

(8) Change in dependency status, name and address of person having custody of children, etc.;

(9) Income information (e.g., change in income or date of receipt of first Social Security payment);

(10) Clarification of medical expenses;

(11) Verification of Medicaid-covered nursing home status;

(12) Burial claim clarification information (e.g., status of unpaid bills);

(13) Whether the veteran has service medical or other records.

c. Beneficiaries are not required to advise VA in writing of changes in income, net worth, dependency or marital status. VA may increase or decrease benefit payments based on information submitted orally, or by e-mail, fax or other electronic means. If the change results in adverse action, a predetermination notice is not required but contemporaneous notice must be sent. However, do not take adverse action with contemporaneous notice or favorable action based on oral information unless you follow the specific telephone contact procedures shown in paragraph 11.18a.

11.18 TELEPHONE, E-MAIL AND FAX CONTACT PROCEDURES

a. Sound discretion must be exercised when requesting information by telephone or e-mail to ensure that the source of the information is reliable. Verification of the source is necessary. If the person is unable to furnish the information requested or if the VA employee remains uncertain of the person’s identity, complete development by letter. VA may not take action based on oral information or statements unless the VA employee receiving the information meets the following conditions:

(1) during the conversation identify yourself as a VA employee who is authorized to receive the information or statement (these are VA employees authorized to take actions under 38 CFR 3.100); and

(2) during the conversation verify the identity of the provider as either the beneficiary or his or her fiduciary by obtaining specific information about the beneficiary that can be verified from the VA records, such as Social Security number, date of birth, branch of military service, dates of military service, or other information; and

(3) during or following the conversation document the following information for the beneficiary’s VA records:

1. the specific information or statement provided; and

2. the date such information or statement was provided; and

3. the identity of the provider; and

4. the steps taken to verify the identity of the provider as being either the beneficiary or his or her fiduciary; and

5. that you informed the provider that the information would be used for the purpose of calculating benefit amounts. (38 CFR 3.217(b))

6. before ending the conversation, inform the beneficiary that even though the information was obtained telephonically, a notification letter will be issued.

b. All information received by telephone from the claimant must be completely documented on VA Form 119, “Report of Contact”, or equivalent, regardless of whether the information will favorably or adversely affect the beneficiary’s award. If the veteran has a power of attorney, send the representative a copy of the VA Form 119.

c. All information received by e-mail from the claimant or beneficiary must be printed out on paper and placed in the claims folder.

d. When information received by telephone, e-mail or fax results in an award or denial action, the notification letter must include a statement of this information as well as the date of the telephone call, e-mail or fax.

e. If benefits are reduced, terminated or otherwise adversely affected based on oral information or statements, they will be retroactively restored if, within 30 days of the date that the notification of adverse action is issued, the beneficiary or his or her fiduciary asserts that the adverse action was based upon information or statements that were inaccurate or upon information that was not provided by the beneficiary or his or her fiduciary. (38 CFR 3.103(b)(4))

11.19 DOCUMENTS SUITABLE FOR RECEIPT BY FAX OR E-MAIL

All documents except original applications and separation documents intended for proof of service to establish entitlement to benefits may be accepted via fax or e-mail. However, if there is any question about the validity of any documents received by fax or e-mail, the original should be requested.

11-III-2

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