62nd Annual
Service Officers
Training
Nashville, TN
September 20, 2012
Pension Management Center
Milwaukee, Wisconsin
Thomas Drews, Coach
James Nelson, Management Analyst
Today’s Agenda
Milwakee Pension Management Center
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Service Area
Responsibilities
Contact Information
Faxing Claims
Authorization
Phone contact
VSO Emergency contact
Claims Folders
How You Can Help?
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VA Form 21-22/New POA guidance
Fully Developed Claims (FDC)
EVRs
Medical Expenses
State home fees/Asst. Living Fees/Independent Living fees
Burials
Net Worth
Liberalizing Law
Overpayments
Debt Management Center
Fiduciary
Dependency Indemnity Compensation
Questions
Service Areas
PMC Responsibilities
Pension Centers
 Original Claims
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Live
Death
DIC
SMP
Burials
Rating Issues
Reopened Claims
Running Awards
– EVRs
– Medical Expense Reports
– Dependency
– Nursing Home
Matching Programs
– IVM
– COLA/CS/RR/MR
– SSA Death
– Provider Proof
Regional Offices
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DRO Reviews
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Fiduciary Services
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Sending Hospital Reports
to PMCs
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Dual Claims are now HRO
issues
Where do I send claims?
Department of Veterans Affairs
Pension Management Center
PO Box 342000
Milwaukee, WI 53234-9907
Authorization Quality of Work
FY 12 Goal: 98%
National FY 12 Quality: 97.5%
PMC Quality: 98%
Rating Quality of Work
FY12 Goal: 98%
National FY12 Accuracy: 98.1%
PMC Quality of work: 99.6%
Average Days a claim is pending
as of 08/20/12
 EP 180 Series: 87.5 days
 EP 120 Series: 79.7 days
 EP 140 Series: 106.9 days
 EP 190 Series: 111 days
 EP 150 Group: 124.5 days
 EP 155: 131.9 days
 EP 137: 107.2 days
 EP 160 Group: 122.9 days
PHONE CONTACT
 There is no direct phone contact with the
Milwaukee PMC for general information
calls. Call the NPCC at:
– 877-294-6380
 There are two email addresses that are the
preferred source to be used for EMERGENT
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CASES ONLY:
One for VSOs co-located at HRO and
encrypted:
– VAVBAMIW/PMC/VSO
 For those at out based locations and anyone
NOT encrypted:
– milpenctrvso@va.gov
– Responses to these addresses will not include
personal identifiable information (PII) if you are not
encrypted
VSO Primary Contact Number
All status of claim inquiries, reports of death
and informal claims go through the National
PMC Call Center number;
1-877-294-6380
Emergency VSO Contact Number
 We consider the following emergencies situations:
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Homeless veterans
Terminal illness
Removal from Nursing Home
Severe Financial hardship
Eviction
 The Milwaukee PMC has a direct line so VSOs can call
to inquire about the current status.
 The number you can call for emergencies is;
414-902-5062
 This number is answered by employees on the
Advocacy Team
Is it ok to Fax and Mail the same exact claim?
Yes. However, you should be aware of the following;
1. It slows down the claims process.
2. It creates duplicate documents which require screening
(time)
3. If there is missing information, development is initiated
(delay)
4. You may fax claims to Virtual VA. The number is
414-902-9470
When is a File Needed?
 The PMC has the ability to work claims without the
file (more timely decision). The ultimate goal is
electronic records, such as Virtual VA.
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For every DIC Claim
 Generally, we do not request files for Death Pension
cases. Only if we absolutely need it.
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Upon request by the PMC (PTO)
How You Can Help?
– Ensure the application/forms are complete. Enter “0” or “N/A” in all
fields on forms.
– Ensure the application/forms and the 21-4142 are properly signed
– Service documents must be properly certified
– For nursing home claims, ensure VA Form 21-0779 and VA Form 218416 are signed by the claimant (if not, a “mark” and two witnesses)
– If the claimant has a caregiver, we must have an Attendant Affidavit
signed by the caregiver and claimant
– Ensure VA Form 21-22 is properly completed and signed
– Ensure you report the amount of interest income (interest bearing
accounts $5,000.00 or greater)
– Send claims directly to the PMC. Sending the claim to the RO delays the
processing.
Who signs a claim? - M21-1MR.I.3.a
1. The claimant
2. A representative is authorized to prepare, present, and
prosecute a claimant’s claim and has the authority to:
a. review the claimant’s records
b. present evidence on behalf of the claimant,
and sign an informal claim, a notice of
disagreement (NOD), or a substantive
appeal on behalf of the claimant.
c. withdraw an appeal
3. Power of Attorneys cannot sign applications for veterans,
including Eligibility Verification Reports (EVRs)
Signatures - cont…
4. Please have the claimant sign documents.
5. VA recognized fiduciaries are an exception.
6. Accredited POAs w/a VA Form 21-22 on file
can sign evidentiary statements and submit
evidence on behalf of the claimant.
7. Accredited POAs cannot sign forms requiring
claimant certification: 21-4142, 21-8416, 21534, 21-526, 21-686c, 21-527
VA Form 21-22 (New changes)
FL 12-16 (Revision of VA Form 21-22, Appointment
of Veterans Service Organization as
Claimant’s Representative)
– Effective June 20, 2012
– Created an additional signature block for VSOs
– Addition of a checkbox for claimants to
authorize their VSO to change their address
– Deletion of Copy 4 of the form designed for
VHA
– Additions and deletions of VSOs listings on the
back of the form
VA Form 21-22 (New changes) cont…
FL 12-16 (Revision of VA Form 21-22, Appointment
of Veterans Service Organization as
Claimant’s Representative)
– Form states that priors versions of VA Form
21-22 will no longer be accepted
– Prior forms will be accepted until Sept 1, 2012
– After Sept 1, 2012, VA will no longer accept any
prior versions of VA Form 21-22
Fully Developed Claims (FDC)
What are Fully Developed Claims?
A FDC is a claim where a Veteran submits certain types of evidence, for
example private treatment records and notice of Federal treatment
records, to VA at the time he or she first files a formal claim and certified
they have no more evidence to submit. VA gathers all federal records the
Veteran identifies, like those from VA Medical Centers and the Social
Security Administration.
This allows the VA to start processing the claim immediately. As a
result, the Veteran and his/her representative do much of the development
that typically takes the VA 175 days to gather. Currently, FDC claims
take and average of 110 days to decide compared to 254 days through the
traditional claims method.
Fully Developed Claims (FDC) cont…
VA Form 21-526EZ, Fully Developed Claim (Compensation)
VA Form 21-527EZ, Fully Developed Claim (Pension)
An FDC must meet the following criteria:
1. Proper form
2. Fully Developed Claim Certification
3. All necessary income and net worth information reported
4. For SMP claims, VA Form 21-2680, Examination for
Housebound Status or Permanent Need for Regular Aid and
Attendance
5. VA SMP based on nursing home status, VA Form 21-0779,
Request for Nursing Home Information in Connection with
Claim for Aid and Attendance
Fully Developed Claims (FDC) cont…
– If claiming dependents, VA Form 21-686c, Declaration of
Status of Dependents must be included
– For Guard and Reserve members, any and all service
treatment records and an identification of any treatment
records from a Federal treatment facility such as a VA
Medical Center
FDC exclusions:
– Claims requiring additional development (with the
exception of service verification)
– Claimant submits a supplemental claim for additional
evidence after receipt of the FDC certification
– Claimant fails to report for an examination
Eligibility Verification Reports
FACTS
1. So far in 2012, we have received 39,407
2. The PMC has approximately 326 left to work
3. We expect to receive another 40,000 starting in
January 2013
HOW YOU CAN HELP WITH EVRs?
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Ensure the form is completed & signed by claimant/fiduciary payee
Complete dependency information (SSN, DOB, address, age, etc.)
Nursing home information (address, whether is Medicaid)
Income (specific changes with exact date of increase/decrease)
Net worth (all bank accounts to include interest income)
Claimant’s signature or mark with two witnesses
– Please note Medical Expense Reports have to be worked with the EVR,
if an EVR was issued. So please send them together. Sending separate
delays the processing.
EVR Medical Expenses
The $800 rule per M21-1MR.V.iii.1.G.42
– Preprinted medical amount indicates the amount
the VA is projecting
– If either actual year, or estimated year is greater
than projected by more than $800, they must
complete VA Form 21-8416.
– If not we have to develop with a threat to remove
the expenses.
– Estimated year is considered a claim for
continuing medical expenses and must either be
granted, developed, or denied.
Medical Expense Directive
 M21-1MR.V.iii.1.G -
show all deductible expenses
 Claims must include the following five elements:
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Purpose
Amount paid
Date paid
Name of provider
For whom paid
 If an element is missing, we have to develop (letter or
phone call). This is where most delays occur
Medical Expenses
 Please use the new VAF 21P-8416, dated February 2012. (Old
versions are still being accepted)
 Use VA Form 21P-8416, not receipts. Receipts most often do
not have the five elements that are required.
 Mileage must state the purpose, and number of miles driven. If
a fee was paid, please make it clear what the fee was for.
 Claimant has to claim nursing home fees.
We cannot rely
solely on the nursing home statement. Therefore if possible,
have the claimant sign any nursing home certificates/VA Form
21-0779.
How should I list UMEs?
Single listing for each provider over the course of
the year; e.g.
– Prescriptions, $1000, CY 2009, Walgreens, Self
– Prescriptions, $500, CY 2009, Rite Aid,
Spouse
List for the entire calendar year, or initial year.
Specific dates would be required if the IY is not
delineated.
We prefer no receipts or prescription printouts,
unless provider proof is requested.
Listing UMEs continued..
 M21-1MR.V.iii.1.G.44d
 Medical expenses allowed on a claim should not be an
arbitrary amount
 VSRs may project certain predictable expenses:
– SMIB (Must be projected)
– Private Medical Insurance
– Attendant Fees if Special Monthly Pension
– Nursing Home Fees
– Their estimated amount on the EVR, if within $800 of
preprinted amount
 If your claimant wants a different specific amount projected,
have them specifically request it in writing. Include the time
period for the projection. The request will be considered.
How are state home fees handled?
If a veteran in a State home is receiving hospital care
or is a patient (as opposed to a resident) in a nursing
home, out-of-pocket amounts actually paid by the
veteran may be allowed as medical expenses.
Amount paid, versus charged is a key factor.
For your reference:
M21-1MR.V.iii.1.G.42
Nursing Home Fees
Allow deduction for NH fees if a responsible official
of the NH certifies that the disabled person is a patient
(as opposed to a resident) of the NH.
Allow a deduction for NH fees even though the NH
may not be licensed by the State to provide skilled or
intermediate care.
For your reference:
M21-1MR.V.iii.1.G.43
In Home Attendants
If rated for Special Monthly Pension
(SMP [A+A or HB])…
– Allow all fees paid to an in-home attendant as long
as the attendant provides medical or nursing
services.
– All reasonable fees paid to individual for personal
care and maintenance of the immediate
environment may be allowed.
– The person does not have to be a licensed health
care professional.
In Home Attendants cont..
 If NOT rated for Special Monthly Pension
(SMP [A+A or HB]) AND a licensed physician has not stated
that a dependent or other relative requires an in-home
attendant…
– Allow expenses paid to an in-home attendant only if the
attendant is a licensed healthcare professional.
– All reasonable fees paid to individual for personal care and
maintenance of the immediate environment may be allowed.
– An attendant affidavit is needed for each caregiver. The
attendant affidavit must be completed by the caregiver and
signed by the claimant.
Custodial Care/Assisted Living Facilities
If a beneficiary or dependent or other person for whom
UMEs can be allowed is maintained in such an
institution because they need to live in a protected
environment, all unreimbursed fees paid to the
institution for custodial care (room and board) and
medical or nursing care are deductible expenses, IF…
Rated for SMP, or
A licensed physician certifies that the individual has a
medical condition that makes such a level of care
necessary.
Independent/Senior Living Facilities
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Just because the VA will not take independent/senior living
facilities’ room and board does not necessarily mean VA can not
take other fees from the facility. (i.e. VA will not take room and
board from independent living facilities if the only service they
provide is transportation to medical appointments. However, VA
can take the amount they charge the claimant for transportation
to medical appointments as a medical expense.)
VA considers the expenses paid to the 3rd party as attendant
fees, but if the facility does not provide the services, VA would
not accept the rent.
Examples of medical services for Independent/Senior Living
Facilities
Questionable Items:
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Medication reminders N,
Medication management Y, Phone Dev will be undertaken
Medication administering Y,
Ambulation assistance Y,
Emergency pull-cords N,
24-hour on-site staff to respond to emergencies N,
Meal preparation N,
Homemaker services N,
Transportation to medical appointments N.
Dependency/Death pension
 Death pension Claims
– Use the new 21-534 (dated Mar 2009).
– Box 22J has a specific question that asks about the
issue of a deemed valid marriage and knowledge of
any impediment to the widow being married to the
veteran in event she doesn’t have all marriage
information
– When completing 21-534, do not list “of record” in
the boxes that ask about marriages. The law
specifically calls for the widow to complete this
section, even if she was on the veteran’s award
– Always answer ALL questions
VAF 21-526 (New)
 Make sure the disability section on the front is
answered as NONE if only filing for pension. This
section is to claim S/C claimed conditions and will
cause a delay if completed and only pension is being
claimed.
 The income sections ask for monthly income. If you
report any amount, it will be annualized.
Example…if you report the annual figure for
interest…specify so VA does not multiply by 12
 Make sure all sections are answered with a
statement, amount, “None” or “N/A”
What delay’s reimbursement for UMEs?
 Problematic issues include:
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Incomplete 8416s.
Initial year not fully accounted for.
Unsigned or incorrectly signed.
Submitting receipts or printouts.
Listing each purchase individually.
Listing SMIB when it is no longer paid.
Any change in SSA which was not previously reported to us
in detail.
– Not including an attendant affidavit for a newly claimed
caregiver.
Burial Claim Eligibility
 Non service-connected burial benefits:
– NSC burial benefits payable if the veteran:
• was in receipt of pension or compensation at the time of
death
• was receiving military retired pay in lieu of compensation at
the time of death
• had an original or reopened claim pending at the time of
death and has been found entitled to compensation or
pension from a date prior to the date of death
• was hospitalized by VA at the time of death
• died while receiving care under VA contract at a non-VA
facility
• died while traveling, under proper authorization and at VA
expense, to or from a specified place for the purpose of
examination, treatment, or care, or
• died on or after October 9, 1996, while a patient at an
approved State Veterans' home per Section 212 of Public Law
(PL) 104-275.
Burial Claim Eligibility cont…
 Non service-connected burial benefits, cont:
– The plot allowance is payable if the veteran was:
• discharged for a disability incurred or aggravated in the line
of duty,
• in receipt of compensation or pension at the time of death,
• receiving retired pay in lieu of compensation at the time of
death,
• a wartime Veteran and his/her body is unclaimed,
• properly hospitalized by VA at the time of death, or
• buried in a State cemetery.
– The plot allowance is not payable if
• burial is in a national cemetery or other cemetery under the
jurisdiction of the United States
• employer has paid or assumed the plot and/or interment
expenses, or
• burial was without cost for plot or interment in a section of a
State or State-owned cemetery used solely for burial of
persons otherwise eligible for burial in a national cemetery.
Burial Claim Eligibility cont..
 Non service-connected burial benefits, cont:
– NSC transportation can be paid if the veteran’s death
occurred while:
• en route for VA authorized examination, treatment, or care
• properly hospitalized at a medical center, domiciliary, or
nursing home under the direct jurisdiction of VA
• receiving nursing home care authorized under 38 U.S.C. 1720
in a non-VA facility, or
• a patient at an approved State nursing home (38 U.S.C.
2303(a)(1)(B) ) and death occurred on or after October 9,
1996.
– Transportation can also be paid in NSC death cases if the
veteran was buried in a national cemetery and:
• had a SC condition at the time of death for which he/she was
receiving disability compensation, or
• was receiving military retired pay or VA pension at the time
of death in lieu of disability compensation.
Burial Claim Eligibility cont..
 Service-connected burial benefits:
– Only paid when we grant service-connection for the
cause of death.
– Not payable for DIC grants under 38 USC 1318 or
1151.
– $2,000 burial benefit (no plot payment)
– Transportation:
• Paid if veteran was buried in a National Cemetery.
• Can also be paid if veteran died in a VAMC, but total
payable cannot exceed $2,000.
Burial Benefits changes PL 111-275, Sec 501
 PL 111-275 increased certain Burial, Funeral
Benefits and Plot Allowances
 NSC burial rate will now be $700.00 for deaths
occurring on/after 10/1/2011 for veterans who
die while properly hospitalized by VA. If not
properly hospitalized or indigent, the rate
remains $300.00.
 NSC plot rate will now be $700.00 for deaths
occurring on/after 10/1/2011 for all eligible
veterans, regardless of the location of death.
 Allows for annual increases in burial and plot
allowances based on Consumer Price Index
beginning in FY 2013, w/first increase on
10/1/2012.
Burial Benefit changes PL 111-275, SEC 604
 EXCLUSION OF CERTAIN AMOUNTS FROM
CONSIDERATION AS INCOME FOR
PURPOSES OF VETERANS PENSION
BENEFITS.
 38 U.S.C. § 1503(a) is amended to authorize VA to
exclude up to $5,000 of income from a state or
municipality that is paid to the Veteran due to
injury or disease when determining annual income
for Veterans pension benefits.
 The amendment applies to determinations of
annual income for calendar years beginning after
October 1, 2011.
Changes PL 111-275 SEC 606
 APPLICABILITY OF LIMITATION TO PENSION
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PAYABLE TO CERTAIN CHILDREN OF VETERANS
OF A PERIOD OF WAR.
38 U.S.C. § 5503(d) is amended to provide VA with the
authority to apply the $90 Medicaid rule to children of
Veterans in receipt of pension. The amendment limits to
$90 a month the amount of pension payable to the child of
a Veteran who receives Medicaid-covered nursing home
care.
VBA ACTION: Since this section was effective on
October 13, 2010, RO employees must immediately
implement action to reduce children’s pension awards to
$90 a month when the child is receiving Medicaidcovered nursing home care.
Net Worth
 Sale of Homestead/Home/Property
– Conversion of assets, not countable as income
– If resulting gain in NW is over $80,000 a Net Worth
Determination will have to be considered (21-8049)
– If benefits are terminated due to Net Worth,
benefits will be stopped the first of the year
following this change
– If Net Worth does not result in termination,
remember, interest and dividends from bank assets
must be reported as income
Stub Year/Initial Year
 This refers to the first full 12-month period of
eligibility following the effective date of benefits
Example: Effective date is 25 Mar 2012
• Initial year is 3/25/12 to 3/31/13
• After this we consider calendar year
• VA will compute to claimant’s advantage for initial year
versus calendar year income/expenses
 If VA asks for specific time periods the EVR and
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21-8416 must reflect those specific time periods
There may be overlapping periods. VA needs to
know initial year and full calendar year.
Liberalizing Law & Pension cont..
 Public Law 107-103 (sections 206-207),
enacted on 9/17/01, changed the disability
requirement for pension. This is a
Liberalizing Law.
 The law allowed pension to be granted
presumptively, without a rating, if:
– The veteran is 65 or older, or
– The veteran is recognized as disabled by the Social
Security Administration, or
– The veteran is a patient in a nursing home.
Liberalizing Law & Pension cont..
 P&F Service interprets Liberalizing Law
rules for pension differently, so we have
adjusted the way we process these at
the Milwaukee PMC.
 If the veteran is entitled by rating
(1521) and presumptively (1513), we
will consider an earlier effective date under
Liberalizing Law, even if pension was granted
via rating.
Liberalizing Law & Pension cont..
 When liberalizing law applies:
– The veteran is granted pension (presumptively or by
rating), and
– The veteran met one of the presumptive requirements
on the date of the law change (9/17/01)* through the
present date of claim, and
– The veteran has never received pension, and
– The veteran was never denied for excessive net
worth.
 If liberalizing law applies, we will solicit for a
claim and request income/expense information
for one year prior to our current entitlement
date.
– For example, if we are granting benefits effective
03/20/12, we will solicit for a claim to consider benefits
from 03/20/11.
What can you do to help
reduce overpayments?
Request a specific, small amount of UMEs.
Advise beneficiaries to inform VA of increases in
income immediately (including SSA), to include
the date payment was first received, over their
signature. Request that immediate action be
taken, and indicate that due process is waived.
Don’t send multiple copies of the same claim.
Understanding the Overpayment Process?
 Once an overpayment is created and evidence shows it is
valid understand the claimant’s options.
 Shortly after the debt is created they will receive a letter
from the Debt Management Center (DMC) in St. Paul, MN.
At this point, the PMC no longer is involved.
 The claimant has the following options:
– Request a waiver of the debt
– Request a limited withholding of the debt
– Pay the debt in full
What are DMC Time Limits?
Once the DMC notice of debt letter is mailed to
the claimant;
– 30 days to request a waiver, limited withholding
or pay the debt before his running benefits are
withheld to collect
– After 30 days, he can still request a limited
withholding
– If a request for waiver is received within 30
days, benefits are not withheld during the
waiver decision process
– 180 days to request a waiver of the debt
PMC Fiduciary Procedures
 The PMC identifies claimants may be incompetent, prepares
a proposal rating and issues due process. A 607 EP is
established.
 A DLP (date last paid) award is completed and all retro
benefits are withheld pending final incompetency rating and
a fiduciary being named.
 Due process expires or an answer is received, a final rating of
competency/incompetency is prepared. If incompetent:
– 297 EP is established and a 21-592 is prepared and sent to
HRO FID or FID HUB Dept.
– 21-555 received from HRO FID or FID HUB and w/h
benefits are released
DIC Eligibility
 What is DIC?
Dependency and Indemnity Compensation (DIC) is
defined as a monthly payment made to a surviving
spouse, child, or parent because the cause of death was
service connected on or after January 1, 1957, or
before January 1, 1957, if the survivor elects to receive
DIC in lieu of death compensation.
DIC Eligibility cont…
1. DIC under U.S.C. 1310(a)
– Generally, to determine entitlement to DIC, VA
needs evidence showing:
• The cause of death, and
• that the cause of death was related to or
hastened by:
– a service-connected (SC) condition, or
– related to a disease or injury that existed
during active military service.
DIC Eligibility cont…
 2. DIC under 38 U.S.C. 1318
– DIC can be paid if a Veteran was in receipt of, or entitled to
receive, compensation for a totally disabling SC disability (to
include IU)
• for ten or more years immediately preceding death
• continuously for a period of not less than five years from
the date of separation from service until death, or
• for a period of not less than one year immediately
preceding death for a former prisoner of war who died
after September 30, 1999.
DIC Eligibility cont…
3. DIC under U.S.C. 1151
– DIC can be awarded if the Veteran’s death was
attributable to:
• hospital care, medical or surgical treatment, or
examination furnished the Veteran under any
law administered by the Secretary,
• participation in vocational rehabilitation
training under 38 U.S.C. Chapter 31, or
• participation in compensated work therapy
(CWT).
DIC Eligibility cont…
4. In Service Death
– All in-service death claims are processed initially
by the Philadelphia RO and Insurance Center
(ROIC).
Initial processing of a claim for DIC may begin
based on receipt of the following documents:
– DD Form 1300, Report of Casualty, or
– Interim DD Form 1300, and
– VA Form 21-534a, Application for Dependency
and Indemnity Compensation by a Surviving
Spouse or Child—In-Service Death Only
How do you access VA’s manual??
The VA has an internet based manual available for
you to review at any time – WARMS (Web
Automated Reference Material System):
http://www.benefits.va.gov/WARMS/Site_Map.asp
The Milwaukee
VA Pension Center
Staff and Employees
Thank You for Your
Cooperation and Service!
Questions