English French Notes Complete/Exclude Elig. Code: Amt.: $ House Bound: Tot.Ann. VA Check Amt.: $ Amount Earned Annual Income (SPOUSE): Amount of Annual Social Security (SPOUSE): Type of other Annual Retirement (SPOUSE): Amount of other Annual Retirement (SPOUSE): Amount of other Annual Income (SPOUSE): Amount of Earned Annual Income (PAYEE): Amount Annual Soc. Sec. (PAYEE): Receiving Soc. Sec. (PAYEE): Other Annual Retirement (PAYEE): Amount Other Annual Income (PAYEE): ****** HINQ Upload/edit ****** Verification screen only Patient file BIRLS ONLY BIRLS/C&P NOT UPDATED HINQ Response ** BIRLS indicates Patient is deceased. ** VA Monetary Ben. Terminated - Means Test Required ** Man.ver. Not issued Pat. Type: Elig. Stat.: Vet. Y/N: Stat. Date: Disab. Ind.: Elig. code: WARNING: Error Indicators for .. Alert found. Screen HINQ Update . another request pending, alert cleared This patient data is being edited by another user Checking the alerts . . need more changes LOAD/EDIT Screen SC D HINQ has data not in patient file ` Patient file has data not in HINQ ` HINQ, Patient file are different ` Screen ( Do you wish to acknowledge inconsistencies and clear this Alert ? If the patient file has data that should not be updated by HINQ, this Alert can be acknowledged and cleared by entering 'Y'es. Otherwise, just continue Press RETURN to continue,'Y'es to acknowledge, '^' to exit: Alert will be cleared Alerts have been cleared 3-SC Disabilities 3+SC Disabilities Pension Disability 5?SC Combined % SC LESS THAN 2?Folder Location 5?VA Check/Net Award Entering a request in the HINQ suspense file... Checking alert data Clear corrected HINQ alerts Clearing corrected HINQ alerts No alerts cleared... IOINHI;IOINLOW;IOBON;IOBOFF Is this the patient to update (YES, NO, IGNORE, DISPLAY, ALERT)? YES// You are not processing an Alert, 'A'lert update and display not available. 'Y'es, Will continue with this patient 'N'o, Go next patient 'I'gnore, Patient will NOT appear in ALL option until reHINQ 'D'isplay will show you the HINQ mail message. 'A'lert, will update and display the Alert if processing alerts '^' to quit * This option will print out a report, identical to the mail * * messages, of the patients in the suspense file with a * * successful HINQ request. * BIRLS only response and the 'Diagnostic Verified Indicator' is NO. Verify SC at folder location: No updating allowed. Your version of MAS is NOT greater than 5.1, thus the Unemployable field is not in your patient file. No uploading of this field allowed. to CONTINUE, to QUIT, to update: HINQ data does NOT seem right. Data appears to be missing for Please re-HINQ for this patient. 30 days or greater DVBWCHK...This init should run after PIMS v5.3 is installed <> *** Updating DISABILITY CONDITION file (#31) per VA circular 21-95-2, dated Feb. 1, 1995 The Disability Condition file (31) update has finished. disability codes were added. 0-DAY LETTER Updating '0-DAY LETTER' in the EAS MT LETTER File (#713.3) According to our records you have not responded to our previous requests to complete the financial section of VA Form 10-10EZ, Application for Health Benefits. This is to inform you that your current financial assessment (means test) has expired. How Does This Affect Your Eligibility for Cost Free Care? o We do not have a current means test for you on file as is required to determine your eligibility for either cost-free care or reduced inpatient copayments. How Does This Affect Your Enrollment? o We are unable to determine your priority for enrollment in the VA health care system. What Do You Need To Do? o Complete, sign and return a new VA Form 10-10EZ, including the financial section. o Read the enclosed VA Form 4107VHA, Your Rights to Appeal our Decision. If you disagree with our decision, you or your representative may complete a Notice of Disagreement and return it to the Enrollment Coordinator or Health Benefits Advisor at your local VA health care What If You Have Questions? DGNEW( NOTE: An error occurred when updating the 0-DAY LETTER Please contact the VistA Help Desk. 30-DAY LETTER Updating '30-DAY LETTER' in the EAS MT LETTER File (#713.3) Each year VA requires most nonservice-connected veterans and 0% service- connected veterans to complete a financial assessment (means test). Our records show that your annual means test is due. As of this date we have not received the updated financial income information we requested in a previous letter. What Does This Mean To You? o An updated means test is needed to determine your ability to pay copayments for your medical care and medications and your priority for enrollment in the VA health care system. o Failure to complete the means test by the anniversary date will cause your priority for enrollment in the VA health care system to lapse. o Complete and sign the enclosed Financial Assessment portion of the enclosed VA Form 10-10EZ, Application for Health Benefits, reporting income and assets for the previous calendar year. o Return the completed and signed form in the enclosed envelope before your means test anniversary date. o When you report to your next health care appointment, bring your health insurance card so we may update your health insurance information. o Notify us if you feel you received this letter in error. 60-DAY LETTER Updating '60-DAY LETTER' in the EAS MT LETTER File (#713.3) o Complete and sign the Financial Assessment portion of the enclosed VA Form 10-10EZ, Application for Health Benefits, reporting income and assets for the previous calendar year. Pre-Installation Complete, the EAS MT Letters have been updated. *** Updating EAS MT LETTERS file(#713.3)*** *** Updating 0-DAY LETTER *** *** 0-DAY LETTER not updated *** *** Updating 30-DAY LETTER *** *** 30-DAY LETTER not updated *** *** Updating 60-DAY LETTER *** *** 60-DAY LETTER not updated *** Pre-scan for un-flagged 0-day letters? Pre-scan will provide the number of records which will have the 0-day Flag-to-Print flag set to 'YES' when this routine is run in the conversion mode. Enter 'YES' to pre-scan, 'NO' to convert the 0-day print flags Beginning scan for un-flagged 0-day letters records scanned will have the 0-day flag set to print SITE IS NOT A DCD PILOT SITE POST-INSTALLATION COMPLETE EAS*1*20 POST-INSTALL EAS*1*20 POST INSTALL TASK # QUEUED TO RUN PATCH EAS*1*22 POST INSTALL EAS MT LETTERS Post-Install was not tasked off Post-Install tasked: [ Post Install - EAS*1*22 G.EAS MTLETTERS PATCH EAS-1-22 Entries were removed from the EAS MT LETTER STATUS File (#713.2) which did not have a valid pointer to the EAS MT PATIENT STATUS File (#713.1). The entries removed were for the processing dates listed below. This is provided as information only. Date Processed Records Removed The following patients in the EAS MT PATIENT STATUS File (#713.1) do not have a corresponding entry in the EAS MT LETTER STATUS File (#713.2). You can try re-generating the Means Test Letter dates for these patients by running the REGEN procedure from the post-install routine by entering 'D REGEN^EAS122PT' at the programmer prompt. See the Patch Instructions for more details. Re-generate Means Test Letter Dates for patients identified in patch EAS*1*22 cleanup? - Patient Merge Cleanup Process - PATIENT MERGE CLEANUP EAS*1.0* : PATIENT MERGE CLEANUP - PROCESS STOPPED BY USER : PATIENT MERGE CLEANUP - SUMMARY REPORT EAS MT 30 DAY LETTER PRINT ** Adding a new entry to LTC CO-PAY EXEMPTION file (#714.1). LTC IS SERVICE RELATED - COMBAT VET ELIGIBLE already exists in file #714.1. not added to file #714.1 *** Updating LTC COPAY EXEMPTION (File #714.1) *** - Modifying entry #11 ERROR: Entry #11 not updated .01///LTC RELATED TO HOSPICE CARE - Modifying entry #2 ERROR: Entry #2 not updated .01///INCOME (LAST YEAR) BELOW LTC THRESHOLD - Adding entry #12 INCOME (CURRENT YEAR) BELOW LTC THRESHOLD The Post Install will now process through PATIENT (#2) file to determine User Enrollee status for each Veteran by checking inpatient/outpatient encounter for current fiscal year, any future appointments and any fee basis authorizations. EAS*1*25 USER ENROLLEE INITIAL DETERMINATION PROCESS User Enrollee initial determination process was completed in previous run. is currently running User Enrollee determination process. Duplicate process cannot be started. CURRENT IEN by the user. Please restart the process by using the following command at the programmer prompt: Post install process for initial User Enrollee determination is completed. GMTII - USER ENROLLEE INITIAL DETERMINATION PROCESS NAIK.CHINTAN@FORUM.VA.GOV Site Station number: Site Name: Process started at : Process completed at : Total Veterans processed : Total Veterans with UE status: PATIENT ADDRESS INQUIRY *** Address could not be determined *** *** No Address On File For This Patient *** Patient Address: UNKNOWN STREET ADDRESS UNKNOWN CITY UNKNOWN STATE Bad Address Indicator: Address Change Date: Address Change Source: Address Change Site: LEGALLY SEPARATED EXPENSE(408.21, Answer Yes or No where applicable (Otherwise provide the requested information) 3. Are You Eligible for Medicaid? |3A. Are You Enrolled in Medicare Part A (Hospital Insurance) |3B. Effective Date (If 4. Are You Enrolled in Medicare Part B (Medical Insurance) |4A. Effective Date (If |4B. Medicare Claim Number SECTION II - INSURANCE INFORMATION 5. Are You Covered By Health Insurance (including coverage through a spouse)? (If , provide the following information for all insurance company(s) providing coverage to you.) . Name of Insurance Company A. Address of Insurance Company B. Phone Number of Insurance Company C. Name of Policy Holder D. Relationship of Policy Holder E. Policy Number F. Group Name and/or Number SECTION III - SPOUSE/DEPENDENT INFORMATION 9. Current Marital Status 9B. Spouse Residing in the Community? |9C. Spouse's Social Security Number 9A. Spouse Residing in the Community? |9B. Spouse's Social Security Number A. Dependent's Date of Birth B. Dependent's Social Security Number C. Dependent Residing in the Community? We need to collect information regarding income, assets, and expenses for you and your spouse. If you do not wish to provide this information you must sign agreeing to make copayments and will be charged the maximum copayment amount for all services. See the top of page 2, read, sign, and date. I do not wish to provide my detailed financial information. I understand that I will be assessed the maximum copayment amount for extended care services and agree to pay the applicable VA copayment as required by law. Signature SECTION IV - FIXED ASSETS (VETERAN AND SPOUSE) 1. Residence (Market value minus any outstanding mortgage or lien - exclude if veteran receiving only non-institutional services or spouse or dependent residing in community). 2. Other Residences/Land/Farm or Ranch (Market value minus any outstanding mortgage or lien) 3. Vehicle(s)* (Value minus any outstanding lien - exclude if veteran is receiving only non-institutional services or spouse or dependent residing in community). | SUBTOTAL (Sum of lines 1 through 3) SECTION V - LIQUID ASSETS (VETERAN AND SPOUSE) 1. Cash, e.g., interest, dividends from IRA, 401K's and other tax deferred annuities (including checking, savings, money market, etc.) 2. Stocks, bonds, mutual funds, SEP's, and other retirement annuities, self-employed person) 3. Other Liquid Assets (Includes such items as stamp or coin collections, art work, collectibles household furniture and other household goods, clothing, jewelry, and personal items minus amount owed). #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################