[Federal Register Volume 81, Number 32 (Thursday, February 18, 2016)]
[Notices]
[Pages 8359-8360]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-03288]


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DEPARTMENT OF VETERANS AFFAIRS

[OMB Control No. 2900-0219]


Proposed Information Collection (Civilian Health and Medical 
Program of the Department of Veterans Affairs (CHAMPVA) Benefits--
Application, Claim, Other Health Insurance & Potential Liability); 
Activity: Comment Request

AGENCY: Veterans Health Administration, Department of Veterans Affairs.

ACTION: Notice.

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SUMMARY: The Veterans Health Administration (VHA) is announcing an 
opportunity for public comment on the proposed collection of certain 
information by the agency. Under the Paperwork Reduction Act (PRA) of 
1995, Federal agencies are required to publish notice in the Federal 
Register concerning each proposed collection of information, including 
each proposed revision of a currently approved collection, and allow 60 
days for public comment in response to the notice. This notice solicits 
comments on information needed to identify areas for improvement in 
clinical training programs.

DATES: Written comments and recommendations on the proposed collection 
of information should be received on or before April 18, 2016.

ADDRESSES: Submit written comments on the collection of information 
through the Federal Docket Management System (FDMS) at 
www.Regulations.gov; or to Brian McCarthy, Office of Regulatory and 
Administrative Affairs, Veterans Health Administration (10B4), 
Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 
20420 or email: [email protected]. Please refer to ``OMB Control 
No. 2900-0219'' in any correspondence. During the comment period, 
comments may be viewed online through FDMS.

FOR FURTHER INFORMATION CONTACT: Brian McCarthy at (202) 461-6345.

SUPPLEMENTARY INFORMATION: Under the PRA of 1995 (Pub. L. 104-13; 44 
U.S.C. 3501-3521), Federal agencies must obtain approval from OMB for 
each collection of information they conduct

[[Page 8360]]

or sponsor. This request for comment is being made pursuant to section 
3506(c)(2)(A) of the PRA.
    With respect to the following collection of information, VHA 
invites comments on: (1) Whether the proposed collection of information 
is necessary for the proper performance of VHA's functions, including 
whether the information will have practical utility; (2) the accuracy 
of VHA's estimate of the burden of the proposed collection of 
information; (3) ways to enhance the quality, utility, and clarity of 
the information to be collected; and (4) ways to minimize the burden of 
the collection of information on respondents, including through the use 
of automated collection techniques or the use of other forms of 
information technology.

Titles

1. VA Form 10-10d, Application for CHAMPVA Benefits
2. VA Form 10-7959a, CHAMPVA Claim Form
3. VA Form 10-7959c, CHAMPVA Other Health Insurance (OHI) Certification
4. VA Form 10-7959d, CHAMPVA Potential Liability Claim
5. VA Form 10-7959e, VA Claim for Miscellaneous Expenses
6. Payment (beneficially claims)
7. Review and Appeal Process
    OMB Control Number: 2900-0219.
    Type of Review: Revision of a currently approved collection.
    Abstracts:
    1. VA Form 10-10d, Application for CHAMPVA Benefits, is used to 
determine eligibility of persons applying for healthcare benefits under 
the CHAMPVA program in accordance with 38 U.S.C. 501 and 1781.
    2. VA Form 10-7959a, CHAMPVA Claim Form, is used to adjudicate 
claims for CHAMPVA benefits in accordance with 38 U.S.C. 501 and 1781, 
and 10 U.S.C. 1079 and 1086. This information is required for accurate 
adjudication and processing of beneficiary submitted claims. The claim 
form is also instrumental in the detection and prosecution of fraud. In 
addition, the claim form is the only mechanism to obtain, on an interim 
basis, other health insurance (OHI) information.
    3. Except for Medicaid and health insurance policies that are 
purchased exclusively for the purpose of supplementing CHAMPVA 
benefits, CHAMPVA is always the secondary payer of healthcare benefits 
(38 U.S.C. 501 and 1781, and 10 U.S.C. 1086). VA Form 10-7959c, 
CHAMPVA--Other Health Insurance (OHI) Certification, is used to 
systematically obtain OHI information and to correctly coordinate 
benefits among all liable parties.
    4. The Federal Medical Care Recovery Act (42 U.S.C. 2651-2653), 
mandates recovery of costs associated with healthcare services related 
to an injury/illness caused by a third party. VA Form 10-7959d, CHAMPVA 
Potential Liability Claim, provides basic information from which 
potential liability can be assessed. Additional authority includes 38 
U.S.C. 501; 38 CFR 1.900 et seq.; 10 U.S.C. 1079 and 1086; 42 U.S.C. 
2651-2653; and Executive Order 9397.
    5. VA Form 10-7959e, VA Claim for Miscellaneous Expenses, 
information collection is needed to carry out the health care programs 
for certain children of Korea and/or Vietnam veterans authorized under 
38 U.S.C., chapter 18, as amended by section 401, P.L. 106-419 and 
section 102, P.L. 108-183. VA's medical regulations 38 CFR part 17 
(17.900 through 17.905) establish regulations regarding provision of 
health care for certain children of Korea and Vietnam veterans and 
women Vietnam veterans' children born with spina bifida and certain 
other covered birth defects. These regulations also specify the 
information to be included in requests for preauthorization and claims 
from approved health care providers.
    6. Payment of Claims for Provision of Health Care for Certain 
Children of Korea and/or Vietnam Veterans (includes provider billing 
and VA Forms 10-7959e). This data collection is for the purpose of 
claiming payment/reimbursement of expenses related to spina bifida and 
certain covered birth defects. Beneficiaries utilize VA Form 10-7959e, 
VA Claim for Miscellaneous Expenses. Providers utilize provider 
generated billing statements and standard billing forms such as: 
Uniform Billing-Forms UB-04, and CMS 1500, Medicare Health Insurance 
Claims Form. VA would be unable to determine the correct amount to 
reimburse providers for their services or beneficiaries for covered 
expenses without the requested information. The information is 
instrumental in the timely and accurate processing of provider and 
beneficiary claims for reimbursement. The frequency of submissions is 
not determined by VA, but will determined by the provider or claimant 
and will be based on the volume of medical services and supplies 
provided to patients and claims for reimbursement are submitted 
individually or in batches.
    7. Review and Appeal Process Regarding Provision of Health Care or 
Payment Relating to Provision of Health Care for Certain Children of 
Korea and/or Vietnam Veterans. The provisions of 38 CFR 17.904 
establish a review process regarding disagreements by an eligible 
veteran's child or representative with a determination concerning 
provision of health care or a health care provider's disagreement with 
a determination regarding payment. The person or entity requesting 
reconsideration of such determination is required to submit such a 
request to the Chief Business Office Purchased Care (CBOPC) (Attention: 
Chief, Customer Service), in writing within one year of the date of 
initial determination. The request must state why the decision is in 
error and include any new and relevant information not previously 
considered. After reviewing the matter, a Customer Service Advisor 
issues a written determination to the person or entity seeking 
reconsideration. If such person or entity remains dissatisfied with the 
determination, the person or entity is permitted to submit within 90 
days of the date of the decision a written request for review by the 
Director, CBOPC.
    Affected Public: Individuals or households.
    Estimated Annual Burden:
    1. VA Form 10-10d--4,411 hours.
    2. VA Form 10-7959a--37,336 hours.
    3. VA Form 10-7959c--13,456 hours.
    4. VA Form 10-7959d--467 hours.
    5. VA Form 10-7959e--200 hours.
    6. Payment (beneficially claims)--500 hours.
    7. Review and Appeal Process--200 hours.
    Estimated Average Burden per Respondent:
    1. VA Form 10-10d--10 minutes.
    2. VA Form 10-7959a--10 minutes.
    3. VA Form 10-7959c--10 minutes.
    4. VA Form 10-7959d--7 minutes.
    5. VA Form 10-7959e--15 minutes.
    6. Payment (beneficially claims)--10 minutes.
    7. Review and Appeal Process--20 minutes.
    Frequency of Response: Annually.
    Estimated Annual Responses:
    1. VA Form 10-10d--26,468.
    2. VA Form 10-7959a--224,018.
    3. VA Form 10-7959c--80,733.
    4. VA Form 10-7959d--4,000.
    5. VA Form 10-7959e--800.
    6. Payment (beneficially claims)--3,000.
    7. Review and Appeal Process--600.

    By direction of the Secretary.
Kathleen M. Manwell,
Program Analyst, VA Privacy Service, Office of Privacy and Records 
Management, Department of Veterans Affairs.
[FR Doc. 2016-03288 Filed 2-17-16; 8:45 am]
 BILLING CODE 8320-01-P