[Federal Register Volume 81, Number 129 (Wednesday, July 6, 2016)]
[Notices]
[Pages 44096-44097]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-15983]



[[Page 44096]]

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DEPARTMENT OF VETERANS AFFAIRS

[OMB Control No. 2900-0219]


Agency 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: In compliance with the Paperwork Reduction Act (PRA) of 1995 
(44 U.S.C. 3501-3521), this notice announces that the Veterans Health 
Administration (VHA), Department of Veterans Affairs, will submit the 
collection of information abstracted below to the Office of Management 
and Budget (OMB) for review and comment. The PRA submission describes 
the nature of the information collection and its expected cost and 
burden; it includes the actual data collection instrument.

DATES: Comments must be submitted on or before August 5, 2016.

ADDRESSES: Submit written comments on the collection of information 
through www.Regulations.gov, or to Office of Information and Regulatory 
Affairs, Office of Management and Budget, Attn: VA Desk Officer; 725 
17th St. NW., Washington, DC 20503 or sent through electronic mail to 
[email protected]. Please refer to ``OMB Control No. 2900-
0219'' in any correspondence.

FOR FURTHER INFORMATION CONTACT: Cynthia Harvey-Pryor, Enterprise 
Records Service (005R1B), Department of Veterans Affairs, 810 Vermont 
Avenue NW., Washington, DC 20420, (202) 461-5870 or email 
[email protected]. Please refer to ``OMB Control No. 2900-
0219.''

SUPPLEMENTARY INFORMATION: 
    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.
    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. Sections 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. Sections 
501 and 1781, and 10 U.S.C. Sections 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. Sections 501 and 1781, and 10 U.S.C. Section 
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. Section 501; 38 CFR 1.900 et seq.; 10 U.S.C. 
Sections 1079 and 1086; 42 U.S.C. Sections 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, 
Public Law 106-419 and section 102, Public Law 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--206 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--824.
    6. Payment (beneficially claims)--3,000.

[[Page 44097]]

    7. Review and Appeal Process--600.

    By direction of the Secretary.
Kathleen Manwell,
Program Analyst, VA Privacy Service, Office of Privacy and Records 
Management, Department of Veterans Affairs.
[FR Doc. 2016-15983 Filed 7-5-16; 8:45 am]
 BILLING CODE 8320-01-P