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###### Department of Veterans Affairs

          - [OMB Control No. 2900-0823]

# AGENCY:

Veterans Health Administration, Department of Veterans Affairs.

# ACTION:

Notice.

# SUMMARY:

In compliance with the Paperwork Reduction Act (PRA) of 1995, this notice announces that the Veterans Health Administration, 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, and it includes the actual data collection instrument.

# DATES:

                        Written comments and recommendations for the proposed information collection should be sent within 30 days of publication of this notice to                         *www.reginfo.gov/​public/​do/​PRAMain.*                         Find this particular information collection by selecting “Currently under 30-day Review—Open for Public Comments” or by using the search function. Refer to “OMB Control No. 2900-0823.”                    

# FOR FURTHER INFORMATION CONTACT:

                        Danny S. Green, Office of Quality, Performance and Risk (OQPR), Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420, (202) 421-1354 or email                         *danny.green2@va.gov*                         Please refer to “OMB Control No. 2900-0823” in any correspondence.                    

# SUPPLEMENTARY INFORMATION:

*Authority:*44 U.S.C. 3501-21.                

*Title:*                     Expanded Access to Non-VA Care through the MISSION Act: Veterans Community Care Program (VA Forms 10-10143, 10-10143a, 10-10143b, 10-10143c, 10-10143e, 10-10143f and 10-10143g).                

*OMB Control Number:*                     2900-0823.                

*Type of Review:*                     Revision and extension of a currently approved collection.                

*Abstract:*                     Section 101 of the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 requires VA to implement the Veterans Community Care Program to furnish care in the community to covered Veterans through eligible entities and providers, under circumstances as further prescribed in the MISSION Act. VA currently collects information that will be required to implement the Veterans Community Care Program (VCCP) under the Veterans Choice Program, through an OMB approved collection 2900-0823.                

OMB Collection 2900-0823 now includes VA Form 10-10143, Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Community Care Program; VA Form 10-10143a, Veterans Community Care Health Insurance Certification; VA Form 10-10143b, Submission of Medical Record Information under the Veterans Community Care Program; VA Form 10-10143c, Submission of Information on Credentials and Licenses by Eligible Entities and Providers; and VA Form 10-10143e, Secondary Authorization Request for VA Community Care. In addition, two new forms that received emergency PRA clearances from OMB in 2020 are included in 2900-0823: VA Form 10-10143f, Community Care Document Cover Sheet; and VA Form 10-10143g, Non-VA Hospital Emergency Notification.

VA seeks to update OMB collection 2900-0823 to implement the Veterans Community Care Program by updating the title of VA forms and any associated statutory citations to be consistent with the new program and the MISSION Act, by adding a new cover sheet to use when submitting documentation from providers of non-VA emergent care, by adding a new 72-hour notification form to be used when a Veteran receives emergent care from a non-VA provider, and by updating burden hours to account for estimated increased use of community care under the new program.

This collection of information is required to properly adjudicate and implement the requirements of the MISSION Act.

a. VA Form 10-10143 will collect Veteran information on whether covered Veterans would elect to receive authorized care under the Veterans Community Care Program (VCCP) if certain conditions are met, as required by 38 U.S.C. 1703(d)(3). This form also will allow a covered Veteran to specify a particular non-VA entity or provider.

                    b. VA Form 10-10143a will collect other health insurance information from covered Veterans who elect to participate in the VCCP, as required by 38 U.S.C. 1705A. This information also is required by 38 U.S.C. 1703(j), which requires VA to recover or collect reasonable charges for community care that is furnished from a health care plan contract described in 38 U.S.C. 1729.                          ( print page 77488)    

c. VA Form 10-10143b will collect health records of covered Veterans from non-VA health care entities and providers for care authorized under the VCCP, as required by 38 U.S.C. 1703(a)(2)(A), which requires VA to establish a mechanism to receive medical records from non-VA providers. A copy of all medical and dental records (including but not limited to images, test results, and notes or other records of what care was provided and why) related to a Veteran's care provided under the VCCP must be submitted to VA, including any claims for payment for the furnishing of such care.

d. VA Form 10-10143c will collect information from non-VA entities and providers concerning relevant credentials and licenses as required for such entities or providers to furnish care and services generally. This information is authorized by section 133 of the MISSION Act, which requires VA to establish competency standards for non-VA providers, as well as 38 U.S.C. 1703C(a)(1), which requires VA to establish certain standards of quality for furnishing care and services (including through non-VA providers).

e. VA Form 10-10143e will collect secondary authorization requests from non-VA entities and providers to furnish care and services in addition to or supporting the original authorization for care. This information is required by 38 U.S.C. 1703(a)(3), which establishes that a covered Veteran may only receive care or services under the VCCP upon VA's authorization of such care or services.

f. VA Form 10-10143f will allow for the submission of paper documents in support of a non-VA provider claim for emergency care rendered in the community when not accompanied by a paper Health Care Claim form. This Community Care Document Cover Sheet will be used exclusively for the submission of medical documentation for unauthorized emergent services for patients otherwise covered by VA.

g. VA Form 10-10143g will be used to provide 72-hour notification to VA when a Veteran receives emergent care from a non-VA provider. This form should be completed by the non-VA provider within 72 hours of the beginning of treatment.

                    An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The                     **Federal Register**                     Notice with a 60-day comment period soliciting comments on this collection of information was published at 85 FR 158 on August 14, 2020, pages 49720 and 49721.                

## VA Form 10-10143

*Affected Public:*                     Individuals or households.                

*Estimated Annual Burden:*                     610,833 hours.                

*Estimated Average Burden per Respondent:*                     10 minutes.                

*Frequency of Response:*                     Once annually.                

*Estimated Number of Respondents:*                     3,665,000.                

## VA Form 10-10143a

*Affected Public:*                     Individuals or households.                

*Estimated Annual Burden:*                     610,833 hours.                

*Estimated Average Burden per Respondent:*                     10 minutes.                

*Frequency of Response:*                     Once annually.                

*Estimated Number of Respondents:*                     3,665,000.                

## VA Form 10-10143b

*Affected Public:*                     Private Sector.                

*Estimated Annual Burden:*                     1,039,332 hours.                

*Estimated Average Burden per Respondent:*                     5 minutes.                

*Frequency of Response:*                     Average of 34 times annually.                

*Estimated Number of Respondents:*                     366,823.                

## VA Form 10-10143c

*Affected Public:*                     Private Sector.                

*Estimated Annual Burden:*                     10,190 hours.                

*Estimated Average Burden per Respondent:*                     5 minutes.                

*Frequency of Response:*                     Once annually.                

*Estimated Number of Respondents:*                     122,274.                

## VA Form 10-10143e

*Affected Public:*                     Private Sector.                

*Estimated Annual Burden:*                     611,372 hours.                

*Estimated Average Burden per Respondent:*                     20 minutes.                

*Frequency of Response:*                     Average of 5 times annually.                

*Estimated Number of Respondents:*                     366,823.                

## VA Form 10-10143f

*Affected Public:*                     Private Sector.                

*Estimated Annual Burden:*                     41,667 hours.                

*Estimated Average Burden per Respondent:*                     5 minutes.                

*Frequency of Response:*                     Once annually.                

*Estimated Number of Respondents:*                     500,000.                

## VA Form 10-10143g

*Affected Public:*                     Private Sector.                

*Estimated Annual Burden:*                     83,333 hours.                

*Estimated Average Burden per Respondent:*                     10 minutes.                

*Frequency of Response:*                     Once annually.                

*Estimated Number of Respondents:*                     500,000.                

By direction of the Secretary.

Danny S. Green,

Interim VA Clearance Officer, Office of Quality, Performance and Risk (OQPR), Department of Veterans Affairs.

[FR Doc. 2020-26575 Filed 12-1-20; 8:45 am]

BILLING CODE 8320-01-P