86414 Federal Register / Vol. 89, No. 210 / Wednesday, October 30, 2024 / Notices 

5. Title: Records to be made and 

retained by financial institutions (31 

CFR 1010.410 and 31 CFR 1022.420). 

OMB Control Number: 1506–0058. 

Type of Review: Extension without 

change of a currently approved 

collection. 

Description: Each financial institution 

must retain an original or copy of 

records related to extensions of credit in 

excess of $10,000 (other than those 

secured by real property), and records 

related to transfers of funds, currency, 

other monetary instruments, checks, 

investment securities, or credit of more 

than $10,000 to or from the United 

States (31 CFR 1010.410(a) through (d)). 

Banks and non-bank financial 

institutions must also maintain records 

related to, and include certain 

information as part of, funds transfers or 

transmittals of funds involving more 

than $3,000 (31 CFR 1010.410(e) and 

(f)). 

In addition, under 31 CFR 1022.420, 

each provider or seller of prepaid access 

is required to maintain access to 

transactional records generated in the 

ordinary course of business that would 

be needed to reconstruct prepaid access 

activation, loads, reloads, purchases, 

withdrawals, transfers, or other prepaidrelated transactions. 

Form: None. 

Affected Public: Financial 

Institutions. 

Estimated Number of Respondents: 

273,832. 

Frequency of Response: On occasion. 

Estimated Total Number of Annual 

Responses: 320,352. 

Estimated Time per Response: Varies 

from 5 to 50 hours depending on 

requirement and type of institution. 

Estimated Total Annual Burden 

Hours: 4,015,839. 

6. Title: Additional Records to be 

Made and Retained by Banks (31 CFR 

1020.410). 

OMB Control Number: 1506–0059. 

Type of Review: Extension without 

change of a currently approved 

collection. 

Description: A bank must retain an 

original or copy of certain records, as 

specified in section 31 CFR 1020.410. 

Form: None. 

Affected Public: Banks. 

Estimated Number of Respondents: 

10,062. 

Frequency of Response: On occasion. 

Estimated Total Number of Annual 

Responses: 10,062. 

Estimated Time per Response: 100 

hours. 

Estimated Total Annual Burden 

Hours: 1,006,200. 

(Authority: 44 U.S.C. 3501 et seq.) 

Spencer W. Clark, 

Treasury PRA Clearance Officer. 

[FR Doc. 2024–25231 Filed 10–29–24; 8:45 am] 

BILLING CODE 4810–02–P 

DEPARTMENT OF VETERANS 

AFFAIRS 

[OMB Control No. 2900–0219] 

Agency Information Collection Activity 

Under OMB Review: CHAMPVA 

Benefits—Application, Claim, Other 

Health Insurance, Potential Liability & 

Miscellaneous Expenses 

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 (VHA), 

Department of Veterans Affairs (VA), 

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: Comments and 

recommendations for the proposed 

information collection should be sent by 

November 29, 2024. 

ADDRESSES: To submit comments and 

recommendations for the proposed 

information collection, please type the 

following link into your browser: 

www.reginfo.gov/public/do/PRAMain, 

select ‘‘Currently under Review—Open 

for Public Comments,’’ then search the 

list for the information collection by 

Title or ‘‘OMB Control No. 2900–0219.’’ 

FOR FURTHER INFORMATION CONTACT: VA 

PRA information: Maribel Aponte, 202– 

461–8900, vacopaperworkreduact@

va.gov. 

SUPPLEMENTARY INFORMATION: 

Title: CHAMPVA Benefits— 

Application, Claim, Other Health 

Insurance, Potential Liability & 

Miscellaneous Expenses. 

OMB Control Number: 2900–0219. 

https://www.reginfo.gov/public/do/ 

PRASearch. 

Type of Review: Revision of a 

currently approved collection. 

Abstract: The information collection 

includes several forms, as well as a 

review and appeal process, which are 

used to administer the Civilian Health 

And Medical Program of the Department 

of Veterans Affairs (CHAMPVA). The 

collection is revised to include an 

increase in burden hours based on 

program data that reflects an increase in 

claim submissions, OHI forms, appeals 

and clinical reviews due to increased 

enrollment. The collection also includes 

a portal for submission of the 

information in the 10–10d program 

application form, which is expected to 

be completed by the end of calendar 

year 2024. This portal will allow 

applicants to complete and submit VA 

Form 10–10d electronically rather than 

by submission of a hard copy form, 

which has been the standard application 

process prior to technological 

advancement allowing electronic 

submission and processing. This portal 

represents a separate avenue for 

applicants to submit VA Form 10–10d; 

however, it does not affect the burden 

of collection for applicants or VA. 

VA Form 10–10d: Application for 

CHAMPVA Benefits 

VA Form 10–7959a: CHAMPVA Claim 

Form 

VA Form 10–7959c: CHAMPVA Other 

Health Insurance (OHI) Certification 

VA Form 10–7959d: CHAMPVA 

Potential Liability Claim 

VA Form 10–7959e: VA Claim for 

Miscellaneous Expenses 

Review and Appeal Process 

Clinical Review 

a. 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. 

b. 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. 

c. 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. 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). 


ddrumheller on DSK120RN23PROD with NOTICES1
Federal Register / Vol. 89, No. 210 / Wednesday, October 30, 2024 / Notices 86415 

d. VA Form 10–7959d, CHAMPVA 

Potential Liability Claim, provides basic 

information from which potential third 

party liability can be assessed. 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. 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. 

e. VA Form 10–7959e, VA Claim for 

Miscellaneous Expenses, is used to 

adjudicate claims for certain children of 

Korea, Vietnam, and Thailand 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, Vietnam, and 

Thailand 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. 

f. Review and Appeal Process pertains 

to the approval of health care, or 

approval for payment relating to the 

provision of health care, under the 

Veteran Family Member Programs. The 

provisions of the Veterans Appeals 

Improvement and Modernization Act of 

2017 (AMA, Pub. L. 115–55), chapter 51 

of 38 U.S.C., or legacy claims under 38 

CFR 17.277 and 38 CFR 17.904 establish 

a review process regarding 

disagreements by an eligible beneficiary 

of a Veteran Family Member Program, 

provider, veteran, or other 

representative of the veteran or 

beneficiary, 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 in writing (including 

electronic where available). If such 

person or entity remains dissatisfied 

with the determination, the person or 

entity is permitted to submit a written 

request for additional review (VHA 

Notice 2024–07). 

g. Clinical Review pertains to the 

requirement of VHA to preauthorize 

certain medical services under 38 CFR 

17.273 and 38 CFR 17.902. Clinical 

review determines if services are 

medically necessary and appropriate to 

allow under the Veteran Family Member 

Programs. The person requesting the 

services must submit medical 

documentation or applicable supporting 

material for review. 

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 89 FR 

70692, August 30, 2024. 

Affected Public: Individuals or 

Households. 

Estimated Annual Burden: 37,867 

total hours. 

VA Form 10–10d—8,963 hours. 

VA Form 10–7959a—12,486 hours. 

VA Form 10–7959c—8,947 hours. 

VA Form 10–7959d—239 hours. 

VA Form 10–7959e—200 hours. 

Review and Appeal Process—6,255 

hours. 

Clinical Review—777 hours. 

Estimated Average Burden per 

Respondent: 

VA Form 10–10d—10 minutes. 

VA Form 10–7959a—10 minutes. 

VA Form 10–7959c—10 minutes. 

VA Form 10–7959d—7 minutes. 

VA Form 10–7959e—15 minutes. 

Review and Appeal Process—30 

minutes. 

Clinical Review—20 minutes. 

Frequency of Response: Once 

annually. 

Estimated Number of Respondents: 

200,056 total. 

VA Form 10–10d—53,775. 

VA Form 10–7959a—74,914. 

VA Form 10–7959c—53,680. 

VA Form 10–7959d—2,045. 

VA Form 10–7959e—800. 

Review and Appeal Process—12,510. 

Clinical Review—2,332. 

Authority: 44 U.S.C. 3501 et seq. 

Maribel Aponte, 

VA PRA Clearance Officer, Office of 

Enterprise and Integration, Data Governance 

Analytics, Department of Veterans Affairs. 

[FR Doc. 2024–24926 Filed 10–29–24; 8:45 am] 

BILLING CODE 8320–01–P 


ddrumheller on DSK120RN23PROD with NOTICES1