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###### Department of Veterans Affairs

          - [OMB Control No. 2900-0219]

# 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:

Comments must be submitted on or before February 1, 2018.

# 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                         *oira_submission@omb.eop.gov.*                         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                         *cynthia.harvey-pryor@va.gov.*                         Please refer to “OMB Control No. 2900-0219” in any correspondence.                    

# SUPPLEMENTARY INFORMATION:

*Authority:*38 U.S.C. 501 and 1781, 10 U.S.C. 1079 and 1086, 42 U.S.C. 2651, 2652 and 2653

*Title:*                     CHAMP VA Benefits—Application, Claim, Other Health Insurance & Potential Liability                

*OMB Control Number:*                     2900-0219.                

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

*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

8. Clinical Review

*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, 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                           ( print page 208)                        request for review by the Director, CBOPC.                

                    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 82 FR 40832 on August 28, 2017, page 40832.                

*Affected Public:*                     Individuals or households.                

*Estimated Annual Burden:*

1. VA Form 10-10d—7,000 hours.

2. VA Form 10-7959a—13,500 hours.

3. VA Form 10-7959c—16,666 hours.

4. VA Form 10-7959d—467 hours.

5. VA Form 10-7959e—1,350 hours.

6. Payment (beneficially claims)—183 hours.

7. Review and Appeal Process—6,577 hours.

8. Clinical Review—433 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—30 minutes.

8. Clinical Review—20 minutes.

*Frequency of Response:*                     Annually.                

*Estimated Annual Responses:*

1. VA Form 10-10d—42,000.

2. VA Form 10-7959a—81,000.

3. VA Form 10-7959c—100,000.

4. VA Form 10-7959d—4,000.

5. VA Form 10-7959e—5,400.

6. Payment (beneficially claims)—1,100.

7. Review and Appeal Process—13,154.

8. Clinical Review—1,300.

By direction of the Secretary.

Cynthia Harvey-Pryor,

Department Clearance Officer, Office of Quality, Privacy and Risk, Department of Veterans Affairs.

[FR Doc. 2017-28296 Filed 12-29-17; 8:45 am]

 BILLING CODE 8320-01-P