Federal Register / Vol. 83, No. 1 / Tuesday, January 2, 2018 / Notices 207 

DEPARTMENT OF VETERANS 

AFFAIRS 

[OMB Control No. 2900–0219] 

Agency Information Collection Activity 

Under OMB Review: CHAMP VA 

Benefits—Application, Claim, Other 

Health Insurance & Potential Liability 

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.harveypryor@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 


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208 Federal Register / Vol. 83, No. 1 / Tuesday, January 2, 2018 / Notices 

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 


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