Federal Register / Vol. 86, No. 105 / Thursday, June 3, 2021 / Notices 29883 

DEPARTMENT OF VETERANS 

AFFAIRS 

[OMB Control No. 2900–0219] 

Agency Information Collection 

Activity: CHAMPVA Benefits— 

Application, Claim, Other Health 

Insurance, Potential Liability & 

Miscellaneous Expenses 

AGENCY: Veterans Health 

Administration, Department of Veterans 

Affairs. 

ACTION: Notice. 

SUMMARY: Veterans Health 

Administration (VHA), Department of 

Veterans Affairs (VA), is announcing an 

opportunity for public comment on the 

proposed collection of certain 

information by the agency. Under the 

Paperwork Reduction Act (PRA) of 

1995, Federal agencies are required to 

publish notice in the Federal Register 

concerning each proposed collection of 

information, including each proposed 

extension of a currently approved 

collection, and allow 60 days for public 

comment in response to the notice. 

DATES: Written comments and 

recommendations on the proposed 

collection of information should be 

received on or before August 2, 2021. 

ADDRESSES: Submit written comments 

on the collection of information through 

Federal Docket Management System 

(FDMS) at www.Regulations.gov or to 

Janel Keyes, Office of Regulations, 

Appeals, and Policy (10BRAP), 

Department of Veterans Affairs, 810 

Vermont Avenue NW, Washington, DC 

20420 or email to Janel.Keyes@va.gov. 

Please refer to ‘‘OMB Control No. 2900– 

0219’’ in any correspondence. During 

the comment period, comments may be 

viewed online through FDMS. 

FOR FURTHER INFORMATION CONTACT: 

Maribel Aponte, Office of Enterprise 

and Integration, Data Governance 

Analytics (008), 1717 H Street NW, 

Washington, DC 20006, (202) 266–4688 

or email maribel.aponte@va.gov. Please 

refer to ‘‘OMB Control No. 2900–0219’’ 

in any correspondence. 

SUPPLEMENTARY INFORMATION: Under the 

PRA of 1995, Federal agencies must 

obtain approval from the Office of 

Management and Budget (OMB) for each 

collection of information they conduct 

or sponsor. This request for comment is 

being made pursuant to Section 

3506(c)(2)(A) of the PRA. 

With respect to the following 

collection of information, VHA invites 

comments on: (1) Whether the proposed 

collection of information is necessary 

for the proper performance of VHA’s 

functions, including whether the 

information will have practical utility; 

(2) the accuracy of VHA’s estimate of 

the burden of the proposed collection of 

information; (3) ways to enhance the 

quality, utility, and clarity of the 

information to be collected; and (4) 

ways to minimize the burden of the 

collection of information on 

respondents, including through the use 

of automated collection techniques or 

the use of other forms of information 

technology. 

Authority: Public Law 104–13; 44 

U.S.C. 3501–3521. 

Title: CHAMPVA Benefits— 

Application, Claim, Other Health 

Insurance, Potential Liability & 

Miscellaneous Expenses. 

OMB Control Number: 2900–0219. 

Type of Review: Reinstatement with 

change of a previously approved 

collection. 

Abstract 

This 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). 

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). 

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 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. 

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 chapter 51 of 38 U.S.C. or 

38 CFR 17.276 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. If such person 

or entity remains dissatisfied with the 

reconsideration determination, the 

person or entity is permitted to submit 

a written request for additional review. 

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 


khammond on DSKJM1Z7X2PROD with NOTICES
29884 Federal Register / Vol. 86, No. 105 / Thursday, June 3, 2021 / Notices 

Programs. The person requesting the 

services must submit medical 

documentation or applicable supporting 

material for review. 

Affected Public: Individuals and 

households. 

Estimated Annual Burden: 34,548 

total hours. 

VA Form 10–10d—8,963 hours. 

VA Form 10–7959a—9,167 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: 

180,142 total. 

VA Form 10–10d—53,775. 

VA Form 10–7959a—55,000. 

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. 

By direction of the Secretary. 

Maribel Aponte, 

VA PRA Clearance Officer, Office of 

Enterprise and Integration/Data Governance 

Analytics, Department of Veterans Affairs. 

[FR Doc. 2021–11618 Filed 6–2–21; 8:45 am] 

BILLING CODE 8320–01–P 

DEPARTMENT OF VETERANS 

AFFAIRS 

Solicitation of Nominations for 

Appointment to the Advisory 

Committee on Tribal and Indian Affairs, 

Amended 

ACTION: Notice. 

SUMMARY: The Department of Veterans 

Affairs (VA), Office of Public and 

Intergovernmental Affairs (OPIA), Office 

of Tribal Government Relations (OTGR), 

is seeking nominations of qualified 

candidates to be considered for 

appointment as a member of the 

Advisory Committee on Tribal and 

Indian Affairs (‘‘the Committee’’). 

DATES: Nominations for membership on 

the Committee must be received no later 

than 5:00 p.m. EST on June 16, 2021. 

ADDRESSES: All nomination packages 

(Application, should be mailed to the 

Office of Tribal Government Relations, 

810 Vermont Ave. NW, Suite 915H 

(075), Washington, DC 20420 or email 

us at tribalgovernmentconsultation@

va.gov. 

FOR FURTHER INFORMATION CONTACT: Ms. 

Stephanie Birdwell and David ‘‘Clay’’ 

Ward, Office of Tribal Government 

Relations, 810 Vermont Ave. NW, Ste 

915H (075), Washington, DC 20420, 

Telephone (202) 461–7400. A copy of 

the Committee charter can be obtained 

by contacting Mr. David ‘‘Clay’’ Ward or 

by accessing the website managed by 

OTGR at https://www.va.gov/TRIBAL

GOVERNMENT/index.asp. 

SUPPLEMENTARY INFORMATION: In 

carrying out the duties set forth, the 

Committee responsibilities include, but 

not limited to: (1) Identify for the 

Department evolving issues of relevance 

to Indian tribes, tribal organizations and 

Native American Veterans relating to 

programs and services of the 

Department; 

(2) Propose clarifications, 

recommendations and solutions to 

address issues raised at tribal, regional 

and national levels, especially regarding 

any tribal consultation reports; 

(3) Provide a forum for Indian tribes, 

tribal organizations, urban Indian 

organizations, Native Hawaiian 

organizations and the Department to 

discuss issues and proposals for changes 

to Department regulations, policies and 

procedures; 

(4) Identify priorities and provide 

advice on appropriate strategies for 

tribal consultation and urban Indian 

organizations conferring on issues at the 

tribal, regional, or national levels; 

(5) Ensure that pertinent issues are 

brought to the attention of Indian tribes, 

tribal organizations, urban Indian 

organizations and Native Hawaiian 

organizations in a timely manner, so 

that feedback can be obtained; 

(6) Encourage the Secretary to work 

with other Federal agencies and 

Congress so that Native American 

Veterans are not denied the full benefit 

of their status as both Native Americans 

and Veterans; 

(7) Highlight contributions of Native 

American Veterans in the Armed 

Forces; 

(8) Make recommendations on the 

consultation policy of the Department 

on tribal matters; 

(9) Support a process to develop an 

urban Indian organization confer policy 

to ensure the Secretary confers, to the 

maximum extent practicable, with 

urban Indian organizations; and 

(10) With the Secretary’s written 

approval, conduct other duties as 

recommended by the Committee. 

Authority: The Committee was 

established in accordance with section 

7002 of Public Law 116–315 (H.R. 

7105—Johnny Isakson and David P. Roe, 

M.D. Veterans Health Care and Benefits 

Improvement Act of 2020). In 

accordance with Public Law 116–315, 

the Committee provides advice and 

guidance to the Secretary of Veterans 

Affairs on all matters relating to Indian 

tribes, tribal organizations, Native 

Hawaiian organizations and Native 

American Veterans. The Committee 

serves in an advisory capacity and 

advises the Secretary on ways the 

Department can improve the programs 

and services of the Department to better 

serve Native American Veterans. 

Committee members make 

recommendations to the Secretary 

regarding such activities. 

Membership Criteria: OTGR is 

requesting nominations for upcoming 

vacancies on the Committee. The 

Committee will be composed of 15 

members. As required by statute, the 

members of the Committee are 

appointed by the Secretary from the 

general public, including: 

(1) At least one member of each of the 

12 service areas of the Indian Health 

Service is represented in the 

membership of the Committee 

nominated by Indian tribes or tribal 

organization. 

(2) At least one member of the 

Committee represents the Native 

Hawaiian Veteran community 

nominated by a Native Hawaiian 

Organization. 

(3) At least one member of the 

Committee represents urban Indian 

organizations nominated by a national 

urban Indian organization. 

(4) Not fewer than half of the 

members are Veterans, unless the 

Secretary determines that an insufficient 

number of qualified Veterans were 

nominated. 

(5) No member of the Committee may 

be an employee of the Federal 

Government. 

In accordance with Public Law 116– 

315, the Secretary determines the 

number and terms of service for 

members of the Committee, which are 

appointed by the Secretary, except that 

a term of service of any such member 

may not exceed a term of two years. 

Additionally, a member may be 

reappointed for one additional term at 

the Secretary’s discretion. 

Professional Qualifications: In 

addition to the criteria above, VA 

seeks— 

(1) Diversity in professional and 

personal qualifications; 


khammond on DSKJM1Z7X2PROD with NOTICES