[Federal Register Volume 82, Number 165 (Monday, August 28, 2017)]
[Notices]
[Pages 40832-40833]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-18159]


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DEPARTMENT OF VETERANS AFFAIRS

[OMB Control No. 2900-0219]


Agency Information Collection Activity: CHAMP VA Benefits--
Application, Claim, Other Health Insurance & Potential Liability

AGENCY: Veterans Health Administration, Department of Veterans Affairs.

ACTION: Notice.

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SUMMARY: Veterans Health Administration, 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 revision 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 October 27, 2017.

ADDRESSES: Submit written comments on the collection of information 
through Federal Docket Management System (FDMS) at www.Regulations.gov 
or to Brian McCarthy, Veterans Health Administration, Office of 
Regulatory and Administrative Affairs (10B4), Department of Veterans 
Affairs, 810 Vermont Avenue NW., Washington, DC 20420 or email to 
<a href="/cdn-cgi/l/email-protection#96d4e4fff7f8b8dbf5d5f7e4e2feefa2d6e0f7b8f1f9e0"><span class="__cf_email__" data-cfemail="ecae9e858d82c2a18faf8d9e988495d8ac9a8dc28b839a">[email protected]</span></a>. 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: Brian McCarthy at (202) 461-6345.

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: 38 U.S.C. Sections 501 and 1781, 10 U.S.C. Sections 1079 
and 1086, 42 U.S.C. Sections 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. Sections 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. Sections 
501 and 1781, and 10 U.S.C. Sections 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. Sections 501 and 1781, and 10 U.S.C. Section 
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. Section 501; 38 CFR 1.900 et seq.; 10 U.S.C. 
Sections 1079 and 1086; 42 U.S.C. Sections 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

[[Page 40833]]

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 request for review by the Director, CBOPC.

    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 and Compliance, 
Department of Veterans Affairs.
[FR Doc. 2017-18159 Filed 8-25-17; 8:45 am]
 BILLING CODE 8320-01-P


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