40832 Federal Register / Vol. 82, No. 165 / Monday, August 28, 2017 / Notices 

the amount submitted for payment is 

less than the amount billed, VA will 

accept the submission as payment, 

subject to verification at VA’s 

discretion. A VA employee having 

responsibility for collection of such 

charges may request that the third party 

payer submit evidence or information to 

substantiate the appropriateness of the 

payment amount (e.g., health plan 

policies, provider agreements, medical 

evidence, proof of payment to other 

providers demonstrating the amount 

paid for the same care and services VA 

provided). This information would be 

needed to determine whether the thirdparty payer has met the test of properly 

demonstrating its equivalent private 

sector provider payment amount for the 

same care or services and within the 

same geographic area as provided by 

VA. This form provides for requesting 

patient medical records, health plan 

policies, provider agreements and any 

type or records that provide evidence of 

medical services and proof of payments 

made to others for the same medical 

care and services. 

If VA accepts the submitted payment 

that is less than the billed charges, the 

third party payer can be subject to rate 

verification. In the event that rate 

verification is conducted, the results can 

be used to negotiate better rates, recoup 

underpayments, or amend agreements. 

Absent a third party payer agreement, 

VA should also be reimbursed billed 

charges or the amount third party payers 

would pay to non-government entities. 

Affected Public: Individuals and 

households. 

Estimated Annual Burden: 800 hours. 

Estimated Average Burden per 

Respondent: 120 minutes. 

Frequency of Response: Annually. 

Estimated Number of Respondents: 

400. 

By direction of the Secretary. 

Cynthia Harvey-Pryor, 

Department Clearance Officer Office of 

Quality and Compliance, Department of 

Veterans Affairs. 

[FR Doc. 2017–18158 Filed 8–25–17; 8:45 am] 

BILLING CODE 8320–01–P 

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. 

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 Brian.McCarthy4@

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: 

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 


asabaliauskas on DSKBBXCHB2PROD with NOTICES
Federal Register / Vol. 82, No. 165 / Monday, August 28, 2017 / Notices 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 

DEPARTMENT OF VETERANS 

AFFAIRS 

Geriatrics and Gerontology Advisory 

Committee; Notice of Meeting 

The Department of Veterans Affairs 

(VA) gives notice under the Federal 

Advisory Committee Act that a meeting 

of the Geriatrics and Gerontology 

Advisory Committee will be held on 

October 23–24, 2017 at the Department 

of Veterans Affairs, 810 Vermont 

Avenue NW., Washington, DC. On 

October 23rd, the session will be held 

in Room 730 and begin at 1:00 p.m. and 

end at 5 p.m. On October 24th, the 

session will be held in Room 630 and 

begin at 8 a.m. and end at 4:30 p.m. This 

meeting is open to the public. 

The purpose of the Committee is to 

provide advice to the Secretary of VA 

and the Under Secretary for Health on 

all matters pertaining to geriatrics and 

gerontology. The Committee assesses 

the capability of VA health care 

facilities and programs to meet the 

medical, psychological, and social 

needs of older Veterans and evaluates 

VA programs designated as Geriatric 

Research, Education, and Clinical 

Centers. 

The meeting will feature 

presentations and discussions on VA’s 

geriatrics and extended care programs, 

aging research activities, updates on 

VA’s employee staff working in the area 

of geriatrics (to include training, 

recruitment and retention approaches), 

Veterans Health Administration (VHA) 

strategic planning activities in geriatrics 

and extended care, recent VHA efforts 

regarding dementia and program 

advances in palliative care, and 

performance and oversight of VA 

Geriatric Research, Education, and 

Clinical Centers. 

No time will be allocated at this 

meeting for receiving oral presentations 

from the public. Interested parties 

should provide written comments for 

review by the Committee to Mrs. 

Alejandra Paulovich, Program Analyst, 

Geriatrics and Extended Care Services 

(10P4G), Department of Veterans 

Affairs, 810 Vermont Avenue NW., 

Washington, DC 20420, or via email at 

Alejandra.Paulovich@va.gov. 

Individuals who wish to attend the 

meeting should contact Mrs. Paulovich 

at (202) 461–6016. 

Dated: August 23, 2017. 

LaTonya L. Small, 

Federal Committee Management Officer. 

[FR Doc. 2017–18206 Filed 8–25–17; 8:45 am] 

BILLING CODE 8320–01–P 


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