81 FR 21667 - Proposed Information Collection (Civilian Health And Medical Program of the Department of Veterans Affairs (CHAMPVA) Benefits-Application, Claim, Other Health Insurance & Potential Liability); Activity: Comment Request

DEPARTMENT OF VETERANS AFFAIRS

Federal Register Volume 81, Issue 70 (April 12, 2016)

Page Range		21667-21669
FR Document		2016-08348

The Veterans Health Administration (VHA) 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. This notice solicits comments on information needed to identify areas for improvement in clinical training programs.

Federal Register, Volume 81 Issue 70 (Tuesday, April 12, 2016)

[Federal Register Volume 81, Number 70 (Tuesday, April 12, 2016)]
[Notices]
[Pages 21667-21669]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2016-08348]


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DEPARTMENT OF VETERANS AFFAIRS

[OMB Control No. 2900-0219]


Proposed Information Collection (Civilian Health And Medical 
Program of the Department of Veterans Affairs (CHAMPVA) Benefits--
Application, Claim, Other Health Insurance & Potential Liability); 
Activity: Comment Request

AGENCY: Veterans Health Administration, Department of Veterans Affairs.

ACTION: Notice.

-----------------------------------------------------------------------

SUMMARY: The Veterans Health Administration (VHA) 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. This notice solicits 
comments on information needed to identify areas for improvement in 
clinical training programs.

DATES: Written comments and recommendations on the proposed collection 
of information should be received on or before June 13, 2016.

ADDRESSES: Submit written comments on the collection of information 
through the Federal Docket Management System

[[Page 21668]]

(FDMS) at www.Regulations.gov; or to Brian McCarthy, Office of 
Regulatory and Administrative Affairs, Veterans Health Administration 
(10B4), Department of Veterans Affairs, 810 Vermont Avenue NW., 
Washington, DC 20420 or email: [email protected]. 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 (Pub. L. 104-13; 44 
U.S.C. 3501-3521), Federal agencies must obtain approval from 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.
    For RIN 2900-AP09, the Notice of Proposed Rule Making (NPRM) 
package was not submitted to OMB for review at the time of publication 
of the NPRM.
    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

    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, P.L. 106-419 and 
section 102, P.L. 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--4,411 hours.
    2. VA Form 10-7959a--37,336 hours.
    3. VA Form 10-7959c--13,456 hours.
    4. VA Form 10-7959d--467 hours.
    5. VA Form 10-7959e--200 hours.
    6. Payment (beneficially claims)--500 hours.
    7. Review and Appeal Process--200 hours.

[[Page 21669]]

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--20 minutes.
    Frequency of Response: Annually.

Estimated Annual Responses

    1. VA Form 10-10d--26,468.
    2. VA Form 10-7959a--224,018.
    3. VA Form 10-7959c--80,733.
    4. VA Form 10-7959d--4,000.
    5. VA Form 10-7959e--800.
    6. Payment (beneficially claims)--3,000.
    7. Review and Appeal Process--600.

    By direction of the Secretary.
 Kathleen M. Manwell,
 Program Analyst, VA Privacy Service, Office of Privacy and Records 
Management, Department of Veterans Affairs.
[FR Doc. 2016-08348 Filed 4-11-16; 8:45 am]
 BILLING CODE 8320-01-P

Federal Register / Vol. 81, No. 70 / Tuesday, April 12, 2016 / Notices 21667

arrival, visitors will be required to Standards, 12 CFR part 30, Appendix B performance of the functions of the
present valid government-issued photo and part 170, Appendix B (collectively, OCC, including whether the information
identification and to submit to security Security Guidelines), which implement has practical utility;
screening in order to inspect and section 501(b), require each entity (b) The accuracy of the OCC’s
photocopy comments. supervised by the OCC (supervised estimate of the burden of the
All comments received, including institution) to consider and adopt a information collection;
attachments and other supporting response program, as appropriate, that (c) Ways to enhance the quality,
materials, are part of the public record specifies actions to be taken when the utility, and clarity of the information to
and subject to public disclosure. Do not supervised institution suspects or be collected;
include any information in your detects that unauthorized individuals (d) Ways to minimize the burden of
comment or supporting materials that have gained access to customer the collection on respondents, including
you consider confidential or information. through the use of automated collection
inappropriate for public disclosure. The Interagency Guidance on techniques or other forms of information
FOR FURTHER INFORMATION CONTACT: Response Programs for Unauthorized technology; and
Shaquita Merritt, OCC Clearance Customer Information and Customer (e) Estimates of capital or start-up
Officer, (202) 649–5490 or, for persons Notice (Breach Notice Guidance 1), costs and costs of operation,
who are deaf or hard of hearing, TTY, which interprets the Security maintenance, and purchase of services
(202) 649–5597, Legislative and Guidelines, states that, at a minimum, a to provide information.
Regulatory Activities Division, Office of supervised institution’s response
Dated: April 6, 2016.
the Comptroller of the Currency, 400 7th program should contain procedures for
the following: Mary Hoyle Gottlieb,
Street SW., Suite 3E–218, Mail Stop Regulatory Specialist, Legislative and
(1) Assessing the nature and scope of
9W–11, Washington, DC 20219. Regulatory Activities Division.
an incident, and identifying what
SUPPLEMENTARY INFORMATION: Under the customer information systems and types [FR Doc. 2016–08321 Filed 4–11–16; 8:45 am]
PRA (44 U.S.C. 3501–3520), Federal of customer information have been BILLING CODE 4810–33–P
agencies must obtain approval from the accessed or misused;
OMB for each collection of information (2) Notifying its primary Federal
they conduct or sponsor. ‘‘Collection of regulator as soon as possible when the DEPARTMENT OF VETERANS
information’’ is defined in 44 U.S.C. supervised institution becomes aware of AFFAIRS
3502(3) and 5 CFR 1320.3(c) to include an incident involving unauthorized
agency requests or requirements that access to, or use of, sensitive customer [OMB Control No. 2900–0219]
members of the public submit reports, information;
keep records, or provide information to (3) Consistent with the OCC’s Proposed Information Collection
a third party. Section 3506(c)(2)(A) of Suspicious Activity Report regulations, (Civilian Health And Medical Program
the PRA (44 U.S.C. 3506(c)(2)(A)) notifying appropriate law enforcement of the Department of Veterans Affairs
requires Federal agencies to provide a authorities and filing a timely SAR in (CHAMPVA) Benefits—Application,
60-day notice in the Federal Register situations in which a Federal criminal Claim, Other Health Insurance &
concerning each proposed collection of violation requires immediate attention, Potential Liability); Activity: Comment
information, including each proposed such as when a reportable violation is Request
extension of an existing collection of ongoing; AGENCY: Veterans Health
information, before submitting the (4) Taking appropriate steps to Administration, Department of Veterans
collection to OMB for approval. To contain and control the incident in an Affairs.
comply with this requirement, the OCC effort to prevent further unauthorized
access to, or use of, customer ACTION: Notice.
is publishing notice of the proposed
collection of information set forth in information, for example, by SUMMARY: The Veterans Health
this document. monitoring, freezing, or closing affected Administration (VHA) is announcing an
The OCC is proposing to extend, with accounts, while preserving records and opportunity for public comment on the
revision, the approval of the following other evidence; and proposed collection of certain
information collection: (5) Notifying customers as warranted.
This collection of information covers information by the agency. Under the
Title: Notice Regarding Unauthorized Paperwork Reduction Act (PRA) of
Access to Customer Information. the notice provisions in the Breach
Notice Guidance. 1995, Federal agencies are required to
OMB Control No.: 1557–0227. publish notice in the Federal Register
Description: Section 501(b) of the Type of Review: Regular.
Affected Public: Businesses or other concerning each proposed collection of
Gramm-Leach-Bliley Act (15 U.S.C. information, including each proposed
6801) requires the OCC to establish for-profit.
Estimated Number of Respondents: revision of a currently approved
appropriate standards for national banks collection, and allow 60 days for public
20.
relating to administrative, technical, and Total Estimated Annual Burden: 720 comment in response to the notice. This
physical safeguards: (1) To insure the hours. notice solicits comments on information
security and confidentiality of customer Frequency of Response: On occasion. needed to identify areas for
records and information; (2) to protect Comments submitted in response to improvement in clinical training
against any anticipated threats or
asabaliauskas on DSK3SPTVN1PROD with NOTICES

this notice will be summarized and programs.
hazards to the security or integrity of included in the request for OMB
such records; and (3) to protect against DATES: Written comments and
approval. All comments will become a
unauthorized access to, or use of, such matter of public record. Comments are recommendations on the proposed
records or information that could result invited on: collection of information should be
in substantial harm or inconvenience to (a) Whether the collection of received on or before June 13, 2016.
any customer. information is necessary for the proper ADDRESSES: Submit written comments
The Interagency Guidelines on the collection of information through
Establishing Information Security 1 12 CFR part 30, Appendix B, Supplement A. the Federal Docket Management System

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21668 Federal Register / Vol. 81, No. 70 / Tuesday, April 12, 2016 / Notices

(FDMS) at www.Regulations.gov; or to 2. VA Form 10–7959a, CHAMPVA Expenses. Providers utilize provider
Brian McCarthy, Office of Regulatory Claim Form, is used to adjudicate generated billing statements and
and Administrative Affairs, Veterans claims for CHAMPVA benefits in standard billing forms such as: Uniform
Health Administration (10B4), accordance with 38 U.S.C. 501 and Billing-Forms UB–04, and CMS 1500,
Department of Veterans Affairs, 810 1781, and 10 U.S.C. 1079 and 1086. This Medicare Health Insurance Claims
Vermont Avenue NW., Washington, DC information is required for accurate Form. VA would be unable to determine
20420 or email: Brian.McCarthy4@ adjudication and processing of the correct amount to reimburse
va.gov. Please refer to ‘‘OMB Control beneficiary submitted claims. The claim providers for their services or
No. 2900–0219’’ in any correspondence. form is also instrumental in the beneficiaries for covered expenses
During the comment period, comments detection and prosecution of fraud. In without the requested information. The
may be viewed online through FDMS. addition, the claim form is the only information is instrumental in the
FOR FURTHER INFORMATION CONTACT: mechanism to obtain, on an interim timely and accurate processing of
Brian McCarthy at (202) 461–6345. basis, other health insurance (OHI) provider and beneficiary claims for
information. reimbursement. The frequency of
SUPPLEMENTARY INFORMATION: Under the
3. Except for Medicaid and health submissions is not determined by VA,
PRA of 1995 (Pub. L. 104–13; 44 U.S.C.
insurance policies that are purchased but will determined by the provider or
3501–3521), Federal agencies must exclusively for the purpose of
obtain approval from OMB for each claimant and will be based on the
supplementing CHAMPVA benefits, volume of medical services and supplies
collection of information they conduct CHAMPVA is always the secondary
or sponsor. This request for comment is provided to patients and claims for
payer of healthcare benefits (38 U.S.C. reimbursement are submitted
being made pursuant to section 501 and 1781, and 10 U.S.C. 1086). VA
3506(c)(2)(A) of the PRA. individually or in batches.
Form 10–7959c, CHAMPVA—Other
With respect to the following 7. Review and Appeal Process
Health Insurance (OHI) Certification, is
collection of information, VHA invites used to systematically obtain OHI Regarding Provision of Health Care or
comments on: (1) Whether the proposed information and to correctly coordinate Payment Relating to Provision of Health
collection of information is necessary benefits among all liable parties. Care for Certain Children of Korea and/
for the proper performance of VHA’s 4. The Federal Medical Care Recovery or Vietnam Veterans. The provisions of
functions, including whether the Act (42 U.S.C. 2651–2653), mandates 38 CFR 17.904 establish a review
information will have practical utility; recovery of costs associated with process regarding disagreements by an
(2) the accuracy of VHA’s estimate of healthcare services related to an injury/ eligible veteran’s child or representative
the burden of the proposed collection of illness caused by a third party. VA Form with a determination concerning
information; (3) ways to enhance the 10–7959d, CHAMPVA Potential provision of health care or a health care
quality, utility, and clarity of the Liability Claim, provides basic provider’s disagreement with a
information to be collected; and (4) information from which potential determination regarding payment. The
ways to minimize the burden of the liability can be assessed. Additional person or entity requesting
collection of information on authority includes 38 U.S.C. 501; 38 reconsideration of such determination is
respondents, including through the use CFR 1.900 et seq.; 10 U.S.C. 1079 and required to submit such a request to the
of automated collection techniques or 1086; 42 U.S.C. 2651–2653; and Chief Business Office Purchased Care
the use of other forms of information Executive Order 9397. (CBOPC) (Attention: Chief, Customer
technology. 5. VA Form 10–7959e, VA Claim for Service), in writing within one year of
For RIN 2900–AP09, the Notice of Miscellaneous Expenses, information the date of initial determination. The
Proposed Rule Making (NPRM) package collection is needed to carry out the request must state why the decision is
was not submitted to OMB for review at health care programs for certain in error and include any new and
the time of publication of the NPRM. children of Korea and/or Vietnam relevant information not previously
Titles: veterans authorized under 38 U.S.C., considered. After reviewing the matter,
1. VA Form 10–10d, Application for chapter 18, as amended by section 401, a Customer Service Advisor issues a
CHAMPVA Benefits P.L. 106–419 and section 102, P.L. 108– written determination to the person or
2. VA Form 10–7959a, CHAMPVA 183. VA’s medical regulations 38 CFR entity seeking reconsideration. If such
Claim Form part 17 (17.900 through 17.905) person or entity remains dissatisfied
3. VA Form 10–7959c, CHAMPVA establish regulations regarding with the determination, the person or
Other Health Insurance (OHI) provision of health care for certain entity is permitted to submit within 90
Certification children of Korea and Vietnam veterans days of the date of the decision a written
4. VA Form 10–7959d, CHAMPVA and women Vietnam veterans’ children request for review by the Director,
Potential Liability Claim born with spina bifida and certain other CBOPC.
5. VA Form 10–7959e, VA Claim for covered birth defects. These regulations Affected Public: Individuals or
Miscellaneous Expenses also specify the information to be households.
6. Payment (beneficially claims) included in requests for
7. Review and Appeal Process preauthorization and claims from Estimated Annual Burden
OMB Control Number: 2900–0219. approved health care providers. 1. VA Form 10–10d—4,411 hours.
Type of Review: Revision of a 6. Payment of Claims for Provision of
Health Care for Certain Children of 2. VA Form 10–7959a—37,336 hours.
asabaliauskas on DSK3SPTVN1PROD with NOTICES

currently approved collection.
Korea and/or Vietnam Veterans 3. VA Form 10–7959c—13,456 hours.
Abstracts (includes provider billing and VA 4. VA Form 10–7959d—467 hours.
1. VA Form 10–10d, Application for Forms 10–7959e). This data collection is
5. VA Form 10–7959e—200 hours.
CHAMPVA Benefits, is used to for the purpose of claiming payment/
determine eligibility of persons reimbursement of expenses related to 6. Payment (beneficially claims)—500
applying for healthcare benefits under spina bifida and certain covered birth hours.
the CHAMPVA program in accordance defects. Beneficiaries utilize VA Form 7. Review and Appeal Process—200
with 38 U.S.C. 501 and 1781. 10–7959e, VA Claim for Miscellaneous hours.

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$Federal Register / Vol. 81, No. 70 / Tuesday, April 12, 2016 / Notices 21669 Estimated Average Burden Per 7. Review and Appeal Process—20 6. Payment (beneficially claims)— Respondent minutes. 3,000. Frequency of Response: Annually. 7. Review and Appeal Process—600. 1. VA Form 10–10d—10 minutes. Estimated Annual Responses By direction of the Secretary. 2. VA Form 10–7959a—10 minutes. Kathleen M. Manwell, 3. VA Form 10–7959c—10 minutes. 1. VA Form 10–10d—26,468. Program Analyst, VA Privacy Service, Office 4. VA Form 10–7959d—7 minutes. 2. VA Form 10–7959a—224,018. of Privacy and Records Management, 5. VA Form 10–7959e—15 minutes. 3. VA Form 10–7959c—80,733. Department of Veterans Affairs. 6. Payment (beneficially claims)—10 4. VA Form 10–7959d—4,000. [FR Doc. 2016–08348 Filed 4–11–16; 8:45 am] minutes. 5. VA Form 10–7959e—800. BILLING CODE 8320–01–P asabaliauskas on DSK3SPTVN1PROD with NOTICES VerDate Sep<11>2014 17:18 Apr 11, 2016 Jkt 238001 PO 00000 Frm 00137 Fmt 4703 Sfmt 9990 E:\FR\FM\12APN1.SGM 12APN1$

Document Created: 2016-04-12 00:46:39
Document Modified: 2016-04-12 00:46:39

Category		Regulatory Information
Collection		Federal Register
sudoc Class		AE 2.7: GS 4.107: AE 2.106:
Publisher		Office of the Federal Register, National Archives and Records Administration
Section		Notices
Action		Notice.
Dates		Written comments and recommendations on the proposed collection of information should be received on or before June 13, 2016.
Contact		Brian McCarthy at (202) 461-6345.
FR Citation		81 FR 21667