81 FR 44096 - Agency Information Collection: (Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) Benefits-Application, Claim, Other Health Insurance & Potential Liability)
DEPARTMENT OF VETERANS AFFAIRS Federal Register Volume 81, Issue 129 (July 6, 2016)
Federal Register Volume 81, Issue 129 (July 6, 2016)
| Page Range | 44096-44097 | |
| FR Document | 2016-15983 |
[Federal Register Volume 81, Number 129 (Wednesday, July 6, 2016)] [Notices] [Pages 44096-44097] From the Federal Register Online [www.thefederalregister.org] [FR Doc No: 2016-15983] [[Page 44096]] ----------------------------------------------------------------------- DEPARTMENT OF VETERANS AFFAIRS [OMB Control No. 2900-0219] Agency 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: In compliance with the Paperwork Reduction Act (PRA) of 1995 (44 U.S.C. 3501-3521), this notice announces that the Veterans Health Administration (VHA), 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; it includes the actual data collection instrument. DATES: Comments must be submitted on or before August 5, 2016. 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 [email protected]. 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 [email protected]. Please refer to ``OMB Control No. 2900- 0219.'' SUPPLEMENTARY INFORMATION: 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. 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 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--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--206 hours. 6. Payment (beneficially claims)--500 hours. 7. Review and Appeal Process--200 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--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--824. 6. Payment (beneficially claims)--3,000. [[Page 44097]] 7. Review and Appeal Process--600. By direction of the Secretary. Kathleen Manwell, Program Analyst, VA Privacy Service, Office of Privacy and Records Management, Department of Veterans Affairs. [FR Doc. 2016-15983 Filed 7-5-16; 8:45 am] BILLING CODE 8320-01-P
![44096 Federal Register / Vol. 81, No. 129 / Wednesday, July 6, 2016 / Notices
DEPARTMENT OF VETERANS Type of Review: Revision. providers for their services or beneficiaries
AFFAIRS Abstracts: for covered expenses without the requested
information. The information is instrumental
[OMB Control No. 2900–0219] 1. VA Form 10–10d, Application for in the timely and accurate processing of
CHAMPVA Benefits, is used to determine provider and beneficiary claims for
Agency Information Collection: eligibility of persons applying for healthcare reimbursement. The frequency of
benefits under the CHAMPVA program in submissions is not determined by VA, but
(Civilian Health and Medical Program accordance with 38 U.S.C. Sections 501 and
of the Department of Veterans Affairs will determined by the provider or claimant
1781.
(CHAMPVA) Benefits—Application, and will be based on the volume of medical
2. VA Form 10–7959a, CHAMPVA Claim
Claim, Other Health Insurance & services and supplies provided to patients
Form, is used to adjudicate claims for
and claims for reimbursement are submitted
Potential Liability) CHAMPVA benefits in accordance with 38
individually or in batches.
U.S.C. Sections 501 and 1781, and 10 U.S.C.
Activity: Comment Request. 7. Review and Appeal Process Regarding
Sections 1079 and 1086. This information is
Provision of Health Care or Payment Relating
AGENCY: Veterans Health required for accurate adjudication and
to Provision of Health Care for Certain
Administration, Department of Veterans processing of beneficiary submitted claims.
Children of Korea and/or Vietnam Veterans.
Affairs. The claim form is also instrumental in the
detection and prosecution of fraud. In The provisions of 38 CFR 17.904 establish a
ACTION: Notice. addition, the claim form is the only review process regarding disagreements by
mechanism to obtain, on an interim basis, an eligible veteran’s child or representative
SUMMARY: In compliance with the other health insurance (OHI) information. with a determination concerning provision of
Paperwork Reduction Act (PRA) of 1995 3. Except for Medicaid and health health care or a health care provider’s
(44 U.S.C. 3501–3521), this notice insurance policies that are purchased disagreement with a determination regarding
announces that the Veterans Health exclusively for the purpose of supplementing payment. The person or entity requesting
CHAMPVA benefits, CHAMPVA is always reconsideration of such determination is
Administration (VHA), Department of
the secondary payer of healthcare benefits required to submit such a request to the Chief
Veterans Affairs, will submit the Business Office Purchased Care (CBOPC)
collection of information abstracted (38 U.S.C. Sections 501 and 1781, and 10
U.S.C. Section 1086). VA Form 10–7959c, (Attention: Chief, Customer Service), in
below to the Office of Management and writing within one year of the date of initial
CHAMPVA—Other Health Insurance (OHI)
Budget (OMB) for review and comment. Certification, is used to systematically obtain determination. The request must state why
The PRA submission describes the OHI information and to correctly coordinate the decision is in error and include any new
nature of the information collection and benefits among all liable parties. and relevant information not previously
its expected cost and burden; it includes 4. The Federal Medical Care Recovery Act considered. After reviewing the matter, a
the actual data collection instrument. (42 U.S.C. 2651–2653), mandates recovery of Customer Service Advisor issues a written
costs associated with healthcare services determination to the person or entity seeking
DATES: Comments must be submitted on reconsideration. If such person or entity
related to an injury/illness caused by a third
or before August 5, 2016. party. VA Form 10–7959d, CHAMPVA remains dissatisfied with the determination,
ADDRESSES: Submit written comments Potential Liability Claim, provides basic the person or entity is permitted to submit
on the collection of information through information from which potential liability within 90 days of the date of the decision a
www.Regulations.gov, or to Office of can be assessed. Additional authority written request for review by the Director,
Information and Regulatory Affairs, includes 38 U.S.C. Section 501; 38 CFR 1.900 CBOPC.
Office of Management and Budget, Attn: et seq.; 10 U.S.C. Sections 1079 and 1086; 42 Affected Public: Individuals or
U.S.C. Sections 2651–2653; and Executive
VA Desk Officer; 725 17th St. NW., Order 9397.
households.
Washington, DC 20503 or sent through 5. VA Form 10–7959e, VA Claim for Estimated Annual Burden:
electronic mail to oira_submission@ Miscellaneous Expenses, information 1. VA Form 10–10d—4,411 hours.
omb.eop.gov. Please refer to ‘‘OMB collection is needed to carry out the health 2. VA Form 10–7959a—37,336 hours.
Control No. 2900–0219’’ in any care programs for certain children of Korea 3. VA Form 10–7959c—13,456 hours.
correspondence. and/or Vietnam veterans authorized under 38 4. VA Form 10–7959d—467 hours.
U.S.C., chapter 18, as amended by section 5. VA Form 10–7959e—206 hours.
FOR FURTHER INFORMATION CONTACT: 401, Public Law 106–419 and section 102,
Cynthia Harvey-Pryor, Enterprise 6. Payment (beneficially claims)—500
Public Law 108–183. VA’s medical
Records Service (005R1B), Department hours.
regulations 38 CFR part 17 (17.900 through
of Veterans Affairs, 810 Vermont 17.905) establish regulations regarding 7. Review and Appeal Process—200
Avenue NW., Washington, DC 20420, provision of health care for certain children hours.
(202) 461–5870 or email cynthia.harvey- of Korea and Vietnam veterans and women Estimated Average Burden Per
pryor@va.gov. Please refer to ‘‘OMB Vietnam veterans’ children born with spina Respondent:
Control No. 2900–0219.’’
bifida and certain other covered birth defects. 1. VA Form 10–10d—10 minutes.
These regulations also specify the 2. VA Form 10–7959a—10 minutes.
SUPPLEMENTARY INFORMATION: information to be included in requests for 3. VA Form 10–7959c—10 minutes.
Titles: preauthorization and claims from approved 4. VA Form 10–7959d—7 minutes.
1. VA Form 10–10d, Application for health care providers.
6. Payment of Claims for Provision of
5. VA Form 10–7959e—15 minutes.
CHAMPVA Benefits 6. Payment (beneficially claims)—10
Health Care for Certain Children of Korea
2. VA Form 10–7959a, CHAMPVA and/or Vietnam Veterans (includes provider minutes.
Claim Form billing and VA Forms 10–7959e). This data 7. Review and Appeal Process—20
3. VA Form 10–7959c, CHAMPVA collection is for the purpose of claiming minutes.
Other Health Insurance (OHI) payment/reimbursement of expenses related Frequency of Response: Annually.
Certification to spina bifida and certain covered birth Estimated Annual Responses:
4. VA Form 10–7959d, CHAMPVA defects. Beneficiaries utilize VA Form 10–
ehiers on DSK5VPTVN1PROD with NOTICES
1. VA Form 10–10d—26,468.
Potential Liability Claim 7959e, VA Claim for Miscellaneous 2. VA Form 10–7959a—224,018.
5. VA Form 10–7959e, VA Claim for Expenses. Providers utilize provider
generated billing statements and standard 3. VA Form 10–7959c—80,733.
Miscellaneous Expenses 4. VA Form 10–7959d—4,000.
billing forms such as: Uniform Billing-Forms
6. Payment (beneficially claims) UB–04, and CMS 1500, Medicare Health 5. VA Form 10–7959e—824.
7. Review and Appeal Process Insurance Claims Form. VA would be unable 6. Payment (beneficially claims)—
OMB Control Number: 2900–0219. to determine the correct amount to reimburse 3,000.
VerDate Sep<11>2014 15:04 Jul 05, 2016 Jkt 238001 PO 00000 Frm 00111 Fmt 4703 Sfmt 4703 E:\FR\FM\06JYN1.SGM 06JYN1](https://thefederalregister.org/doc/81_FR_44225/page/1.svg)
![Federal Register / Vol. 81, No. 129 / Wednesday, July 6, 2016 / Notices 44097
7. Review and Appeal Process—600. 3501–21), Federal agencies must obtain DEPARTMENT OF VETERANS
By direction of the Secretary. approval from the Office of Management AFFAIRS
Kathleen Manwell, and Budget (OMB) for each collection of [OMB Control No. 2900–0798]
Program Analyst, VA Privacy Service, Office information they conduct or sponsor.
of Privacy and Records Management, This request for comment is being made Proposed Information Collection
Department of Veterans Affairs. pursuant to Section 3506(c)(2)(A) of the (Beneficiary Travel Mileage
[FR Doc. 2016–15983 Filed 7–5–16; 8:45 am] PRA. Reimbursement Application Form, VA
BILLING CODE 8320–01–P With respect to the following Form 10–3542)
collection of information, NCA invites Activity: Comment Request
comments on: (1) Whether the proposed AGENCY: Veterans Health
DEPARTMENT OF VETERANS collection of information is necessary Administration, Department of Veterans
AFFAIRS for the proper performance of NCA’s Affairs.
[OMB Control No. 2900–0559] functions, including whether the ACTION: Notice.
information will have practical utility;
Proposed Information Collection (State (2) the accuracy of NCA’s estimate of the SUMMARY: The Veterans Health
Cemetery Data Sheet and Cemetery burden of the proposed collection of Administration (VHA), Department of
Grant Document) Activity: Comment Veterans Affairs (VA), is announcing an
information; (3) ways to enhance the
Request opportunity for public comment on the
quality, utility, and clarity of the proposed collection of certain
AGENCY: National Cemetery information to be collected; and (4) information by the agency. Under the
Administration, Department of Veterans ways to minimize the burden of the Paperwork Reduction Act (PRA) of
Affairs. collection of information on 1995, Federal agencies are required to
ACTION: Notice. respondents, including through the use publish notice in the Federal Register
of automated collection techniques or concerning each proposed collection of
SUMMARY: The National Cemetery the use of other forms of information information, including each proposed
Administration (NCA), Department of technology. extension of a currently approved
Veterans Affairs (VA), is announcing an collection, and allow 60 days for public
Title: State Cemetery Data, VA Form
opportunity for public comment on the comment in response to the notice. This
proposed collection of certain 40–0241 and Cemetery Grant
Documents, 40–0895 Series. notice solicits comments on the VHA
information by the agency. Under the Beneficiary Travel (BT) program, which
Paperwork Reduction Act (PRA) of OMB Control Number: 2900–0559. provides mileage reimbursement to
1995, Federal agencies are required to Type of Review: Revision of an qualified Veterans or other claimant(s)
publish notice in the Federal Register approved collection. who incur expense in traveling to
concerning each proposed collection of healthcare.
information, including each revised Abstract: VA Form 40–0241 and
Cemetery Grant Documents, 40–0895 DATES: Written comments and
collection allow 60 days for public
Series, are required to provide data recommendations on the proposed
comment in response to the notice. This
regarding the number of interments collection of information should be
notice solicits comments on information
conducted at State Veterans cemeteries received on or before September 6,
needed to determine when to begin
and support grant applications each 2016.
development of additional acreage for
burial space and, in so doing, to year. This data is necessary for budget, ADDRESSES: Submit written comments
anticipate when to provide money to oversight and compliance purposes on the collection of information through
expand or improve these National associated with exiting and Federal Docket Management System
Cemeteries. establishment of new State and Tribal (FDMS) at www.Regulations.gov or to
government Veteran cemeteries. Brian McCarthy, Office of Regulatory
DATES: Written comments and and Administrative Affairs, Veterans
recommendations on the proposed Affected Public: Individuals or
Health Administration (10B4),
collection of information should be households. Department of Veterans Affairs, 810
received on or before September 6, Estimated Annual Burden: 10,049. Vermont Avenue NW., Washington, DC
2016. 20420 or email: Brian.McCarthy4@
Estimated Average Burden per
ADDRESSES: Submit written comments Respondent: 15 minutes. va.gov. Please refer to ‘‘OMB Control
on the collection of information through No. 2900–0798’’ in any correspondence.
Federal Docket Management System Frequency of Response: One-time. During the comment period, comments
(FDMS) at www.Regulations.gov or to Estimated Number of Respondents: may be viewed online through the
Willie Lewis, National Cemetery 286. FDMS.
Administration (43D3), Department of Dated: June 11, 2016. FOR FURTHER INFORMATION CONTACT:
Veterans Affairs, 810 Vermont Avenue Brian McCarthy at (202) 461–6345.
By direction of the Secretary.
NW., Washington, DC 20420; or email:
Kathleen Manwell, SUPPLEMENTARY INFORMATION: Under the
willie.lewis@va.gov. Please refer to
Program Analyst, VA Privacy Service, Office
PRA of 1995 (Pub. L. 104–13; 44 U.S.C.
‘‘OMB Control No. 2900–0559’’ in any
of Privacy and Records Management, 3501–3521), Federal agencies must
correspondence. During the comment
Department of Veterans Affairs. obtain approval from the Office of
period, comments may be viewed online
ehiers on DSK5VPTVN1PROD with NOTICES
[FR Doc. 2016–15986 Filed 7–5–16; 8:45 am]
Management and Budget (OMB) for each
through the FDMS.
collection of information they conduct
FOR FURTHER INFORMATION CONTACT: BILLING CODE 8320–01–P
or sponsor. This request for comment is
Willie Lewis at (202) 461–4242 or FAX being made pursuant to Section
(202) 501–2240. 3506(c)(2)(A) of the PRA.
SUPPLEMENTARY INFORMATION: Under the With respect to the following
PRA of 1995 (Pub. L. 104–13; 44 U.S.C. collection of information, VHA invites
VerDate Sep<11>2014 15:04 Jul 05, 2016 Jkt 238001 PO 00000 Frm 00112 Fmt 4703 Sfmt 4703 E:\FR\FM\06JYN1.SGM 06JYN1](https://thefederalregister.org/doc/81_FR_44225/page/2.svg)
Document Created: 2016-07-06 07:55:45
Document Modified: 2016-07-06 07:55:45
| 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 | Comments must be submitted on or before August 5, 2016. | |
| Contact | Cynthia Harvey-Pryor, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420, (202) 461-5870 or email [email protected] Please refer to ``OMB Control No. 2900- 0219.'' | |
| FR Citation | 81 FR 44096 |
2025 Federal Register | Disclaimer | Privacy Policy
USC | CFR | eCFR