81 FR 8359 - 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 32 (February 18, 2016)

Page Range		8359-8360
FR Document		2016-03288

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 32 (Thursday, February 18, 2016)

[Federal Register Volume 81, Number 32 (Thursday, February 18, 2016)]
[Notices]
[Pages 8359-8360]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2016-03288]


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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 April 18, 2016.

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

[[Page 8360]]

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.

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.
    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. 2016-03288 Filed 2-17-16; 8:45 am]
 BILLING CODE 8320-01-P

Federal Register / Vol. 81, No. 32 / Thursday, February 18, 2016 / Notices 8359

Office of Small and Disadvantaged (FDMS) at www.Regulations.gov or to By direction of the Secretary.
Business Utilization (OSDBU) will use Nancy J. Kessinger, Veterans Benefits Kathleen M. Manwell,
the VA Form 0896a to collect Administrations (20M33), Department Program Analyst, VA Privacy Service, Office
information from subcontractors to of Veterans Affairs, 810 Vermont of Privacy and Records Management,
compare information obtained from Avenue NW., Washington, DC 20420 or Department of Veterans Affairs.
subcontracting plans submitted by email to nancy.kessinger@va.gov. Please [FR Doc. 2016–03286 Filed 2–17–16; 8:45 am]
prime contractors in order to determine refer to ‘‘OMB Control No. 2900–0086’’ BILLING CODE 8320–01–P
the accuracy of the data reported by in any correspondence. During the
prime contractors. The form has been comment period, comments may be
modified to allow the collection of viewed online through FDMS. DEPARTMENT OF VETERANS
information from multiple AFFAIRS
subcontractors in the same form. FOR FURTHER INFORMATION CONTACT:
Nancy J. Kessinger at (202) 632–8924 or [OMB Control No. 2900–0219]
Affected Public: VA Prime
Contractors. FAX (202) 632–8925. Proposed Information Collection
Estimated Annual Burden: 610 hours. SUPPLEMENTARY INFORMATION: Under the (Civilian Health and Medical Program
Estimated Average Burden per PRA of 1995 (Pub. L. 104–13; 44 U.S.C. of the Department of Veterans Affairs
Respondent: 2 hours. 3501–21), Federal agencies must obtain (CHAMPVA) Benefits—Application,
Frequency of Response: Once a year. approval from the Office of Management Claim, Other Health Insurance &
Estimated Number of Respondents: Potential Liability); Activity: Comment
and Budget (OMB) for each collection of
305. Request
information they conduct or sponsor.
By direction of the Secretary. This request for comment is being made AGENCY: Veterans Health
Kathleen M. Manwell, pursuant to Section 3506(c)(2)(A) of the Administration, Department of Veterans
Program Analyst, VA Privacy Service, Office PRA. Affairs.
of Privacy and Records Management,
Department of Veterans Affairs.
With respect to the following ACTION: Notice.
collection of information, VBA invites
[FR Doc. 2016–03285 Filed 2–17–16; 8:45 am] SUMMARY: The Veterans Health
comments on: (1) Whether the proposed
BILLING CODE 8320–01–P
collection of information is necessary Administration (VHA) is announcing an
for the proper performance of VBA’s opportunity for public comment on the
functions, including whether the proposed collection of certain
DEPARTMENT OF VETERANS information by the agency. Under the
AFFAIRS information will have practical utility;
(2) the accuracy of VBA’s estimate of the Paperwork Reduction Act (PRA) of
[OMB Control No. 2900–0086] burden of the proposed collection of 1995, Federal agencies are required to
information; (3) ways to enhance the publish notice in the Federal Register
Proposed Information Collection— concerning each proposed collection of
quality, utility, and clarity of the
Request for a Certificate of Eligibility information, including each proposed
information to be collected; and (4)
VA Form 26–1880 revision of a currently approved
ways to minimize the burden of the
collection, and allow 60 days for public
AGENCY: Veterans Benefits collection of information on
comment in response to the notice. This
Administration, Department of Veterans respondents, including through the use
notice solicits comments on information
Affairs. of automated collection techniques or needed to identify areas for
ACTION: Notice; comment request. the use of other forms of information improvement in clinical training
technology. programs.
SUMMARY: The Veterans Benefits
Title: Request for a Certificate of DATES: Written comments and
Administration (VBA), Department of
Veterans Affairs (VA), is announcing an Eligibility. recommendations on the proposed
opportunity for public comment on the OMB Control Number: 2900–0086. collection of information should be
proposed collection of certain Type of Review: Revision of a received on or before April 18, 2016.
information by the agency. Under the currently approved collection. ADDRESSES: Submit written comments
Paperwork Reduction Act (PRA) of on the collection of information through
Abstract: Under Title 38, U.S.C.,
1995, Federal agencies are required to the Federal Docket Management System
publish notice in the Federal Register section 3702, authorizes collection of
(FDMS) at www.Regulations.gov; or to
concerning each proposed collection of this information to help determine a
Brian McCarthy, Office of Regulatory
information, including each proposed Veteran’s qualification for a VA-
and Administrative Affairs, Veterans
revision of a currently approved guaranteed home loan. An agency may
Health Administration (10B4),
collection, and allow 60 days for public not conduct or sponsor, and a person is Department of Veterans Affairs, 810
comment in response to the notice. not required to respond to a collection Vermont Avenue NW, Washington, DC
The holder of a vendee account which of information unless it displays a 20420 or email: Brian.McCarthy4@
has been guaranteed by the Department currently valid OMB control number. va.gov. Please refer to ‘‘OMB Control
of Veterans Affairs (VA) may request VA Affected Public: Individuals or No. 2900–0219’’ in any correspondence.
to repurchase a loan as provided in 38 households. During the comment period, comments
CFR 36. may be viewed online through FDMS.
mstockstill on DSK4VPTVN1PROD with NOTICES

Estimated Annual Burden: 80, 250
DATES: Written comments and hours. FOR FURTHER INFORMATION CONTACT:
recommendations on the proposed Brian McCarthy at (202) 461–6345.
Estimated Average Burden per
collection of information should be SUPPLEMENTARY INFORMATION: Under the
Respondent: 15 minutes.
received on or before April 18, 2016. PRA of 1995 (Pub. L. 104–13; 44 U.S.C.
ADDRESSES: Submit written comments Frequency of Response: One-time. 3501–3521), Federal agencies must
on the collection of information through Estimated Number of Respondents: obtain approval from OMB for each
Federal Docket Management System 321,000. collection of information they conduct

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8360 Federal Register / Vol. 81, No. 32 / Thursday, February 18, 2016 / Notices

or sponsor. This request for comment is used to systematically obtain OHI Payment Relating to Provision of Health
being made pursuant to section information and to correctly coordinate Care for Certain Children of Korea and/
3506(c)(2)(A) of the PRA. benefits among all liable parties. or Vietnam Veterans. The provisions of
With respect to the following 4. The Federal Medical Care Recovery 38 CFR 17.904 establish a review
collection of information, VHA invites Act (42 U.S.C. 2651–2653), mandates process regarding disagreements by an
comments on: (1) Whether the proposed recovery of costs associated with eligible veteran’s child or representative
collection of information is necessary healthcare services related to an injury/ with a determination concerning
for the proper performance of VHA’s illness caused by a third party. VA Form provision of health care or a health care
functions, including whether the 10–7959d, CHAMPVA Potential provider’s disagreement with a
information will have practical utility; Liability Claim, provides basic determination regarding payment. The
(2) the accuracy of VHA’s estimate of information from which potential person or entity requesting
the burden of the proposed collection of liability can be assessed. Additional reconsideration of such determination is
information; (3) ways to enhance the authority includes 38 U.S.C. 501; 38 required to submit such a request to the
quality, utility, and clarity of the CFR 1.900 et seq.; 10 U.S.C. 1079 and Chief Business Office Purchased Care
information to be collected; and (4) 1086; 42 U.S.C. 2651–2653; and (CBOPC) (Attention: Chief, Customer
ways to minimize the burden of the Executive Order 9397. Service), in writing within one year of
collection of information on 5. VA Form 10–7959e, VA Claim for the date of initial determination. The
respondents, including through the use Miscellaneous Expenses, information request must state why the decision is
of automated collection techniques or collection is needed to carry out the in error and include any new and
the use of other forms of information health care programs for certain relevant information not previously
technology. children of Korea and/or Vietnam considered. After reviewing the matter,
veterans authorized under 38 U.S.C., a Customer Service Advisor issues a
Titles chapter 18, as amended by section 401, written determination to the person or
1. VA Form 10–10d, Application for P.L. 106–419 and section 102, P.L. 108– entity seeking reconsideration. If such
CHAMPVA Benefits 183. VA’s medical regulations 38 CFR person or entity remains dissatisfied
2. VA Form 10–7959a, CHAMPVA part 17 (17.900 through 17.905) with the determination, the person or
Claim Form establish regulations regarding entity is permitted to submit within 90
3. VA Form 10–7959c, CHAMPVA provision of health care for certain days of the date of the decision a written
Other Health Insurance (OHI) children of Korea and Vietnam veterans request for review by the Director,
Certification and women Vietnam veterans’ children CBOPC.
4. VA Form 10–7959d, CHAMPVA born with spina bifida and certain other Affected Public: Individuals or
Potential Liability Claim covered birth defects. These regulations households.
5. VA Form 10–7959e, VA Claim for also specify the information to be Estimated Annual Burden:
Miscellaneous Expenses included in requests for 1. VA Form 10–10d—4,411 hours.
6. Payment (beneficially claims) preauthorization and claims from 2. VA Form 10–7959a—37,336 hours.
7. Review and Appeal Process approved health care providers. 3. VA Form 10–7959c—13,456 hours.
OMB Control Number: 2900–0219. 6. Payment of Claims for Provision of 4. VA Form 10–7959d—467 hours.
Type of Review: Revision of a Health Care for Certain Children of 5. VA Form 10–7959e—200 hours.
currently approved collection. Korea and/or Vietnam Veterans 6. Payment (beneficially claims)—500
Abstracts: (includes provider billing and VA hours.
1. VA Form 10–10d, Application for Forms 10–7959e). This data collection is 7. Review and Appeal Process—200
CHAMPVA Benefits, is used to for the purpose of claiming payment/ hours.
determine eligibility of persons reimbursement of expenses related to Estimated Average Burden per
applying for healthcare benefits under spina bifida and certain covered birth Respondent:
the CHAMPVA program in accordance defects. Beneficiaries utilize VA Form 1. VA Form 10–10d—10 minutes.
with 38 U.S.C. 501 and 1781. 10–7959e, VA Claim for Miscellaneous 2. VA Form 10–7959a—10 minutes.
2. VA Form 10–7959a, CHAMPVA 3. VA Form 10–7959c—10 minutes.
Expenses. Providers utilize provider 4. VA Form 10–7959d—7 minutes.
Claim Form, is used to adjudicate generated billing statements and 5. VA Form 10–7959e—15 minutes.
claims for CHAMPVA benefits in standard billing forms such as: Uniform 6. Payment (beneficially claims)—10
accordance with 38 U.S.C. 501 and Billing-Forms UB–04, and CMS 1500, minutes.
1781, and 10 U.S.C. 1079 and 1086. This Medicare Health Insurance Claims 7. Review and Appeal Process—20
information is required for accurate Form. VA would be unable to determine minutes.
adjudication and processing of the correct amount to reimburse Frequency of Response: Annually.
beneficiary submitted claims. The claim providers for their services or Estimated Annual Responses:
form is also instrumental in the beneficiaries for covered expenses 1. VA Form 10–10d—26,468.
detection and prosecution of fraud. In without the requested information. The 2. VA Form 10–7959a—224,018.
addition, the claim form is the only information is instrumental in the 3. VA Form 10–7959c—80,733.
mechanism to obtain, on an interim timely and accurate processing of 4. VA Form 10–7959d—4,000.
basis, other health insurance (OHI) provider and beneficiary claims for 5. VA Form 10–7959e—800.
information. reimbursement. The frequency of 6. Payment (beneficially claims)—
3. Except for Medicaid and health submissions is not determined by VA, 3,000.
7. Review and Appeal Process—600.
mstockstill on DSK4VPTVN1PROD with NOTICES

insurance policies that are purchased but will determined by the provider or
exclusively for the purpose of claimant and will be based on the By direction of the Secretary.
supplementing CHAMPVA benefits, volume of medical services and supplies Kathleen M. Manwell,
CHAMPVA is always the secondary provided to patients and claims for Program Analyst, VA Privacy Service, Office
payer of healthcare benefits (38 U.S.C. reimbursement are submitted of Privacy and Records Management,
501 and 1781, and 10 U.S.C. 1086). VA individually or in batches. Department of Veterans Affairs.
Form 10–7959c, CHAMPVA—Other 7. Review and Appeal Process [FR Doc. 2016–03288 Filed 2–17–16; 8:45 am]
Health Insurance (OHI) Certification, is Regarding Provision of Health Care or BILLING CODE 8320–01–P

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Document Created: 2016-02-18 07:46:52
Document Modified: 2016-02-18 07:46:52

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 April 18, 2016.
Contact		Brian McCarthy at (202) 461-6345.
FR Citation		81 FR 8359