Supporting Statement for 2900-0648, Foreign Medical Program, Continued
1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.
This information collection is needed to carry out the health care benefits allowed by the Foreign Medical Program (FMP). It is a federal health benefits program for veterans administered by the Department of Veterans Affairs (VA) Veterans Health Administration (VHA). FMP is a Fee for Service (indemnity plan) program. FMP provides reimbursement for VA adjudicated service-connected conditions. Title 38 CFR 17.35 states that the VA will provide coverage for the veteran’s service-connected disability when the veteran is residing or traveling overseas.
The VA Form 10-7959f-1, Foreign Medical Program (FMP) Registration Form, is used to register into the Foreign Medical Program those veterans with service-connected disabilities that are living or traveling overseas. Title 38 CFR 17.125(d) states that requests for consideration of claim reimbursement from approved health care providers and veterans are to be mailed to VHA Health Administration Center (HAC). The VA Form 10-7959f-2, Claim Cover Sheet – Foreign Medical Program (formerly numbered VA Form 10-7959f) streamlines the claims submission process for claimants or physicians while also reducing the time spent by VA on processing FMP claims. The cover sheet will allow foreign providers/veterans with a better understanding of basic information required for the processing and payment of claims.
2. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.
The veteran will complete VA Form 10-7959f-1 for the purpose of enrollment in FMP. Information is entered into the FMP data base for maintaining enrollment records and for future processing of claims.
The VA Form 10-7959f-2 was designed for the purpose of submitting claims for payment/ reimbursement of expenses related to veterans who are overseas except for the Philippines with a service-connected disability. The professional staff at the VHA Health Administration Center, Denver, Colorado, will use this information to determine the appropriateness of veteran information; i.e. name, address, Social Security Number and VA claim number for bills submitted for consideration of claim payment. Use of this form by providers or veteran is optional. However, the form outlines the basic veteran information necessary for consideration of claims for reimbursement. The information is also instrumental in the timely and accurate processing of provider claims for reimbursement. The frequency of submissions will be based on the volume of medical services provided to patients and whether providers/veterans choose to submit claims for reimbursement individually or in batches. VA also accepts provider generated billing statements, Uniform Billing-Forms (UB) 92, and Medicare Health Insurance Claims Form, HCFA 1500. The VA Form 10-7959f-2, Claim Cover Sheet – Foreign Medical Program (formerly numbered VA Form 10-7959f) was renumbered because the Registration form is submitted before the Claims Cover Sheet.
3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.
The FMP does not currently have plans to receive registration forms from foreign countries as we are trying to meet the HIPPAA requirements. VA Form 10-7959f-1 will be produced as an Adobe Reader extended pdf fill-in document, which can be completed, saved, and printed. It contains information that can be used in the future for submission of the information electronically. The HAC is implementing this process with some of our other forms and once the details are worked out and tested this form can follow with those same capabilities.
The FMP does not currently receive foreign claims electronically as we do not have the capability to accept EDIFAC claims (standard transaction set for foreign claims) and receipt of foreign claims electronically is not a part of HIPAA requirements. VA Form 10-7959f-2 is currently produced as an Adobe Reader extended pdf fill-in document, which can be completed, saved, and printed. The HAC is implementing the process of electronic submission with some of our other forms and once the details are worked out and tested this form can follow with those capabilities
4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.
Similar information is not available from other sources. The VA does not currently possess an alternative source for the required information.
5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.
No small businesses or other small entities are impacted by the VA Form 10-7959f-1 information collection.
Small businesses and other entities provide much of the information on VA Form 10-7959f-2. However, the number of hours involved does not significantly impact these businesses. Only essential information is requested from each provider. To reduce the burden on all providers, including smaller ones, VA will accept provider generated billing statements and or commercially available forms such as the Uniform Billing-Forms (UB) 92 or HCFA 1500, the Medicare Health Insurance Claim forms. Foreign providers basically use their own type of “billing invoice”. Countries such as Panama do use the UB 92 & HCFA 1500. The information required from providers includes the date of service, location of service, address of provider, as well as a signature certifying the service.
6. Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.
If any of this information is not collected on VA Form 10-7959f-1, VA would be unable to register veterans residing or traveling overseas into the Foreign Medical Program to reimburse VA adjudicated service-connected conditions.
For VA Form 10-7959f-2, the frequency of payment is dependent upon the frequency of submission of the information; we have little control over how often this information is submitted. However, the amount of data collected is kept to a minimum. If any of this information was not collected, VA would be unable to process provider claims for payment or reimbursement of medical care.
7. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.
There are no special circumstances that will require collection to be conducted in a manner inconsistent with the guidelines in 5 CFR 1320.6.
8. a. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.
The notice of Proposed Information Collection Activity was published in the Federal Register on June 29, 2006 (Volume 71, Number 125. Page 37167). We received no comments in response to this notice.
b. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances which preclude consultation every three years with representatives of those from whom information is to be obtained.
The VA Form 10-7959f-1 is a simple one-time form for registration requiring only basic information, such as: Name, Address, Social Security Number, VA Claim File Number and Phone/Fax Number.
For the VA Form 10-7959f-2, VA has consulted the claims processors in the FMP of the Health Administration Center. The purpose of this consultation was to obtain their views regarding the availability of data, frequency of collection, clarity of instructions, disclosure and recordkeeping format and on the data elements to be recorded, disclosed, or reported. In addition, staff at the VHA Health Administration Center provided the expertise and advice gained in reviewing numerous public and private health insurance forms. This expertise and advice resulted in the VA determination to use provider generated billing statements or existing forms (e.g., UB 92 and HCFA 1500) in lieu of creating new VA forms. Foreign medical providers use foreign codes (diagnosis, procedure, etc) and submit billing invoices in different foreign languages. As the FMP is unable to incorporate a “detailed/specific” claim form for the type of medical service in each country, a simple form was created to ensure veterans/providers submit the required information.
Additionally, outside consultation is also conducted with the public regarding both forms through the 60- and 30-day Federal Register notices.
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
No gifts will be made to respondents. The purpose of the information is to either register veterans in the program or to reimburse veterans or health care providers for services rendered to veterans when this relates to their service-connected disability.
10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.
Assurances of confidentiality are contained in 38 U.S.C. 5701 and 7332. Respondents are informed that the information collected will become part of records that comply with the Privacy Act of 1974. These documents are part of the system of records identified as 54VA17 “Health Administration Center Foreign Medical Program Records – VA” as set forth in the 2003 Compilation of Privacy Act Issuances via online GPO access at http://www.access.gpo.gov/su_docs/aces/2003_pa.html.
11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.
Respondents are not asked questions of a sensitive nature.
12. a. Estimate of the hour burden of the collection of information is estimated at:
Calculation of Annual Burden With More Than One Response |
||||||
VA Form |
Respondents |
Frequency |
Responses Annually |
Minutes |
Divided by 60 |
Annual Burden Hours |
10-7959f-1 |
1,660 |
1 |
1,660 |
4 |
60 |
111 |
10-7959f-2 |
1,660 |
12 |
19,920 |
11 |
60 |
3,652 |
TOTAL |
3,320 |
|
21,580 |
|
|
3,763 |
b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB 83-I.
See Attachment to OMB 83I.
c. Provide estimates of annual cost to respondents for the hour burdens for collections of information. (The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.)
The cost to respondents is estimated at $56,445 (3,763 hours x $15 per hour).
13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).
a. There are no capital, start-up, operation or maintenance costs.
b. Cost estimates are not expected to vary widely. The only cost is that for the time of the respondent.
c. There is no anticipated capital start-up cost components or requests to provide information.
14. Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.
The annual estimated cost to the Federal Government is $24,223.
Federal Government Processing/Analyzing Costs |
|||||||
|
Salary |
Responses |
Equals |
Minutes |
Divided by 60 |
Total |
|
10-7959f-1, Clerical Processing, GS 5/5 |
$13.68 |
1,660 |
$22,709 |
4 |
60 |
$1,514 |
|
10-7959f-2, Clerical Processing, GS 5/5 |
$13.68 |
19,920 |
$272,506 |
5 |
60 |
$22,709 |
|
Printing |
$2,500 |
||||||
TOTAL |
|
$24,223 |
|||||
15. Explain the reason for any changes reported in Items 13 or 14 on OMB Form 83-I.
16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.
No publication of this data is planned.
17. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.
VA seeks to minimize its cost to itself of collecting, processing and using the information by seeking an exemption that waives the displaying of the expiration date on VA Forms. Not only is this form printed by the HAC, this form may be reproduced by the respondents and veterans service organizations from the Internet and then stocked. If we are required to display an expiration date, it would result in unnecessary waste of existing stock of the forms. Inclusion of the expiration date would place an unnecessary burden on the respondent (since they would find it necessary to obtain a newer version, while VA would have accepted the old one).
18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.
There are no exceptions to the certification statement identified in item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB Form 83-I.
No statistical methods are used in selecting respondents
Page
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT REGARDING COLLECTION OF PROVIDER |
| Last Modified By | Denise McLamb |
| File Modified | 2006-08-24 |
| File Created | 2006-08-24 |