OMB approves
this collection consistent with the memo from VA on 6/14/07 and the
revised forms attached. Upon expiration of the collection, VA will
update OMB on the progress of electronic implementation.
Inventory as of this Action
Requested
Previously Approved
06/30/2010
36 Months From Approved
06/30/2007
119,200
0
2,375,500
19,668
0
394,667
0
0
0
Used by CHAMP VA claimants to claim
reimbursement for medical care and by VA to determine eligibility,
process claims, detect fraud and recover costs from third
parties.
US Code:
38 USC Section 1781 Name of Law: Medical care for survivors and
dependents of certain veterans
US Code:
10 USC Section 1079 Name of Law: Contracts for medical care for
spouses and children: plans
US Code:
10 USC Section 1086 Name of Law: Contracts for health benefits
for certain members, former members, and their dependents
US Code:
42 USC Section 2651 Name of Law: Recovery by United States
US Code:
38 USC Section 501 Name of Law: Rules and regulations
US Code:
42 USC Section 2652 Name of Law: Regulations
US Code:
42 USC Section 2653 Name of Law: Limitation or repeal of other
provisions for recovery of hospital and medical care costs
EO: EO 9397 Name/Subject of EO: Number System for
Federal Accounts Relating to Individual Persons
The previous estimate submitted
by this office made an invalid assumption that a VA Form 10-7959a
was required for every medical claim that is created in the
facility. A more correct estimate would be that only 15% of all
claims require a VA Form 10-7959a, since this form is ONLY used by
a taxpayer requesting repayment for out of pocket costs. The
majority of claims are received directly from the doctor, pharmacy,
or hospital, and not from the taxpayer. Thus, this is considered a
routine business practice and these agencies are not required to
use this form. VA Form 10-7959d usage figure has been reduced to
the figure stated, based on the current conditions within the HACs
department that process these. They are anticipating increasing the
workforce to process more of these in the future.
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.
Form VA Form 10-10d CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability
2900-0219 justification.DOC
CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability