1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.
VA Form 10-583, Claim for Payment of Cost of Unauthorized Medical Services is used by non-Department health care providers as a claim for the cost of unauthorized hospital and medical care they have provided, and by veterans as a claim for reimbursement of such costs authorized by 38 U.S.C. 1728. VA facilities use VA Form 10-2065, Funeral Arrangements, to initiate, authorize and document expenditures relating to burial benefits proscribed in 38 U.S.C. Chapter 23, Burial Benefits and Chapter 24, National Cemeteries and Memorials. VA Form 10-2511, Authority and Invoice for Travel by Ambulance or Other Hired Vehicle is used to initiate, authorize, and document expenditures associated with beneficiary travel as authorized in 38 U.S.C. 111, Payments or allowances for beneficiary travel. Request for payment of Beneficiary travel under 38 U.S.C. 111 also can be made without this form. VA Form 10-7078, Authorization and Invoice for Medical and Hospital Services is used by VA facilities to initiate, authorize and document expenditures for care provided under authority of Title 38 United States Code (U.S.C.) 1703, Contracts for hospital care and medical services in non-Department facilities; 38 U.S.C 1725, Reimbursement for emergency treatment; and 38 U.S.C. 1728, Reimbursement of certain medical expenses.
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.
a. VA Form 10-2065 is part of the Decedent Affairs Package. The form is completed during the interview with relatives of the deceased, and identifies the funeral home to which the remains are to be released. The family signs the form designating that it reflects their wishes. It is used as a control document when VA is requested to arrange for the transportation of the deceased from the place of death to the place of burial, and/or when burial is requested in a National Cemetery.
b. The following forms are used to claim payment for reimbursement and to authorize and process payment of medical and ambulance or other hired vehicles services provided by a non-Federal provider.
(1) VA Form 10-583 is a claim form used for request and payment of certain unauthorized non-VA medical services. The form is used by administrative personnel in VA clinics of FEE Basis jurisdiction to collect information for determining the legal and medical eligibility of applicants for payment or reimbursement of the costs of unauthorized medical services obtained by a veteran. The form is completed by the applicant as an official claim for such benefits and by VA officials to certify the authority for payment or reimbursement and to authorize such payment. If the collection of information were not carried out, our ability to provide reimbursement or payment for these costs would be negated.
(2) VA facility administrative personnel use VA Form 10-2511 to process payment for ambulance or other hired vehicular forms of transportation for eligible veterans to and from VA health care facilities for examination, treatment or care. When payment is not requested on the date of service, persons requesting payment may request reimbursement in writing or in person without this form.
(3) Administrative personnel in VA medical facilities use VA Form 10-7078 to authorize expenditures from the medical care account and process payment of medical and hospital services provided by other than Federal health providers to VA beneficiaries. Lack of this form would complicate management and record keeping of expenditures for medical care provided at VA expense by the private sector.
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 four forms are currently in a fill able format on the Internet. However, because of attachments and signatures, veterans are not currently able to submit the forms via the web. Several re-engineering projects are underway that will support collection of electronic submission data. The exception would be VA Form 10-2065. It is expected that the encounter will still require the physical presence of the Veteran’s representative at the field office. Management officials have reviewed the forms to assure that all the information sought is essential. Improved information technology will not decrease the burden on the public. Although total automation has not totally adopted, the VA will accept billing from private providers submitted on any local billing form or UB (Uniform Billing) 92.
4. Describe effort 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.
There is no data available that can be modified for this purpose. Each individual form is an individual entity and is required for adjudication and payment authorization.
5. If the collection of information impacts small businesses or other small entities (Item 5 of OMB form 83-1) describe any methods used to minimize burden.
Since the VA Form 10-2065 is an application for individual benefits, no small businesses or other small entities are impacted by the information collection. The remaining forms have been designed to minimize the information collection burden on the public. The public completes only Part II on VA Form 10-7078 and 10-2511 and only Part I on VA Form 10-583. Additionally, to decrease the burden on the respondent, the VA will accept billing from private providers submitted on any local billing form or UB (Uniform Billing) 92.
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 the information on VA Form 10-2065 were not collected, VA’s ability to dispose of the remains of deceased veterans would be seriously hampered. This data cannot be collected less frequently because it is collected upon the veteran’s death. The data on VA Forms 10-583, 10-2511, and 10-7078 validate the funds appropriation sources when payment is made as well as document payment for services provided specific veterans for certain dates or periods of service. If this information were not collected, VA ability to track veteran care and expenditures would be impaired. The information on these forms cannot be collected less frequently as they are claims that are required for payment.
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 such special circumstances.
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 August 29, 2007, Pages 49758-49759 (Volume 72, Number 167). 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.
No outside consultations, other than the request for the 30- and 60-day public comment in the Federal Register, were made as only essential information is solicited. Responses to the questions on these forms are considered standard business practice.
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
No payment or gift is provided to respondents.
10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statue, 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 the Consolidated Health Record that complies with the Privacy Act of 1974. These forms are part of the system of records identified as 24VA19 “Patient Medical Record – VA” as set forth in the Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.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.
There are no sensitive questions involved in this data collection.
12. Estimate of the hour burden of the collection of information:
a. Based on past experience, we make the following estimate of the total burden:
Respondent Burden |
|||||
VA Form 10-583 |
68,750 responses |
x |
15 minutes |
= |
17,188 hours |
VA Form 10-2065 |
24,630 responses |
x |
5 minutes |
= |
2,053 hours |
VA Form 10-2511 |
70,000 responses |
x |
2 minutes |
= |
2,333 hours |
Request for payment of Beneficiary travel after the date of services |
25,000 responses |
x |
1 minute |
= |
417 hours |
VA Form 10-7078 |
252,000 responses |
x |
2 minutes |
= |
8,400 hours |
TOTAL |
440,380 responses |
|
|
= |
30,391 hours |
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.
See above.
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 the respondents for completing these forms $635,655 (42,377 hours x $15 per hour). We do not require any additional recordkeeping.
13. Provide an estimate of the total annual cost burden to respondents or recordkeeping 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.
a. The estimated annual cost to the Federal Government of VA Form 10-583 is $2,320,981.
Printing and Distribution |
|
= |
$2,100 |
68,750 claims |
x $15.67/hr (GS 5/5) x 2 hours |
= |
$2,154,625 |
68,750 claims |
x $$23.75/hr (GS 9/5) x 5 min. |
= |
$136,068 |
68,750 forms mailed to vets |
x $0.41 |
= |
$28,188 |
|
Total |
|
$2,320,981 |
b. The estimated annual cost to the Federal Government of VA Form 10-2065 is $33,162.
Printing and Distribution |
|
= |
$1,000 |
24,630 claims |
x $15.67/hr x (GS 5/5) x 5 min. |
= |
$32,162 |
|
Total |
|
$33,162 |
The estimated annual cost to the Federal Government of VA Form 10-2511 is $189,346.
Printing and Distribution |
|
= |
$2,000 |
Processing Parts I & III |
70,000 claims x $14.01/hr (GS 4/5) x 4 min. |
= |
$65,380 |
Processing Part III |
70,000 claims x $15.67/hr (GS 5/5) x 2 min. |
= |
$36,563 |
Processing Part IV |
70,000 claims x $12.48/hr (GS 3/5) x 4 min. |
= |
$58,240 |
66,250 forms mailed |
x $0.41 |
= |
$27,163 |
|
Total |
|
$189,346 |
d. The estimated annual cost to the Federal Government of process a claim for Beneficiary travel after services have been provided.
Printing and Distribution |
|
= |
$2,100 |
25,000 claims |
x $14.01/hr (GS 4/5) x 4 min |
= |
$23,350 |
25,000 claims |
x $15.67 (GS 5/5) x 2 min. |
= |
$13,058 |
20,000 veterans deemed eligible and payment subsequently mailed to vets |
x $0.41 |
= |
$8,200 |
|
Total |
|
$46,708 |
e. The estimated annual cost to the Federal Government of VA Form 10-7078 is $1,434,864.00.
Printing and Distribution |
|
= |
$5,000 |
Processing Parts I & III |
252,000 claims x $$12.48/hr (GS 3/5) x 6 min. |
= |
$314,496 |
Admin. Certification |
252,000 claims x $23.75/hr (GS 9/5) x 8 min. |
= |
$798,000 |
Processing Part IV |
252,000 claims x $14.01/hr (GS 4/5) x 4 min. |
= |
$235,368 |
200,000 forms mailed |
x $0. 41 |
= |
$82,000 |
|
Total |
|
$1,434,864.00 |
15. Explain the reason for any program changes or adjustments reported in Items 13 or 14.
Changes to 14 d are due to the steady decrease in the number of hospital admissions.
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.
There are no plans to publish the information collected on any of the forms.
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 the cost to itself of collecting, processing and using the information by not displaying the expiration date. We seek an exemption that waives the displaying of the expiration. These are on-going requirement and there is a continuing and reoccurring need for this information collection.
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.
Collection of Information Employing Statistical Methods.
This collection of information does not employ statistical methods.
Page
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR VA FORM 10-2065, FUNERAL ARRANGEMENTS; VA FORM 10-10, APPLICATION FOR MEDICAL BENEFITS; VA FORM 10-10I, |
| Author | Preferred Customer |
| File Modified | 2007-11-07 |
| File Created | 2007-11-07 |