CHAMP VA Benefits - Application, Claim, Other Health Insurance & Potential Liability

Forms and Documents

Document Name	Status
Form VA Form 10-7959a CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability Form	Modified
2900-0219 Justification A (v6).doc Supporting Statement A	2010-06-01

IC Document Collections

IC ID	Document Title	Status
28467	CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability Form	Modified

ICR Details

OMB Control No: 2900-0219	ICR Reference No: 201001-2900-009
Status: Historical Active	Previous ICR Reference No: 200703-2900-003
Agency/Subagency: VA	Agency Tracking No: 2900-0219
Title: CHAMP VA Benefits - Application, Claim, Other Health Insurance & Potential Liability
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/16/2010
	Date Received in OIRA: 06/02/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2013	36 Months From Approved	08/31/2010
Responses	339,619	0	119,200
Time Burden (Hours)	56,570	0	19,668
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): 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
   US Code: 38 USC Section 1781 Name of Law: Medical care for survivors and dependents of certain veterans
   EO: EO 9397 Name/Subject of EO: Number System for Federal Accounts Relating to Individual Persons
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 39	03/01/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 88	05/07/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability	VA Form 10-7959a, VA Form 10-10d, VA Form 10-7959c, VA Form 10-7959d, VA Form 10-7959e	CHAMPVA Claim Form ,   CHAMPVA Other Health Insurance (OHI) Certification ,   Potential Liability Claim Form ,   Claim for Miscellaneous Expenses ,   Application for Benefits

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	339,619	119,200	0	4,400	216,019	0
Annual Time Burden (Hours)	56,570	19,668	0	900	36,002	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Adjustments: The overall burden hours changed due to an increase in the number of respondents for forms 10-10d and forms 10-7959a, c, d and e. For the change reflected in the number of responses from the last submission, for 10-7959c (CHAMPVA OHI Form): The increase in number from the previous submission is due to the growth of the program over the past three years, increased submission of claims forms, and increased attention to insurance status. Program change:VA Form 10-7959e (previously approved under 2900-0578), and has been incorporated into this 2900-0219 due to the fact that it is a beneficiary claims form that was misinterpreted for its use in provider billing. With a correction in this error, VA Form 10-7959e will only be submitted by the beneficiary for miscellaneous claims. The number of responses was revised in number (see chart on #12). The previous submission indicated 15,000 responses. Upon review it was determined that a more accurate annual usage for this form is no more than approximately 3,000 responses from approximately 250 respondents.

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Annual Cost to Federal Government: $589,334

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 06/02/2010

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