CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-7959c CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability	Form and Instruction	Modified	Available
White Paper PRA justification_080717.docx	Supplementary Document	Uploaded 2017-08-23	Available
2900-0219 Justification_Updates 080717.docx	Supporting Statement A	Uploaded 2017-10-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28467	CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability	Form and Instruction	Modified

ICR Details

OMB Control No: 2900-0219	ICR Reference No: 201708-2900-036
Status: Active	Previous ICR Reference No: 201602-2900-032
Agency/Subagency: VA	Agency Tracking No: 2900-0219
Title: CHAMPVA 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: 03/26/2018
	Date Received in OIRA: 01/10/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2021	36 Months From Approved	09/30/2019
Responses	177,225	0	339,619
Time Burden (Hours)	46,176	0	56,570
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 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
   US Code: 38 USC Section 501 Name of Law: Rules and regulations
   US Code: 38 USC Section 1781 Name of Law: Medical care for survivors and dependents of certain veterans
   US Code: 42 USC Section 2651 Name of Law: Recovery by United States
  

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:
	82 FR 40832	08/28/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 207	01/02/2018
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

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 Other Health Insurance (OHI) Certification ,   Potential Liability Claim Form ,   Claim for Miscellaneous Expenses ,   Application for Benefits ,   CHAMPVA Claim Form

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ICR Summary of Burden

table that charts list 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	177,225	339,619	0	0	-162,394	0
Annual Time Burden (Hours)	46,176	56,570	0	0	-10,394	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Previous versions did not take into account CHAMPVA preauthorization requirements or CHAMPVA appeals. The update also makes changes to the BLS rate used to calculate the public’s burden.

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Annual Cost to Federal Government: $589,334

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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]? No

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: 01/10/2018

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