Expanded Access to Non-VA Care Through the Mission Act: Veterans Community Care Program (VCCP)

Forms and Documents

Document Name	Status
Form 10-10143g VA Form 10-10143g: Non-VA Hospital Emergency Notification Form	New
Form 10-10143f 10-10143f - Community Care Document Cover Sheet Form and Instruction	Modified
Form 10-10143e 10-10143e Secondary Authorization Request (SAR) for VA Community Care Form	Unchanged
Form 10-10143a 10-10143a Health-Care Plan Information for the Veterans Choice Program Form and Instruction	Unchanged
30-day FRN_MISSION Act VCCP_2900-0823_published 100719.pdf Supplementary Document	2020-03-27
60-day FRN_MISSION Act VCCP_2900-0823_published 072219.pdf Supplementary Document	2019-09-30
AQ46(F) PRA Supporting Statement A_revised 2020_FINAL.docx Supporting Statement A	2020-03-31

IC Document Collections

IC ID	Document Title	Status
242010	VA Form 10-10143g: Non-VA Hospital Emergency Notification Form	New
241051	10-10143f - Community Care Document Cover Sheet Form and Instruction	Modified
221260	10-10143e Secondary Authorization Request (SAR) for VA Community Care Form	Unchanged
213638	10-10143c Submission of Information on Credentials and Licenses by Eligible Entities and Providers	Unchanged
213637	10-10143b Submission of Medical Record Information under the Veterans Community Care Program	Unchanged
213636	10-10143a Health-Care Plan Information for the Veterans Choice Program Form and Instruction	Unchanged
213635	10-10143 Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Community Care Program Other-Script	Unchanged

ICR Details

OMB Control No: 2900-0823	ICR Reference No: 202005-2900-018
Status: Historical Active	Previous ICR Reference No: 201905-2900-007
Agency/Subagency: VA	Agency Tracking No: 2900-0823
Title: Expanded Access to Non-VA Care Through the Mission Act: Veterans Community Care Program (VCCP)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 05/29/2020
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/29/2020
	Date Received in OIRA: 05/28/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2020	6 Months From Approved	06/30/2020
Responses	22,758,371	0	22,258,371
Time Burden (Hours)	3,007,560	0	2,924,227
Cost Burden (Dollars)	0	0	0

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Abstract: Section 101 of the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 requires VA to implement the Veterans Community Care Program (VCCP) to furnish care in the community to covered Veterans through eligible entities and providers, under circumstances as further prescribed in the MISSION Act. VA currently collects information that will be required to implement the Veterans Community Care Program under the Veterans Choice Program, through an OMB approved collection 2900-0823. OMB collection 2900-0823 includes VA Form 10-10143, Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Choice Program; VA Form 10-10143a, Health-Care Plan Information for the Veterans Choice Program; VA Form 10-10143b, Submission of Medical Record Information under the Veterans Choice Program; VA Form 10-10143c, Submission of Information on Credentials and Licenses by Eligible Entities and Providers; VA Form 10-10143e, Secondary Authorization Request for VA Community Care; and VA Form 10-10143f, Community Care Document Cover Sheet. A new form is being added to this collection: VA Form 10-10143g, Non-VA Hospital Emergency Notification.

Emergency Justfication: Under the Veterans Community Care Program (VCCP), authorized by 38 U.S.C. section 1703, VA may authorize emergency care for eligible veterans by an in-network provider so long as VA is notified within 72-hours of such care or services being furnished (See 38 C.F.R. § 17.4020). The information needed to authorize care under the 72-hour rule is information that can identify the veteran and provider and whether the episode meets the prudent layperson standard. This information is distinct from when a provider submits a claim for reimbursement. VA Form 10-10143g, Non-VA Hospital Emergency Notification, has been created for this purpose. This new form will be used to provide a 72-hour notification from a non-VA provider who supplies emergent care a Veteran. Due to the current COVID-19 national health situation, OCC respectfully requests an emergency PRA clearance for 10-10143g from OMB. This form has become critical because, at this time, many more Veterans are presenting to non-VA providers with health issues and concerns during the COVID-19 national emergency. Also, the form is needed to effectively pull responsibility for these 72-hour notifications off of the medical staff -- who are struggling to even answer the phones to take these notifications right now. OCC hopes to implement use of this necessary notification form by May 31, 2020.

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Authorizing Statute(s): PL: Pub.L. 115 - 182 101 Name of Law: VA MISSION Act of 2018
  

Citations for New Statutory Requirements: PL: Pub.L. 115 - 182 101 Name of Law: VA MISSION Act of 2018

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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

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 7

IC Title	Form No.	Form Name
10-10143f - Community Care Document Cover Sheet	10-10143f	Community Care Document Cover Sheet
10-10143c Submission of Information on Credentials and Licenses by Eligible Entities and Providers
10-10143 Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Community Care Program
10-10143a Health-Care Plan Information for the Veterans Choice Program	10-10143a	Health Care Plan Information for the Veterans Choice Program
10-10143b Submission of Medical Record Information under the Veterans Community Care Program
10-10143e Secondary Authorization Request (SAR) for VA Community Care	10-10143e	SAR for VA Community Care
VA Form 10-10143g: Non-VA Hospital Emergency Notification	10-10143g	Non-VA Hospital Emergency Notification

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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	22,758,371	22,258,371	0	500,000	0	0
Annual Time Burden (Hours)	3,007,560	2,924,227	0	83,333	0	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: VA Form 10-10143g, Non-VA Hospital Emergency Notification, has been created and added to 2900-0823. This form is necessary to provide a 72-hour notification from a non-VA provider who supplies emergent care a Veteran, as authorized under the Veterans Community Care Program (VCCP).

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Annual Cost to Federal Government:

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? Yes

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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: 05/28/2020

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