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

ICR 202104-2900-006

OMB: 2900-0219

Federal Form Document

ICR Details
2900-0219 202104-2900-006
Received in OIRA 202102-2900-011
VA 2900-0219
CHAMPVA Benefits - Application, Claim, Other Health Insurance, Potential Liability & Misc Expenses
Reinstatement with change of a previously approved collection   No
Regular 09/09/2021
  Requested Previously Approved
36 Months From Approved 03/31/2021
180,142 177,225
34,548 46,176
0 0

Civilian Health And Medical Program of the Department of Veterans Affairs (CHAMPVA) Benefits Forms are used by claimants to submit claims for reimbursement for medical care and by VA to determine benefits eligibility, process claims, detect fraud, and recover costs from third parties -- in accordance with 38 U.S.C. Sections 501 and 1781, and 10 U.S.C. Sections 1079 and 1086. VA Form 10-10d, Application for CHAMPVA Benefits, is used to determine eligibility of persons applying for healthcare benefits under the CHAMPVA program. VA Form 10-7959a, CHAMPVA Claim Form, is used to adjudicate claims for CHAMPVA benefits. The claim form also is instrumental in the detection and prosecution of fraud. VA Form 10-7959c, CHAMPVA Other Health Insurance (OHI) Certification, is used to systematically obtain OHI information and to correctly coordinate benefits among all liable parties. VA Form 10-7959d, CHAMPVA Potential Liability Claim, provides basic information from which potential liability can be assessed. VA Form 10-7959e, VA Claim for Miscellaneous Expenses, is used to adjudicate claims for certain children of Korea and/or Vietnam veterans authorized under 38 U.S.C., chapter 18, as amended by section 401, P.L. 106-419 and section 102, P.L. 108-183. The Clinical Review and Appeal Process regarding provision of health care for CHAMPVA, and Certain Children of Korea and/or Vietnam Veterans, is necessary to provide an appeals process that VA believes is appropriate as a matter of law and policy.

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
   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

Not associated with rulemaking

  86 FR 29883 06/03/2021
86 FR 49412 09/02/2021

  Total Request 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 180,142 177,225 0 180,142 -177,225 0
Annual Time Burden (Hours) 34,548 46,176 0 34,548 -46,176 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Miscellaneous Actions
Changes in the burden are based on program history.

Frances O'Donnell 703 405-2449 [email protected]


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.

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