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

Forms and Documents

Document Name	Status
Form VA Form 10-7959a CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability Form	Removed
Form 10-10d CHAMPVA Application for Benefits Form	Unchanged
Form 10-7959e CHAMPVA Claim for Miscellaneous Expenses Form	Unchanged
Form 10-7959d CHAMPVA Potential Liability Claim Form Form	Unchanged
Form 10-7959c CHAMPVA Other Health Insurance (OTI) Certification Form and Instruction	Unchanged
Form 10-7959a CHAMPVA Claim Form Form	Modified
30-day FRN_CHAMPVA Benefits_2900-0219_pub 09022021.pdf Supplementary Document	2021-09-09
60-day FRN_CHAMPVA Benefits_2900-0219_pub 06032021.pdf Supplementary Document	2021-08-27
Supporting Statement A_2900-0219_CHAMPVA Benefits Forms_updated Sep 2021.docx Supporting Statement A	2021-09-09
Memorandum_Request for Emergency PRA Clearance_CHAMPVA Benefits_Mar 2021.pdf Supplementary Document	2021-03-22

IC Document Collections

IC ID	Document Title	Status
28467	CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability Form	Removed
246422	CHAMPVA Clinical Review	Unchanged
246419	CHAMPVA Appeal Process	Unchanged
246417	CHAMPVA Application for Benefits Form	Unchanged
246411	CHAMPVA Claim for Miscellaneous Expenses Form	Unchanged
246408	CHAMPVA Potential Liability Claim Form Form	Unchanged
246405	CHAMPVA Other Health Insurance (OTI) Certification Form and Instruction	Unchanged
246404	CHAMPVA Claim Form Form	Modified

ICR Details

OMB Control No: 2900-0219	ICR Reference No: 202104-2900-006
Status: Received in OIRA	Previous ICR Reference No: 202102-2900-011
Agency/Subagency: VA	Agency Tracking No: 2900-0219
Title: CHAMPVA Benefits - Application, Claim, Other Health Insurance, Potential Liability & Misc Expenses
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/09/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved	03/31/2021
Responses	180,142	177,225
Time Burden (Hours)	34,548	46,176
Cost Burden (Dollars)	0	0

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Abstract: 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.

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Authorizing Statute(s): 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
  

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:
	86 FR 29883	06/03/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 49412	09/02/2021
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
CHAMPVA Appeal Process
CHAMPVA Application for Benefits	10-10d	CHAMPVA Application for Benefits
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
CHAMPVA Claim Form	10-7959a	CHAMPVA Claim Form
CHAMPVA Claim for Miscellaneous Expenses	10-7959e	CHAMPVA Claim for Miscellaneous Expenses
CHAMPVA Clinical Review
CHAMPVA Other Health Insurance (OTI) Certification	10-7959c	CHAMPVA Other Health Insurance (OHI) Certification
CHAMPVA Potential Liability Claim Form	10-7959d	CHAMPVA Potential Liability Claim Form

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ICR Summary of Burden

	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

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: Changes in the burden are based on program history.

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Annual Cost to Federal Government: $706,317

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? No

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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: 09/09/2021

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