60-day FRN - CHAMPVA BenefitsForms - 2900-0219 - pub 06032021

Federal Register / Vol. 86, No. 105 / Thursday, June 3, 2021 / Notices
DEPARTMENT OF VETERANS
AFFAIRS
[OMB Control No. 2900–0219]

Agency Information Collection
Activity: CHAMPVA Benefits—
Application, Claim, Other Health
Insurance, Potential Liability &
Miscellaneous Expenses
Veterans Health
Administration, Department of Veterans
Affairs.
ACTION: Notice.
AGENCY:

Veterans Health
Administration (VHA), Department of
Veterans Affairs (VA), is announcing an
opportunity for public comment on the
proposed collection of certain
information by the agency. Under the
Paperwork Reduction Act (PRA) of
1995, Federal agencies are required to
publish notice in the Federal Register
concerning each proposed collection of
information, including each proposed
extension of a currently approved
collection, and allow 60 days for public
comment in response to the notice.
DATES: Written comments and
recommendations on the proposed
collection of information should be
received on or before August 2, 2021.
ADDRESSES: Submit written comments
on the collection of information through
Federal Docket Management System
(FDMS) at www.Regulations.gov or to
Janel Keyes, Office of Regulations,
Appeals, and Policy (10BRAP),
Department of Veterans Affairs, 810
Vermont Avenue NW, Washington, DC
20420 or email to [email protected].
Please refer to ‘‘OMB Control No. 2900–
0219’’ in any correspondence. During
the comment period, comments may be
viewed online through FDMS.
FOR FURTHER INFORMATION CONTACT:
Maribel Aponte, Office of Enterprise
and Integration, Data Governance
Analytics (008), 1717 H Street NW,
Washington, DC 20006, (202) 266–4688
or email [email protected]. Please
refer to ‘‘OMB Control No. 2900–0219’’
in any correspondence.
SUPPLEMENTARY INFORMATION: Under the
PRA of 1995, Federal agencies must
obtain approval from the Office of
Management and Budget (OMB) for each
collection of information they conduct
or sponsor. This request for comment is
being made pursuant to Section
3506(c)(2)(A) of the PRA.
With respect to the following
collection of information, VHA invites
comments on: (1) Whether the proposed
collection of information is necessary
for the proper performance of VHA’s
functions, including whether the

khammond on DSKJM1Z7X2PROD with NOTICES

SUMMARY:

VerDate Sep<11>2014

17:23 Jun 02, 2021

Jkt 253001

information will have practical utility;
(2) the accuracy of VHA’s estimate of
the burden of the proposed collection of
information; (3) ways to enhance the
quality, utility, and clarity of the
information to be collected; and (4)
ways to minimize the burden of the
collection of information on
respondents, including through the use
of automated collection techniques or
the use of other forms of information
technology.
Authority: Public Law 104–13; 44
U.S.C. 3501–3521.
Title: CHAMPVA Benefits—
Application, Claim, Other Health
Insurance, Potential Liability &
Miscellaneous Expenses.
OMB Control Number: 2900–0219.
Type of Review: Reinstatement with
change of a previously approved
collection.
Abstract
This information collection includes
several forms, as well as a review and
appeal process, which are used to
administer the Civilian Health And
Medical Program of the Department of
Veterans Affairs (CHAMPVA).
VA Form 10–10d: Application for
CHAMPVA Benefits
VA Form 10–7959a: CHAMPVA Claim
Form
VA Form 10–7959c: CHAMPVA Other
Health Insurance (OHI) Certification
VA Form 10–7959d: CHAMPVA
Potential Liability Claim
VA Form 10–7959e: VA Claim for
Miscellaneous Expenses
Review and Appeal Process
Clinical Review
a. VA Form 10–10d, Application for
CHAMPVA Benefits, is used to
determine eligibility of persons
applying for healthcare benefits under
the CHAMPVA program in accordance
with 38 U.S.C. 501 and 1781.
b. VA Form 10–7959a, CHAMPVA
Claim Form, is used to adjudicate
claims for CHAMPVA benefits in
accordance with 38 U.S.C. 501 and
1781, and 10 U.S.C. 1079 and 1086. This
information is required for accurate
adjudication and processing of
beneficiary submitted claims. The claim
form is also instrumental in the
detection and prosecution of fraud. In
addition, the claim form is the only
mechanism to obtain, on an interim
basis, other health insurance (OHI)
information.
c. 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

PO 00000

Frm 00147

Fmt 4703

Sfmt 4703

29883

parties. Except for Medicaid and health
insurance policies that are purchased
exclusively for the purpose of
supplementing CHAMPVA benefits,
CHAMPVA is always the secondary
payer of healthcare benefits (38 U.S.C.
501 and 1781, and 10 U.S.C. 1086).
d. VA Form 10–7959d, CHAMPVA
Potential Liability Claim, provides basic
information from which potential third
party liability can be assessed. The
Federal Medical Care Recovery Act (42
U.S.C. 2651–2653) mandates recovery of
costs associated with healthcare services
related to an injury/illness caused by a
third party. Additional authority
includes 38 U.S.C. 501; 38 CFR 1.900 et
seq.; 10 U.S.C. 1079 and 1086; 42 U.S.C.
2651–2653; and Executive Order 9397.
e. 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, Public Law
106–419 and section 102, Public Law
108–183. VA’s medical regulations 38
CFR part 17 (17.900 through 17.905)
establish regulations regarding
provision of health care for certain
children of Korea and Vietnam veterans
and women Vietnam veterans’ children
born with spina bifida and certain other
covered birth defects. These regulations
also specify the information to be
included in requests for
preauthorization and claims from
approved health care providers.
f. Review and Appeal Process pertains
to the approval of health care, or
approval for payment relating to the
provision of health care, under the
Veteran Family Member Programs. The
provisions of chapter 51 of 38 U.S.C. or
38 CFR 17.276 and 38 CFR 17.904
establish a review process regarding
disagreements by an eligible beneficiary
of a Veteran Family Member Program,
provider, Veteran, or other
representative of the Veteran or
beneficiary with a determination
concerning provision of health care or a
health care provider’s disagreement
with a determination regarding
payment. The person or entity
requesting reconsideration of such
determination is required to submit
such a request in writing. If such person
or entity remains dissatisfied with the
reconsideration determination, the
person or entity is permitted to submit
a written request for additional review.
g. Clinical Review pertains to the
requirement of VHA to preauthorize
certain medical services under 38 CFR
17.273 and 38 CFR 17.902. Clinical
review determines if services are
medically necessary and appropriate to
allow under the Veteran Family Member

E:\FR\FM\03JNN1.SGM

03JNN1

29884

Federal Register / Vol. 86, No. 105 / Thursday, June 3, 2021 / Notices

Programs. The person requesting the
services must submit medical
documentation or applicable supporting
material for review.
Affected Public: Individuals and
households.
Estimated Annual Burden: 34,548
total hours.
VA Form 10–10d—8,963 hours.
VA Form 10–7959a—9,167 hours.
VA Form 10–7959c—8,947 hours.
VA Form 10–7959d—239 hours.
VA Form 10–7959e—200 hours.
Review and Appeal Process—6,255
hours.
Clinical Review—777 hours.
Estimated Average Burden per
Respondent:
VA Form 10–10d—10 minutes.
VA Form 10–7959a—10 minutes.
VA Form 10–7959c—10 minutes.
VA Form 10–7959d—7 minutes.
VA Form 10–7959e—15 minutes.
Review and Appeal Process—30
minutes.
Clinical Review—20 minutes.
Frequency of Response: Once
annually.
Estimated Number of Respondents:
180,142 total.
VA Form 10–10d—53,775.
VA Form 10–7959a—55,000.
VA Form 10–7959c—53,680.
VA Form 10–7959d—2,045.
VA Form 10–7959e—800.
Review and Appeal Process—12,510.
Clinical Review—2,332.
By direction of the Secretary.
Maribel Aponte,
VA PRA Clearance Officer, Office of
Enterprise and Integration/Data Governance
Analytics, Department of Veterans Affairs.
[FR Doc. 2021–11618 Filed 6–2–21; 8:45 am]
BILLING CODE 8320–01–P

DEPARTMENT OF VETERANS
AFFAIRS
Solicitation of Nominations for
Appointment to the Advisory
Committee on Tribal and Indian Affairs,
Amended
ACTION:

Notice.

The Department of Veterans
Affairs (VA), Office of Public and
Intergovernmental Affairs (OPIA), Office
of Tribal Government Relations (OTGR),
is seeking nominations of qualified
candidates to be considered for
appointment as a member of the
Advisory Committee on Tribal and
Indian Affairs (‘‘the Committee’’).
DATES: Nominations for membership on
the Committee must be received no later
than 5:00 p.m. EST on June 16, 2021.
ADDRESSES: All nomination packages
(Application, should be mailed to the

khammond on DSKJM1Z7X2PROD with NOTICES

SUMMARY:

VerDate Sep<11>2014

17:23 Jun 02, 2021

Jkt 253001

Office of Tribal Government Relations,
810 Vermont Ave. NW, Suite 915H
(075), Washington, DC 20420 or email
us at tribalgovernmentconsultation@
va.gov.
Ms.
Stephanie Birdwell and David ‘‘Clay’’
Ward, Office of Tribal Government
Relations, 810 Vermont Ave. NW, Ste
915H (075), Washington, DC 20420,
Telephone (202) 461–7400. A copy of
the Committee charter can be obtained
by contacting Mr. David ‘‘Clay’’ Ward or
by accessing the website managed by
OTGR at https://www.va.gov/TRIBAL
GOVERNMENT/index.asp.
SUPPLEMENTARY INFORMATION: In
carrying out the duties set forth, the
Committee responsibilities include, but
not limited to: (1) Identify for the
Department evolving issues of relevance
to Indian tribes, tribal organizations and
Native American Veterans relating to
programs and services of the
Department;
(2) Propose clarifications,
recommendations and solutions to
address issues raised at tribal, regional
and national levels, especially regarding
any tribal consultation reports;
(3) Provide a forum for Indian tribes,
tribal organizations, urban Indian
organizations, Native Hawaiian
organizations and the Department to
discuss issues and proposals for changes
to Department regulations, policies and
procedures;
(4) Identify priorities and provide
advice on appropriate strategies for
tribal consultation and urban Indian
organizations conferring on issues at the
tribal, regional, or national levels;
(5) Ensure that pertinent issues are
brought to the attention of Indian tribes,
tribal organizations, urban Indian
organizations and Native Hawaiian
organizations in a timely manner, so
that feedback can be obtained;
(6) Encourage the Secretary to work
with other Federal agencies and
Congress so that Native American
Veterans are not denied the full benefit
of their status as both Native Americans
and Veterans;
(7) Highlight contributions of Native
American Veterans in the Armed
Forces;
(8) Make recommendations on the
consultation policy of the Department
on tribal matters;
(9) Support a process to develop an
urban Indian organization confer policy
to ensure the Secretary confers, to the
maximum extent practicable, with
urban Indian organizations; and
(10) With the Secretary’s written
approval, conduct other duties as
recommended by the Committee.
FOR FURTHER INFORMATION CONTACT:

PO 00000

Frm 00148

Fmt 4703

Sfmt 4703

Authority: The Committee was
established in accordance with section
7002 of Public Law 116–315 (H.R.
7105—Johnny Isakson and David P. Roe,
M.D. Veterans Health Care and Benefits
Improvement Act of 2020). In
accordance with Public Law 116–315,
the Committee provides advice and
guidance to the Secretary of Veterans
Affairs on all matters relating to Indian
tribes, tribal organizations, Native
Hawaiian organizations and Native
American Veterans. The Committee
serves in an advisory capacity and
advises the Secretary on ways the
Department can improve the programs
and services of the Department to better
serve Native American Veterans.
Committee members make
recommendations to the Secretary
regarding such activities.
Membership Criteria: OTGR is
requesting nominations for upcoming
vacancies on the Committee. The
Committee will be composed of 15
members. As required by statute, the
members of the Committee are
appointed by the Secretary from the
general public, including:
(1) At least one member of each of the
12 service areas of the Indian Health
Service is represented in the
membership of the Committee
nominated by Indian tribes or tribal
organization.
(2) At least one member of the
Committee represents the Native
Hawaiian Veteran community
nominated by a Native Hawaiian
Organization.
(3) At least one member of the
Committee represents urban Indian
organizations nominated by a national
urban Indian organization.
(4) Not fewer than half of the
members are Veterans, unless the
Secretary determines that an insufficient
number of qualified Veterans were
nominated.
(5) No member of the Committee may
be an employee of the Federal
Government.
In accordance with Public Law 116–
315, the Secretary determines the
number and terms of service for
members of the Committee, which are
appointed by the Secretary, except that
a term of service of any such member
may not exceed a term of two years.
Additionally, a member may be
reappointed for one additional term at
the Secretary’s discretion.
Professional Qualifications: In
addition to the criteria above, VA
seeks—
(1) Diversity in professional and
personal qualifications;

E:\FR\FM\03JNN1.SGM

03JNN1