CHAMPVA Benefits -
Application, Claim, Other Health Insurance, Potential Liability
& Misc Expenses
Revision of a currently approved collection
No
Regular
10/30/2024
Requested
Previously Approved
36 Months From Approved
10/31/2024
200,056
180,142
37,867
34,548
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, Vietnam , and
Thailand 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
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:
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
The increase in responses and
burden hours takes into account program data showing an increase in
CHAMPVA enrollment and the expected increase in claim submissions,
OHI forms, appeals, and clinical reviews.
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.
Form 10-10d CHAMPVA Application for Benefits
30-day FRN_2900-0219_CHAMPVA Benefits - Forms_published 10302024.pdf
Supporting Statement A_2900-0219_CHAMPVA Benefits Forms_revised Oct 2024.docx
CHAMPVA Clinical Review