CHAMPVA Benefits - Application, Claim, Other Health Insurance, Potential Liability & Misc Expenses
Revision of a currently approved collection
No
Regular
Approved with change
12/03/2024
10/30/2024
OMB is approving this information collection request for a period of three years during which time the agency will request approval to extend or revise the collection if the agency seeks to continue the information collection activity beyond the period approved under this action.
table that charts list comparision
Inventory as of this Action
Requested
Previously Approved
12/31/2027
36 Months From Approved
12/31/2024
200,056
0
180,142
37,867
0
34,548
0
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.
CHAMPVA Clinical Review