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 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.
Title: CHAMPVA Benefits—Application, Claim, Other Health Insurance, Potential Liability & Miscellaneous Expenses.
OMB Control Number: 2900-0219. https://www.reginfo.gov/public/do/PRASearch. (Once at this link, you can enter the OMB Control Number to find the historical versions of this Information Collection.)
Type of Review: Revision of a currently 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). Although the burden numbers have not changed since the last PRA clearance, the collection is being revised to include a portal for submission of the information in the 10-10d program application form, which is expected to be completed by the end of calendar year 2024. This portal will allow applicants to complete and submit VA Form 10-10d electronically rather than by submission of a hard copy form, which has been the standard application process prior to technological advancement allowing electronic submission and processing. This portal represents a separate avenue for applicants to submit VA Form 10-10d; however, it does not affect the burden of collection for applicants or VA.
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 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, Vietnam, and Thailand 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, Vietnam, and Thailand 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 the Veterans Appeals Improvement and Modernization Act of 2017 (AMA, Pub. L. 115-55), chapter 51 of 38 U.S.C., or legacy claims under 38 CFR 17.277 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 (including electronic where available). If such person or entity remains dissatisfied with the determination, the person or entity is permitted to submit a written request for additional review (VHA Notice 2024-07).
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 Programs. The person requesting the services must submit medical documentation or applicable supporting material for review. ( print page 70694)
Affected Public: Individuals or 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.
Authority:44 U.S.C. 3501 et seq.
Maribel Aponte,
VA PRA Clearance Officer, Office of Enterprise and Integration/Data Governance Analytics, Department of Veterans Affairs.
