Proposed Information Collection Activity: Proposed Collection; Comment Request

AGENCY:

Veterans Health Administration, Department of Veterans Affairs.

ACTION:

Notice.

SUMMARY:

The 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 Reinstatement, with change, of a previously approved collection for which approval has expired, and allow 60 days for public comment in response to the notice. This notice solicits comments for information needed to adjudicate and pay healthcare benefit claims.

DATES:

Written comments and recommendations on the proposed collection of information should be received on or before August 7, 2000.

ADDRESSES:

Submit written comments on the collection of information to Ann W. Bickoff, Veterans Health Administration (193B1), Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420. Please refer to “OMB Control No. 2900-0219” in any correspondence.

FOR FURTHER INFORMATION CONTACT:

Ann W. Bickoff at (202) 273-8310 or Fax (202) 273-9381.

SUPPLEMENTARY INFORMATION:

Under the PRA of 1995 (Public Law 104-13; 44 U.S.C., 3501-3520), 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.

Titles

a. Application for CHAMPVA Benefits, VA Form 10-10D.

b. CHAMPVA Claim Form, VA Form 10-7959A.

c. CHAMPVA—Other Health Insurance (OHI) Certification, VA Form 10-7959C.

d. CHAMPVA Potential Liability Claim, VA Form 10-7959D.

e. VA Spina Bifida Healthcare Benefits, Claim for Miscellaneous Expenses, VA Form 10-7959E.

OMB Control Number: 2900-0219.

Type of Review: Reinstatement, with change, of a previously approved collection for which approval has expired.

Abstract: The following forms are used by Civilian Health and Medical Program-VA (CHAMPVA) and spina bifida claimants to claim reimbursement for medical care and by VA to determine eligibility, process claims, detect fraud and recover costs from third parties.

a. VA Form 10-10D is used to determine eligibility of persons applying for healthcare benefits under the CHAMPVA program.

b. VA Form 10-7959A is used to adjudicate claims for CHAMPVA benefits.

c. VA Form 10-7959C is used to systematically obtain Other Health Insurance information and to correctly coordinate benefits among all liable parties.

d. VA Form 10-7959D is used to recover costs associated with healthcare services related to injury or illness caused by a third party.

e. VA Form 10-7959E is used by VA Spina Bifida Healthcare beneficiaries to claim payment or reimbursement for healthcare services and related travel expenses.

Affected Public: Individuals or Households, Business or Other for-Profit.

Estimated Annual Burden: 60,467 hours.

a. VA Form 10-10D—1,500 hours.

b. VA Form 10-7959A—50,000 hours.

c. VA Form 10-7959C—6,200 hours.

d. VA Form 10-7959D—1,167 hours.

e. VA Form 10-7959E—1,600 hours.

Estimated Average Burden Per Respondent

a. VA Form 10-10D—10 minutes.

b. VA Form 10-7959A—10 minutes.

c. VA Form 10-7959C—6 minutes.

d. VA Form 10-7959D—7 minutes.

e. VA Form 10-7959E—4 minutes.

Frequency of Response: On occasion.

Estimated Number of Respondents: 405,000.

a. VA Form 10-10D—9,000.

b. VA Form 10-7959A—300,000.

c. VA Form 10-7959C—62,000.

d. VA Form 10-7959D—10,000.

e. VA Form 10-7959E—24,000.