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Federal Register / Vol. 86, No. 168 / Thursday, September 2, 2021 / Notices ACTION:

Notice.

In compliance with the Paperwork Reduction Act PRA of 1995, this notice announces that the Veterans Health Administration, Department of Veterans Affairs, will submit the collection of information abstracted below to the Office of Management and Budget OMB for review and comment. The PRA
submission describes the nature of the information collection and its expected cost and burden and it includes the actual data collection instrument.
DATES: Written comments and recommendations for the proposed information collection should be sent within 30 days of publication of this notice to www.reginfo.gov/public/do/
PRAMain. Find this particular information collection by selecting Currently under 30-day ReviewOpen for Public Comments or by using the search function. Refer to OMB Control No. 29000219.
FOR FURTHER INFORMATION CONTACT:
Maribel Aponte, Office of Enterprise and Integration, Data Governance Analytics 008, 1717 H Street NW, Washington, DC 20006, 202 2664688
or email maribel.aponte@va.gov. Please refer to OMB Control No. 29000219
in any correspondence.
SUPPLEMENTARY INFORMATION:
Authority: 44 U.S.C. 350121.
Title: CHAMPVA Benefits Application, Claim, Other Health Insurance, Potential Liability &
Miscellaneous Expenses.
OMB Control Number: 29000219.
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 1010d: Application for CHAMPVA Benefits VA Form 107959a: CHAMPVA Claim Form VA Form 107959c: CHAMPVA Other Health Insurance OHI Certification VA Form 107959d: CHAMPVA
Potential Liability Claim VA Form 107959e: VA Claim for Miscellaneous Expenses lotter on DSK11XQN23PROD with NOTICES1

SUMMARY:

Review and Appeal Process Clinical Review a. VA Form 1010d, Application for CHAMPVA Benefits, is used to
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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 107959a, CHAMPVA
Claim Form, is used to adjudicate claims for CHAMPVA benefits in accordance with 38 U.S.C. Sections 501
and 1781, and 10 U.S.C. Sections 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 107959c, 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 107959d, 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. 26512653 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.
26512653; and Executive Order 9397.
e. VA Form 107959e, 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 106419 and section 102, Public Law 108183. VAs 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
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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 providers 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 Programs. The person requesting the services must submit medical documentation or applicable supporting material for review.
An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB
control number. The Federal Register Notice with a 60-day comment period soliciting comments on this collection of information was published at: 86 FR
105 on June 3, 2021, pages 29883 and 29884.
Affected Public: Individuals and households.
Estimated Annual Burden: 34,548
total hours.
VA Form 1010d8,963 hours.
VA Form 107959a9,167 hours.
VA Form 107959c8,947 hours.
VA Form 107959d239 hours.
VA Form 107959e200 hours.
Review and Appeal Process6,255
hours.
Clinical Review777 hours.
Estimated Average Burden per Respondent:
VA Form 1010d10 minutes.
VA Form 107959a10 minutes.
VA Form 107959c10 minutes.
VA Form 107959d7 minutes.
VA Form 107959e15 minutes.
Review and Appeal Process30
minutes.
Clinical Review20 minutes.
Frequency of Response: Once annually.

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