OMB approves this collection consistent with the memo from VA on 6/14/07 and the revised forms attached. Upon expiration of the collection, VA will update OMB on the progress of electronic implementation.
Inventory as of this Action
Requested
Previously Approved
06/30/2010
36 Months From Approved
06/30/2007
119,200
0
2,375,500
19,668
0
394,667
0
0
0
Used by CHAMP VA claimants to claim reimbursement for medical care and by VA to determine eligibility, process claims, detect fraud and recover costs from third parties.
US Code:
38 USC Section 1781
Name of Law: Medical care for survivors and dependents of certain veterans
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 2651
Name of Law: Recovery by United States
US Code:
38 USC Section 501
Name of Law: Rules and regulations
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
EO: EO 9397 Name/Subject of EO: Number System for Federal Accounts Relating to Individual Persons
The previous estimate submitted by this office made an invalid assumption that a VA Form 10-7959a was required for every medical claim that is created in the facility. A more correct estimate would be that only 15% of all claims require a VA Form 10-7959a, since this form is ONLY used by a taxpayer requesting repayment for out of pocket costs. The majority of claims are received directly from the doctor, pharmacy, or hospital, and not from the taxpayer. Thus, this is considered a routine business practice and these agencies are not required to use this form.
VA Form 10-7959d usage figure has been reduced to the figure stated, based on the current conditions within the HACÂs department that process these. They are anticipating increasing the workforce to process more of these in the future.
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 VA Form 10-10d CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability
2900-0219 justification.DOC
CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability