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:
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
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
Adjustments: The overall burden hours changed due to an increase in the number of respondents for forms 10-10d and forms 10-7959a, c, d and e. For the change reflected in the number of responses from the last submission, for 10-7959c (CHAMPVA OHI Form): The increase in number from the previous submission is due to the growth of the program over the past three years, increased submission of claims forms, and increased attention to insurance status.
Program change:VA Form 10-7959e (previously approved under 2900-0578), and has been incorporated into this 2900-0219 due to the fact that it is a beneficiary claims form that was misinterpreted for its use in provider billing. With a correction in this error, VA Form 10-7959e will only be submitted by the beneficiary for miscellaneous claims. The number of responses was revised in number (see chart on #12). The previous submission indicated 15,000 responses. Upon review it was determined that a more accurate annual usage for this form is no more than approximately 3,000 responses from approximately 250 respondents.
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 10-7959a CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability
2900-0219 Justification A (v6).doc
CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability