OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Payment/Reimbursement for Emergency Services for Nonservice-Connected Conditions in Non-VA Facilities, 38 U.S.C. 1725

ICR 201110-2900-004 · OMB 2900-0620 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
2900-0620 justification.docx Supporting Statement A Uploaded 2011-12-20 Available
IC Document Collections
IC IDCollectionTypeStatusForm
28880 Payment/Reimbursement for Emergency Services for Nonservice-Connected Conditions in Non-VA Facilities, 38 U.S.C. 1725 Modified
ICR Details
2900-0620 201110-2900-004
Historical Active 200806-2900-007
VA 2900-0620
Payment/Reimbursement for Emergency Services for Nonservice-Connected Conditions in Non-VA Facilities, 38 U.S.C. 1725
Extension without change of a currently approved collection   No
Regular
Approved without change 03/29/2012
Retrieve Notice of Action (NOA) 12/20/2011
  Inventory as of this Action Requested Previously Approved
03/31/2015 36 Months From Approved 03/31/2012
207,071 0 330,759
51,768 0 82,690
0 0 0
Vets, vet reps and health care providers submit this data to request reimbursement from the federal government for emergency services at a private institution.
US Code: 38 USC 1725 Name of Law: Reimbursement for Emergency Treatment
   US Code: 38 USC 1705 Name of Law: Management of Health Care: Patient Enrollment System
   US Code: 38 USC 1728 Name of Law: Reimbursement of Certain Medical Expenses
   PL: Pub.L. 106 - 117 101 Name of Law: The Veterans Millennium Health Care and Benefits Act
  
None
Not associated with rulemaking
  76 FR 197 10/12/2011
76 FR 243 12/19/2011
No
1
IC Title Form No. Form Name
Payment/Reimbursement for Emergency Services for Nonservice-Connected Conditions in Non-VA Facilities, 38 U.S.C. 1725
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 207,071 330,759 0 0 -123,688 0
Annual Time Burden (Hours) 51,768 82,690 0 0 -30,922 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
The adjustment of -123,688 forms is a result of requiring signed support statements only for claims not submitted on a CMS 1500 or UB04 decreasing the overall burden on health care providers.
$4,992,998
No
No
No
No
No
Uncollected
Denise McLamb 202-565-8374 [email protected]
  No
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.
12/20/2011