03-28369. 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 extension of a currently approved collection, and allow 60 days for public comment in response to the notice. This notice solicits comments for information needed to determine eligibility of persons applying for healthcare benefits under Civilian Health and Medical Program-VA (CHAMPVA) and to adjudicate claims submitted under CHAMPVA.

DATES:

Written comments and recommendations on the proposed collection of information should be received on or before January 12, 2004.

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 [phone] or FAX [phone].

SUPPLEMENTARY INFORMATION:

Under the PRA of 1995 (Pub. L. 104-13; 44 U.S.C. 3501-21), 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.

OMB Control Number: 2900-0219.

Type of Review: Extension of a currently approved collection.

Abstract:

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 accurate adjudicate and process beneficiaries claims for payment/reimbursement of related healthcare expenses.

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.

Affected Public: Individuals or households, Business or other for-profit.

Estimated Annual Burden: 394,667 hours.

a. VA Form 10-10d—3,417 hours.

b. VA Form 10-7959a—383,333 hours.

c. VA Form 10-7959c—5,000 hours.

d. VA Form 10-7959d—2,917 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—10 minutes.

d. VA Form 10-7959d—7 minutes.

Frequency of Response: On occasion.

Estimated Number of Respondents: 2,375,500.

a. VA Form 10-10d—20,500.

b. VA Form 10-7959a—2,300,000.

c. VA Form 10-7959c—30,000.

d. VA Form 10-7959d—25,000.

Dated: November 3, 2003.

By direction of the Secretary.

Jacqueline Parks,

IT Specialist, Records Management Service.