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

Forms and Documents

Document Name	Status
2900-0620 justification.docx Supporting Statement A	2011-12-20

IC Document Collections

IC ID	Document Title	Status
28880	Payment/Reimbursement for Emergency Services for Nonservice-Connected Conditions in Non-VA Facilities, 38 U.S.C. 1725	Modified

ICR Details

OMB Control No: 2900-0620	ICR Reference No: 201110-2900-004
Status: Historical Active	Previous ICR Reference No: 200806-2900-007
Agency/Subagency: VA	Agency Tracking No: 2900-0620
Title: Payment/Reimbursement for Emergency Services for Nonservice-Connected Conditions in Non-VA Facilities, 38 U.S.C. 1725
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/29/2012
	Date Received in OIRA: 12/20/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2015	36 Months From Approved	03/31/2012
Responses	207,071	0	330,759
Time Burden (Hours)	51,768	0	82,690
Cost Burden (Dollars)	0	0	0

---

Abstract: Vets, vet reps and health care providers submit this data to request reimbursement from the federal government for emergency services at a private institution.

---

Authorizing Statute(s): 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
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 197	10/12/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 243	12/19/2011
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 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

---

ICR Summary of Burden

	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

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: 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.

---

Annual Cost to Federal Government: $4,992,998

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 12/20/2011

---