2900-0219 Justification A 8-22-13

VA Form 10-10d, Application for CHAMPVA Benefits

VA Form 10-7959a, ChampVA Claim Form,

VA Form 10-7959c, CHAMPVA other Health Insurance (OHI) Certification

VA Form 10-7959d, CHAMPVA Potential Liability Claim and,

VA Form 10-7959e VA Claim for Miscellaneous Expenses

OMB 2900-0219

A. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.

a. VA Form 10-10d, Application for CHAMPVA Benefits, is used to determine eligibility of persons applying for healthcare benefits under the CHAMPVA program in accordance with 38 U.S.C. Sections 501 and 1781.

b. VA Form 10-7959a, CHAMPVA Claim Form, is used to adjudicate claims for CHAMPVA benefits in accordance with 38 U.S.C. Sections 501 and 1781, and 10 U.S.C. Sections 1079 and 1086. This information is required for accurate adjudication and processing of beneficiary submitted claims. The claim form is also instrumental in the detection and prosecution of fraud. In addition, the claim form is the only mechanism to obtain, on an interim basis, other health insurance (OHI) information.

c. Except for Medicaid and health insurance policies that are purchased exclusively for the purpose of supplementing CHAMPVA benefits, CHAMPVA is always the secondary payer of healthcare benefits (38 U.S.C. Sections 501 and 1781, and 10 U.S.C. Section 1086). VA Form 10-7959c, CHAMPVA ‑ Other Health Insurance (OHI) Certification, is used to systematically obtain OHI information and to correctly coordinate benefits among all liable parties.

4. The Federal Medical Care Recovery Act (42 U.S.C. 2651-2653), mandates recovery of costs associated with healthcare services related to an injury/illness caused by a third party. VA Form 10-7959d, CHAMPVA Potential Liability Claim, provides basic information from which potential liability can be assessed. Additional authority includes 38 U.S.C. Section 501; 38 CFR 1.900 et seq.; 10 U.S.C. Sections 1079 and 1086; 42 U.S.C. Sections 2651-2653; and Executive Order 9397.

5. VA Form 10-7959e, VA Claim for Miscellaneous Expenses, information collection is needed to carry out the health care programs for certain children of Korea and/or Vietnam veterans authorized under 38 U.S.C., chapter 18, as amended by section 401, P.L. 106-419 and section 102, P.L. 108-183. VA’s medical regulations 38 CFR part 17 (17.900 through 17.905) establish regulations regarding provision of health care for certain children of Korea and Vietnam veterans and women Vietnam veterans’ children born with spina bifida and certain other covered birth defects. These regulations also specify the information to be included in requests for preauthorization and claims from approved health care providers.

(1) Preauthorization for Provision of Health Care for Certain Children of Korea and/or Vietnam Veterans. In accordance with the provisions of CFR 17.902, individuals seeking these benefits are required to submit to a benefits advisor of the Chief Business office Purchased Care (CBOPC) a preauthorization request for health care consisting of rental or purchase of durable medical equipment with a rental or purchase price in excess of $2,000, respectively; mental health services; training; substance abuse treatment; dental services; transplantation services; or travel (other than mileage at the General Services Administration rate for privately owned automobiles). The preauthorization request should contain the child’s name and Social Security number; the veteran’s name and Social Security number; the type of service requested; the medical justification; the estimated cost; and the name, address, and telephone number of the provider. Preauthorization would not be required for a condition for which failure to receive immediate treatment poses a serious threat to life or health. Such emergency care should be reported by telephone to the CBOPC within 72 hours of the emergency.

(2) Payment of Claims for Provision of Health Care for Certain Children of Korea and/or Vietnam Veterans (includes provider billing and VA Forms 10-7959e). This data collection is for the purpose of claiming payment/reimbursement of expenses related to spina bifida and certain covered birth defects. Beneficiaries utilize VA Form 10-7959e, VA Claim for Miscellaneous Expenses. Providers utilize provider generated billing statements and standard billing forms such as: Uniform Billing-Forms UB-04, and CMS 1500, Medicare Health Insurance Claims Form. VA would be unable to determine the correct amount to reimburse providers for their services or beneficiaries for covered expenses without the requested information. The information is instrumental in the timely and accurate processing of provider and beneficiary claims for reimbursement. The frequency of submissions is not determined by VA, but will determined by the provider or claimant and will be based on the volume of medical services and supplies provided to patients and claims for reimbursement are submitted individually or in batches.

The provisions of 38 CFR 17.903 require that, as a condition of payment, claims from “approved health care providers” for health care provided under 38 CFR 17.900 through 17.905 must include the following information, as appropriate:

a. With respect to patient identification information:

1. The patient’s full name,

2. Social Security number,

3. Address, and

4. Date of birth

b. With respect to provider identification information (inpatient and outpatient services):

1. Full name

2. Address (such as hospital or physician),

3. Remittance address,

4. Address where services were rendered,

5. Individual provider’s professional status (M.D., Ph.D., R.N., etc.), and

6. Provider tax identification number (TIN) or Social Security number

c. With respect to patient treatment information (long-term care or institutional services):

1. Dates of service (specific and inclusive);

2. Summary level itemization (by revenue code);

3. Dates of service for all absences from a hospital or other approved institution during a period for which inpatient benefits are being claimed;

4. Principal diagnosis established, after study, to be chiefly responsible for causing the patient’s hospitalization;

5. All secondary diagnoses;

6. All procedures performed;

7. Discharge status of the patient; and

8. Institution’s Medicare provider number;

d. With respect to patient treatment information for all other health care providers and ancillary outpatient services:

1. Diagnosis,

2. Procedure code for each procedure, service, or supply for each date of service, and

3. Individual billed charge for each procedure, service, or supply for each date of service;

e. With respect to prescription drugs and medicines and pharmacy supplies:

1. Name,

2. Address of pharmacy where drug was dispensed,

3. Name of drug,

4. National Drug Code (NDC) for drug provided,

5. Strength,

6. Quantity,

7. Date dispensed, and

8. Pharmacy receipt for each drug dispensed (including billed charge), and

9.Diagnosis for which each drug is prescribed.

(3) Review and Appeal Process Regarding Provision of Health Care or Payment Relating to Provision of Health Care for Certain Children of Korea and/or Vietnam Veterans. The provisions of 38 CFR 17.904 establish a review process regarding disagreements by an eligible veteran’s child or representative with a determination concerning provision of health care or a health care provider’s disagreement with a determination regarding payment. The person or entity requesting reconsideration of such determination is required to submit such a request to the CBOPC (Attention: Chief, Customer Service), in writing within one year of the date of initial determination. The request must state why the decision is in error and include any new and relevant information not previously considered. After reviewing the matter, a Customer Service Advisor issues a written determination to the person or entity seeking reconsideration. If such person or entity remains dissatisfied with the determination, the person or entity is permitted to submit within 90 days of the date of the decision a written request for review by the Director, CBOPC.

2. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.

The information requested on these forms is required for the Chief Business Office Purchased Care
(CBOPC) previously named the VA Health Administration Center (HAC) staff to adjudicate/pay healthcare benefit claims.

a. The CBOPC staff uses the VA Form 10-l0d to collect eligibility information from prospective CHAMPVA beneficiaries.

b. VA Form 10-7959a is used by CHAMPVA beneficiaries for each claim for payment/reimbursement of related healthcare expenses. Numerous bills/invoices may accompany a single claim form providing that the billed services are all associated with a single beneficiary. The information is required for the timely and accurate processing of claims.

c. To help ensure that other health insurance information is current, completion of VA Form 10-7959c is periodically solicited (consistent with the health insurance industry standard). To minimize the beneficiary burden, the certification form has been designed to accommodate all CHAMPVA-eligible family members.

d. Upon receipt of a claim or invoice involving treatment of an injury or potential work-related illness, HAC is required to solicit additional information relative to the injury/illness as well as third party claim information. VA Form 10-7959d is designed for this purpose. This information is essential in assessing whether potential liability exists. The form is required on an as needed basis when a claim/ invoice indicate an injury or potential work-related illness.

e. VA Form 10-7959e, used for spina bifida and children of women Korea and/or Vietnam veterans and associated covered condition claims, does require minimal information from health care providers when the beneficiary claims travel expenses. The information required from providers includes the date of service, the provider's tax identification number, as well as a signature certifying the service.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

a. VA Forms 10-10d, 10-7959a , 10-7959c, 10-7959d and 10-7959e currently meet the basic goals of the Government Paperwork Elimination Act (GPEA) because the applicant can complete the forms electronically via the Internet. The forms are then printed and mailed to the CBOPC with supporting documentation. Fill in versions on the web reduce the amount of outgoing paper from the CBOPC. With the advent of online forms, the potential beneficiary or the beneficiary filing a claim can simply download the file after completing it in online and then mail it to us. They do not need to request the forms from us and therefore we save money in printing and storage of hard copy forms, postage and man hours required to mail the forms to the public.

b. It was decided to make the VA Form 10-7959d, Potential Liability Form, an on-line fillable form. This would make all the forms in this collection fillable. It has been decided to post the form on the CHAMPVA web site (by linking back to the VA posted form) after we receive OMB approval for this current submission. This would aid the beneficiary by making the form readily available by grouping it with all the other CHAMPVA forms.

c. In addition, EDI (electronic data interface) was implemented on Oct. 16, 2003 which allows all provider claims to be submitted electronically. This will vastly cut down the amount of mail received for claims as well as the man-hours needed to process these claims. Basically from the provider to the clearinghouse, to the CBOPC and to Austin for payment is now completely electronic.

d. At present, the collection for VA Form 10-7959e, Claim for Miscellaneous Expenses will not make use of automated, electronic, mechanical or other technological collection techniques. In accordance with the Government Paperwork Elimination Act, the feasibility of permitting electronic submission has been explored and we currently have made progress in this area. We have changed most of our program forms, including this one, to be interactively fillable on the internet. New commercial software is now available that allows us to address the transmission of attachments and electronic signatures, and recent changes in methods of business practices has allowed us to move forward. The VA will accept provider generated billing statements and is actively encouraging greater electronic commerce participation throughout the medical care provider population. However, certain 'small' health care providers may not have the electronic equipment that will be necessary to file claims (i.e., reliable Internet access). To comply with HIPAA (Health Insurance Portability and Accountability Act) and GPEA, we will continue to actively promote electronic submission.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

a. Strong consideration was given to incorporating the VA Form 10-l0d with the VA Form 10-10EZ (Application for Health Benefits). However, due to the unique differences in customer populations (veterans vs. dependents and survivors) and the information being solicited, it was quickly recognized that separate application forms were necessary. Rather than diminishing the public burden, a test of the combined application increased the burden as it led to confusion by both populations. There is no known alternative source for collecting the required application information.

b. Information on VA Form 10-7959a such as the other health insurance information and the claimant’s signature and date are specific to each claim submitted. Existing information on file does not substitute for that specificity.

c. There is no existing collection instrument that will meet the requirements of annual OHI certification requested on VA Form 10-7959c. While the 10-7959a does solicit OHI information, it is only required when a beneficiary submits a claim. Since claims submitted directly from providers are not accompanied by a CHAMPVA Claim Form there is no other mechanism to obtain updated OHI information.

d. In regard to VA form 10-7959e, similar information is not available from other sources. The VA does not currently possess and is not aware of an alternative source for the required information.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

The collection of information on VA Forms 10-10d, 10-7959c and 10-7959d is limited to beneficiary supplied information—there is no involvement of small businesses or other entities. The impact on small businesses and other entities is minimized by the VA practice of allowing submission of provider generated universal billing forms, CMS-1500 and UB-04, and the phased-transition process of accepting electronic claims information in lieu of 10-7959a.

For Form 10-7959e small businesses and other entities provide this information. However, the number of hours involved does not significantly impact these businesses. Only essential information is requested from each provider. To reduce the burden on all providers, including smaller ones, VA will accept provider generated billing statements and or commercially available forms such as the UB-04, Uniform Billing Form, or CMS 1500, the Medicare Health Insurance Claim Form. VA Form 10-7959e, used for spina bifida and children of women Korea and/or Vietnam veterans and associated covered condition claims, does require minimal information from health care providers when the beneficiary claims travel expenses. The information required from providers includes the date of service, the provider's tax identification number, as well as a signature certifying the service.

6. Describe the consequences to federal program or policy activities if the collection is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.

Without this information we could not establish benefit eligibility or adjudicate claims. The frequency of collecting information is generally determined by beneficiary utilization. VA Form 10-10d is a one-time requirement unless there is a break in eligibility. Consistent with industry practice, data on VA Form 10-7959c is solicited periodically.

(a) Preauthorization for Provision of Health Care for Certain Children of Korea and/or Vietnam Veterans. If the collection were not conducted, we would not be able to have a preauthorization process that we believe is cost-effective. We have little control over how often people request preauthorization for the types of services and benefits that our regulations require to be preauthorized. However, whenever a requirement for preauthorization is no longer cost-effective, VA eliminated the requirement for preauthorization.

(b) Payment of Claims for Provision of Health Care for Certain Children of Korea and/or Vietnam Veterans (includes VA Form 10-7959e). Since the frequency of payment is dependent upon the frequency of submission of the information, we have little control over how often providers and beneficiaries submit their requests. However, the amount of data collected is kept to a minimum. If any of this information was not collected, VA would be unable to process provider and beneficiary claims for payment or reimbursement of medical care.

(c) Review and Appeal Process Regarding Provision of Health Care or Payment Relating to Provision of Health Care for Certain Children of Korea and/or Vietnam Veterans. If the collection were not conducted, VA would be unable to provide an appeals process that VA believes is appropriate as a matter of law and policy.

7. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.

There are no such special circumstances.

8. a. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.

The notice of Proposed Information Collection Activity was published in the Federal Register on June 10, 2013, Volume 78, No. 111, pages 34709-34710. VA received no comments in response to this notice.

b. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances which preclude consultation every three years with representatives of those from whom information is to be obtained.

Outside consultation is conducted with the public through the 60- and 30-day Federal Register notices. Numerous health insurance industry forms were evaluated before these forms were designed. Not only did we incorporate the best features from these industry forms, each form was beneficiary tested for clarity and ease of use.

For VA Form 10-7959e VA also consulted with representatives of the Spina Bifida Association of America, the Shriners Hospitals, and various Veterans’ Service Organizations including the Disabled American Veterans, American Legion, and the Vietnam Veterans of America. The purpose of this consultation was to obtain their views regarding the availability of data, frequency of collection, clarity of instructions, disclosure and record keeping format and on the data elements to be recorded, disclosed, or reported. In addition, staff at the CBOPC provided the expertise and advice gained in reviewing numerous public and private health insurance forms. This expertise and advice resulted in the VA determination to use provider generated billing statements and existing forms (e.g., UB-04 and CMS 1500) in lieu of creating new VA forms.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payment or gift is provided to respondents.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statue, regulation, or agency policy.

Information collected on these forms is protected by the Privacy Act of 1974, VA confidentiality statutes 38 USC 5701 and 38 USC 7332 and 45 CFR Parts 160 and 164, Health Insurance Portability and Accountability Act. Respondents are informed that the information collected will be included as a part of the system of records identified as 54VA16, Health Administration Center Civilian Health and Medical Program Records-VA as set forth in the 2005 Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.html and disclosures made in accordance with the statute.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

VA Form 10-7959a is a claim form and, thus, contains a Release of Medical Information notice informing claimants that by signing the form they are authorizing the release of claim-related medical information including information that could be considered sensitive. Examples of such sensitive documentation are identified in the statement.

12. Estimate of the hour burden of the collection of information:

a. The annualized burden for this collection is 56,570 hours.

Form #	Respondents	X Response	Responses	X Minutes ÷ 60	Total Hours
10-10d	26,468	1	26,468	10	4,411
10-7959a	28,569	7.8413	224,018	10	37,336
10-7959c	80,733	1	80733	10	13,456
10-7959d	4,000	1	4,000	7	467
10-7959e	400	2	800	15	200
Payment (beneficiary claims)	250	12	3,000	10	500
Review and Appeal Process	200	3	600	20	200
TOTALS	140,620		339,619		56,570

b. Provide estimates of annual cost to respondents for the hour burdens for collections of information. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

The annualized cost to respondents is estimated at $845,925 (56,395 hours x $15/hour).

13. Provide an estimate of the total annual cost burden to respondents or record keepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

a. There is no capital, start-up, operation or maintenance costs.

b. Cost estimates are not expected to vary widely. The only cost is that for the time of the respondent.

c. There is no anticipated recordkeeping burden beyond that which is considered usual and customary.

14. Provide estimates of annual cost to the federal government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.

The cost to the federal government is currently estimated at approximately $589,334. The “per claim” cost has been reduced from previous years because of the ongoing improvements in technological advancements. The HAC's Optical Character Recognition (OCR) capabilities are fully functional, reducing the cost per claim, and the beneficiary population continues their increased use of downloaded fill-in forms on the Internet, eliminating the needs of printing and postage for the organization.

Form	Hourly Salary	Responses	Time to Complete	Total Hours	Cost
10-10d	$15.80	26,468	12 minutes	5,294	$83,639
10-7959a	$15.80	224,018	6 minutes	22,402	$353,948
10-7959c	$15.80	80,733	5 minutes	6,728	$106,298
10-7959d	$15.80	4,000	7 minutes	467	$7,653
10-7959e	$15.80	3,000	30 minutes	1,500	$23,700
Clinical review	$45.32	600	30 minutes	815,760	$13,596
Printing/Distribution/Supplies					$500
	TOTAL				$589,334

15. Explain the reason for any changes reported in Items 13 or 14 of OMB 83-I.

The data collection for 2900-0219, Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) has minor modifications to all forms:

• An organizational name change has been added to all forms. It changes from “The Health Administration Center (HAC)” to “Chief Business Office Purchased Care CBOPC.”

• All the forms have been updated to reflect August 2013.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

There are no plans to publish the results of the information collected.

17. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

VA seeks to minimize the cost to itself of collecting, processing and using the information by not displaying the expiration date. We seek an exemption that waives the displaying of the expiration date on this VA Form. The VA Form may be stocked by the CBOPC or reproduced by the respondents and veterans service organizations from the Internet and then stocked. If we are required to display an expiration date, it would result in unnecessary waste of existing stock of the forms. Inclusion of the expiration date would place an unnecessary burden on the respondent (since they would find it necessary to obtain a newer version, while VA would have accepted the old one).

18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.

There are no exceptions.

B. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS

The number of applications for CHAMPVA benefits determines the frequency of data collection, there are no statistical methods employed.

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