Title 32 National Defense Civilian Health And Medical Program Of The Uniformed Services (CHAMPUS) Part 199.13 TRICARE Dental Program Revision: Rule: (a) General provisions-- (1) Purpose. (2) Applicability.-- (i) Geographic scope. (ii) Agency. (iii) Exclusion of benefit services performed in military dental care facilities. (iv) Exception to the exclusion of services performed in military dental care facilities. (3) Authority and responsibility.-- (i) Legislative authority.-- (A) Joint regulations. (B) Administration. (ii) Organizational delegations and assignments-- (A) Assistant Secretary of Defense (Health Affairs) (ASD(HA)). (B) Evidence of eligibility. (4) Preemption of State and local laws. (5) Plan funds-- (i) Funding sources. (ii) Disposition of funds. (iii) Plan. (iv) Contracting out. (6) Role of Health Benefits Advisor (HBA). (7) Right to information. (8) Utilization review and quality assurance. (b) Definitions. (1) Assignment of benefits. (2) Authorized provider. (3) Beneficiary. (4) Beneficiary liability. (5) By report. (6) Contingency operation. (7) Cost-share. (8) Defense Enrollment Eligibility Reporting System (DEERS). (9) Dental hygienist. (10) Dentist. (11) Diagnostic services. (12) Endodontics. (13) Initial determination. (14) Nonparticipating provider. (15) Oral and maxillofacial surgery. (16) Orthodontics. (17) Participating provider. (18) Party to the initial determination. (19) Periodontics. (20) Preventive services. (21) Prosthodontics. (22) Provider. (23) Restorative services. (c) Eligibility and enrollment-- (1) General. (2) Eligibility-- (i) Persons eligible. (ii) Determination of eligibility status and evidence of eligibility-- (A) Eligibility determination responsibility of the Uniformed Services. (B) Procedures for determination of eligibility. (C) Evidence of eligibility required. (3) Enrollment-- (i) Previous plans-- (A) Basic Active Duty Dependents Dental Benefit Plan. (B) Expanded Active Duty Dependents Dental Benefit Plan. (ii) TRICARE Dental Program (TDP)-- (A) Election of coverage. (B) Premiums-- (C) Enrollment period-- (D) Beginning dates of eligibility. (E) Changes in and termination of enrollment. (d) Premium sharing-- (1) General. (i) Members required to pay a portion of the premium cost. (ii) Members required to pay the full premium cost. (2) Proportion of premium share. (3) Provision for increases in active duty, Selected Reserve and Individual Ready Reserve member’s premium share. (4) Reduction of premium share for enlisted members. (5) Reduction of cost-shares for enlisted members. (6) Premium payment method. (7) Annual notification of premium rates. (e) Plan benefits-- (1) General.-- (i) Scope of benefits. (ii) Authority to act for the plan. (iii) Dental benefits brochure.-- (A) Content. (B) Distribution. (iv) Alternative course of treatment policy. (2) Benefits. (i) Diagnostic and preventive services. (A) Diagnostic services. (B) Preventive services. (ii) General services and services “by report”. (iii) Restorative services. (iv) Endodontic services. (v) Periodontic services. (vi) Prosthodontic services. (vii) Orthodontic services. (viii) Oral and maxillofacial surgery services. (ix) Exclusion of adjunctive dental care. (x) Benefit limitations and exclusions. (xi) Limitation on reduction of benefits. (3) Cost-shares, liability and maximum coverage.-- (i) Cost-shares. (ii) Dental plan contractor liability. (iii) Maximum coverage amounts. (f) Authorized providers-- (1) General. (2) Authorized provider status does not guarantee payment of benefits. (3) Utilization review and quality assurance. (4) Provider required. (5) Participating provider. (6) Nonparticipating provider. (i) Assignment of benefits. (ii) No assignment of benefits. (7) Alternative delivery system-- (i) General. (ii) Defined. (iii) Elective or exclusive arrangement. (iv) Provider election of participation. (v) Limitation on authorized providers. (vi) Charge agreements. (g) Benefit payment-- (1) General. (2) Benefit payment. (3) Fraud, abuse, and conflict of interest. (h) Appeal and hearing procedures. (1) General. (i) Initial determination-- (A) Notice of initial determination and right to appeal. (B) Effect of initial determination. (ii) Participation in an appeal. (A) Parties to the initial determination. (B) Representative. (iii) Burden of proof. (iv) Evidence in appeal and hearing cases. (v) Late filing. (vi) Appealable issue. (vii) Amount in dispute-- (A) General. (B) Calculated amount. (viii) Levels of appeal. (ix) Appeal decision. (2) Reconsideration. (3) Formal review. (4) Hearing-- (i) General. (ii) Authority of the hearing officer. (5) Final decision. (i) Implementing Instructions.