(a)
General.
The Director,
OCHAMPUS, or a designee, is responsible for ensuring that benefits
under CHAMPUS are paid only to the extent described in this part.
Before benefits can be paid, an appropriate claim must be submitted
that includes sufficient information as to beneficiary identification,
the medical services and supplies provided, and double coverage
information, to permit proper, accurate, and timely adjudication
of the claim by the CHAMPUS contractor or OCHAMPUS. Providers must
be able to document that the care or service shown on the claim
was rendered. This section sets forth minimum medical record requirements
for verification of services. Subject to such definitions, conditions,
limitations, exclusions, and requirements as may be set forth in
this part, the following are the CHAMPUS claim filing requirements:
(1) CHAMPUS
identification card required.
A patient shall present his or her applicable
CHAMPUS identification card (that is, Uniformed Services identification
card) to the authorized provider of care that identifies the patient
as an eligible CHAMPUS beneficiary (refer to Sec. 199.3 of this
part).
(2) Claim required.
No benefit may be extended
under the Basic Program or Extended Care Health Option (ECHO) without
submission of an appropriate, complete and properly executed claim
form.
(3) Responsibility
for perfecting claim.
It is the responsibility of the CHAMPUS beneficiary
or sponsor or the authorized provider acting on behalf of the CHAMPUS
beneficiary to perfect a claim for submission to the appropriate
CHAMPUS fiscal intermediary. Neither a CHAMPUS fiscal intermediary nor
OCHAMPUS is authorized to prepare a claim on behalf of a CHAMPUS
beneficiary.
(4) Obtaining appropriate claim form.
CHAMPUS provides
specific CHAMPUS forms appropriate for making a claim for benefits
for various types of medical services and supplies (such as hospital, physician,
or prescription drugs). Claim forms may be obtained from the appropriate
CHAMPUS fiscal intermediary who processes claims for the beneficiary’s
state of residence, from the Director, OCHAMPUS, or a designee,
or from CHAMPUS health benefits advisors (HBAs) located at all Uniformed Services
medical facilities.
(5) Prepayment not required.
A CHAMPUS beneficiary or sponsor
is not required to pay for the medical services or supplies before
submitting a claim for benefits.
(6) Deductible certificate.
If
the calendar year outpatient deductible, as defined in Sec. 199.4(f)(2)
has been met by a beneficiary or a family through the submission
of a claim or claims to a CHAMPUS fiscal intermediary in a geographic
location different from the location where a current claim is being submitted,
the beneficiary or sponsor must obtain a deductible certificate
from the CHAMPUS fiscal intermediary where the applicable individual
or family calendar year deductible was met. Such deductible certificate
must be attached to the current claim being submitted for benefits.
Failure to obtain a deductible certificate under such circumstances
will result in a second individual or family calendar year deductible
being applied. However, this second deductible may be reimbursed
once appropriate documentation, as described in this paragraph is
supplied to the CHAMPUS fiscal intermediary applying the second
deductible (refer to Sec. 199.4 (f)(2)(i)(F)).
(7) Nonavailability
Statement (DD Form 1251).
In some geographic locations or under certain circumstances,
it is necessary for a CHAMPUS beneficiary to determine whether the
required medical care can be provided through a Uniformed Services
facility. If the required medical care cannot be provided by the
Uniformed Services facility, a Nonavailability Statement will be
issued. When required (except for emergencies), this Nonavailability
Statement must be issued before medical care is obtained from civilian
sources. Failure to secure such a statement will waive the beneficiary’s
rights to benefits under CHAMPUS, subject to appeal to the appropriate
hospital commander (or higher medical authority).
(i) Rules applicable
to issuance of Nonavailability Statement.
Appropriate policy guidance
may be issued as necessary to prescribe the conditions for the issuance
and use of a Nonavailability Statement.
(ii) Beneficiary
responsibility.
The beneficiary shall ascertain whether or
not he or she resides in a geographic area that requires obtaining
a Nonavailability Statement. Information concerning current rules
may be obtained from the CHAMPUS fiscal intermediary concerned,
a CHAMPUS HBA or the Director, OCHAMPUS, or a designee.
(iii) Rules in effect
at time civilian care is provided apply.
The applicable rules regarding
Nonavailability Statements in effect at the time the civilian care
is rendered apply in determining whether a Nonavailability Statement
is required.
(iv) Nonavailability
Statement must be filed with applicable claim.
When a claim is submitted
for CHAMPUS benefits that includes services for which a Nonavailability
Statement is required, such statement must be submitted along with
the claim form.
(b)
Information
required to adjudicate a CHAMPUS claim.
Claims received that are not completed
fully and that do not provide the following minimum information
may be returned. If enough space is not available on the appropriate
claim form, the required information must be attached separately
and include the patient’s name and address, be dated, and signed.
(1) Patient’s
identification information.
The following patient identification information
must be completed on every CHAMPUS claim form submitted for benefits
before a claim will be adjudicated and processed:
(i) Patient’s
full name.
(ii) Patient’s residence
address.
(iii) Patient’s date
of birth.
(iv) Patient’s relationship
to sponsor.
Note: If name of patient is different from
sponsor, explain (for example, stepchild or illegitimate child).
(v) Patient’s
identification number (from DD Form 1173).
(vi) Patient’s
identification card effective date and expiration date (from DD
Form 1173).
(vii) Sponsor’s full
name.
(viii) Sponsor’s service
or social security number.
(ix) Sponsor’s grade.
(x) Sponsor’s
organization and duty station. Home port for ships; home address
for retiree.
(xi) Sponsor’s branch
of service or deceased or retiree’s former branch of service.
(xii) Sponsor’s
current status. Active duty, retired, or deceased.
(2) Patient treatment
information.
The
following patient treatment information routinely is required relative
to the medical services and supplies for which a claim for benefits
is being made before a claim will be adjudicated and processed:
(i) Diagnosis.
All applicable
diagnoses are required; standard nomenclature is acceptable. In
the absence of a diagnosis, a narrative description of the definitive
set of symptoms for which the medical care was rendered must be
provided.
(ii) Source of care.
Full name of
source of care (such as hospital or physician) providing the specific medical
services being claimed.
(iii) Full address
of source of care.
This address must be where the care actually
was provided, not a billing address.
(iv) Attending physician.
Name of attending
physician (or other authorized individual professional provider).
(v) Referring physician.
Name and address
of ordering, prescribing, or referring physician.
(vi) Status of patient.
Status of patient
at the time the medical services and supplies were rendered (that
is, inpatient or outpatient).
(vii) Dates of service.
Specific and
inclusive dates of service.
(viii) Inpatient
stay.
Source
and dates of related inpatient stay (if applicable).
(ix) Physicians or
other authorized individual professional providers.
The claims must
give the name of the individual actually rendering the care, along
with the individual’s professional status (e.g., M.D., Ph.D., R.N.,
etc.) and provider number, if the individual signing the claim is
not the provider who actually rendered the service. The following
information must also be included:
(A) Date each service
was rendered.
(B) Procedure code
or narrative description of each procedure or service for each date
of service.
(C) Individual charge
for each item of service or each supply for each date.
(D) Detailed
description of any unusual complicating circumstances related to
the medical care provided that the physician or other individual
professional provider may choose to submit separately.
(x) Hospitals or
other authorized institutional providers.
For care provided by hospitals
(or other authorized institutional providers), the following information
also must be provided before a claim will be adjudicated and processed:
(A) An
itemized billing showing each item of service or supply provided
for each day covered by the claim.
Note: The Director,
OCHAMPUS, or a designee, may approve, in writing, an alternative
billing procedure for RTCs or other special institutions, in which
case the itemized billing requirement may be waived. The particular
facility will be aware of such approved alternate billing procedure.
(B) Any
absences from a hospital or other authorized institution during
a period for which inpatient benefits are being claimed must be
identified specifically as to date or dates and provide details
on the purpose of the absence. Failure to provide such information
will result in denial of benefits and, in an ongoing case, termination
of benefits for the inpatient stay at least back to the date of
the absence.
(C) For hospitals subject
to the CHAMPUS DRG-based payment system (see paragraph (a)(1)(ii)(D)
of Sec. 199.14), the following information is also required:
(1) The principal diagnosis (the diagnosis
established, after study, to be chiefly responsible for causing
the patient’s admission to the hospital).
(2) All secondary diagnoses.
(3) All significant procedures performed.
(4) The discharge status of the beneficiary.
(5) The hospital’s Medicare provider number.
(6) The source of the admission.
(D) Claims
submitted by hospitals (or other authorized institutional providers)
must include the name of the individual actually rendering the care,
along with the individual’s professional status (e.g., M.D., Ph.D.,
R.N., etc.).
(xi) Prescription
drugs and medicines (and insulin).
For prescription drugs and
medicines (and insulin, whether or not a prescription is required)
receipted bills must be attached and the following additional information
provided:
(A) Name of drug.
Note: When the physician or pharmacist so requests,
the name of the drugs may be submitted to the CHAMPUS fiscal intermediary
directly by the physician or pharmacist.
(B) Strength
of drug.
(C) Name and address
of pharmacy where drug was purchased.
(D) Prescription
number of drug being claimed.
(xii) Other authorized
providers.
For
items from other authorized providers (such as medical supplies), an
explanation as to the medical need must be attached to the appropriate
claim form. For purchases of durable equipment under the ECHO it
is necessary also to attach a copy of the preauthorization.
(xiii) Nonparticipating
providers.
When
the beneficiary or sponsor submits the claim to the CHAMPUS fiscal
intermediary (that is, the provider elects not to participate),
an itemized bill from the provider to the beneficiary or sponsor
must be attached to the CHAMPUS claim form.
(3) Medical records/medical
documentation.
Medical
records are of vital importance in the care and treatment of the
patient. Medical records serve as a basis for planning of patient
care and for the ongoing evaluation of the patient’s treatment and
progress. Accurate and timely completion of orders, notes, etc.,
enable different members of a health care team and subsequent health
care providers to have access to relevant data concerning the patient.
Appropriate medical records must be maintained in order to accommodate
utilization review and to substantiate that billed services were
actually rendered.
(i) All care rendered
and billed must be appropriately documented in writing. Failure
to document the care billed will result in the claim or specific
services on the claim being denied CHAMPUS cost-sharing.
(ii) A
pattern of failure to adequately document medical care will result
in episodes of care being denied CHAMPUS cost-sharing.
(iii) Cursory
notes of a generalized nature that do not identify the specific
treatment and the patient’s response to the treatment are not acceptable.
(iv) The
documentation of medical records must be legible and prepared as
soon as possible after the care is rendered. Entries should be made
when the treatment described is given or the observations to be
documented are made. The following are documentation requirements
and specific time frames for entry into the medical records:
(A) General
requirements for acute medical/surgical services:
(1) Admission evaluation report within 24
hours of admission.
(2) Completed
history and physical examination report within 72 hours of admission.
(3) Registered nursing notes at the end of
each shift.
(4) Daily physician
notes.
(B) Requirements specific
to mental health services:
(1) Psychiatric
admission evaluation report within 24 hours of admission.
(2) History and physical examination within
24 hours of admission; complete report documented within 72 hours
for acute and residential programs and within 3 working days for
partial programs.
(3) Individual
and family therapy notes within 24 hours of procedure for acute,
detoxification and Residential Treatment Center (RTC) programs and
within 48 hours for partial programs.
(4) Preliminary treatment plan within 24 hours
of admission.
(5) Master treatment
plan within 5 calendar days of admission for acute care, 10 days
for RTC care, 5 days for full-day partial programs and within 7
days for half-day partial programs.
(6) Family assessment report within 72 hours
of admission for acute care and 7 days for RTC and partial programs.
(7) Nursing assessment report within 24 hours
of admission.
(8) Nursing notes
at the end of each shift for acute and detoxification programs;
every ten visits for partial hospitalization; and at least once
a week for RTCs.
(9) Daily physician
notes for intensive treatment, detoxification, and rapid stabilization
programs; twice per week for acute programs; and once per week for
RTC and partial programs.
(10) Group therapy
notes once per week.
(11) Ancillary
service notes once per week.
Note: A pattern of
failure to meet the above criteria may result in provider sanctions
prescribed under Sec. 199.9.
(4) Double coverage
information.
When
the CHAMPUS beneficiary is eligible for medical benefits coverage
through another plan, insurance, or program, either private or Government,
the following information must be provided:
(i) Name of other
coverage.
Full
name and address of double coverage plan, insurance, or program (such
as Blue Cross, Medicare, commercial insurance, and state program).
(ii) Source of double
coverage.
Source
of double coverage (such as employment, including retirement, private
purchase, membership in a group, and law).
(iii) Employer information.
If source of
double coverage is employment, give name and address of employer.
(iv) Identification
number.
Identification
number or group number of other coverage.
(5) Right to additional
information.
(i) As a condition precedent to the cost-sharing
of benefits under this part or pursuant to a review or audit, whether
the review or audit is prospective, concurrent, or retroactive,
OCHAMPUS or CHAMPUS contractors may request, and shall be entitled
to receive, information from a physician or hospital or other person,
institution, or organization (including a local, state, or Federal
Government agency) providing services or supplies to the beneficiary
for whom claims or requests for approval for benefits are submitted.
Such information and records may relate to the attendance, testing,
monitoring, examination, diagnosis, treatment, or services and supplies
furnished to a beneficiary and, as such, shall be necessary for
the accurate and efficient administration of CHAMPUS benefits. This
may include requests for copies of all medical records or documentation related
to the episode of care. In addition, before a determination on a
request for preauthorization or claim of benefits is made, a beneficiary,
or sponsor, shall provide additional information relevant to the requested
determination, when necessary. The recipient of such information
shall hold such records confidential except when:
(A) Disclosure
of such information is authorized specifically by the beneficiary;
(B) Disclosure
is necessary to permit authorized governmental officials to investigate
and prosecute criminal actions; or
(C) Disclosure is authorized
or required specifically under the terms of DoD Directive 5400.7
and 5400.11, the Freedom of Information Act, and the Privacy Act
(refer to paragraph (m) of Sec. 199.1 of this part).
(ii) For
the purposes of determining the applicability of and implementing
the provisions of Secs. 199.8 and 199.9, or any provision of similar
purpose of any other medical benefits coverage or entitlement, OCHAMPUS
or CHAMPUS fiscal intermediaries, without consent or notice to any beneficiary
or sponsor, may release to or obtain from any insurance company
or other organization, governmental agency, provider, or person,
any information with respect to any beneficiary when such release
constitutes a routine use duly published in the Federal Register
in accordance with the Privacy Act.
(iii) Before a beneficiary’s
claim of benefits is adjudicated, the beneficiary or the provider(s)
must furnish to CHAMPUS that information which is necessary to make
the benefit determination. Failure to provide the requested information
will result in denial of the claim. A beneficiary, by submitting
a CHAMPUS claim(s) (either a participating or nonparticipating claim),
is deemed to have given consent to the release of any and all medical
records or documentation pertaining to the claims and the episode
of care.
(c) Signature on CHAMPUS
Claim Form--
(1) Beneficiary
signature.
CHAMPUS
claim forms must be signed by the beneficiary except under the conditions
identified in paragraph (c)(1)(v) of this section. The parent or
guardian may sign for any beneficiary under 18 years.
(i) Certification
of identity.
This
signature certifies that the patient identification information provided
is correct.
(ii) Certification
of medical care provided.
This signature certifies that the specific
medical care for which benefits are being claimed actually were
rendered to the beneficiary on the dates indicated.
(iii) Authorization
to obtain or release information.
Before requesting additional
information necessary to process a claim or releasing medical information,
the signature of the beneficiary who is 18 years old or older must
be recorded on or obtained on the CHAMPUS claim form or on a separate release
form. The signature of the beneficiary, parent, or guardian will
be requested when the beneficiary is under 18 years.
Note: If the care was rendered to a minor and a custodial
parent or legal guardian requests information prior to the minor
turning 18 years of age, medical records may still be released pursuant
to the signature of the parent or guardian, and claims information
may still be released to the parent or guardian in response to the
request, even though the beneficiary has turned 18 between the time
of the request and the response. However, any follow-up request
or subsequent request from the parent or guardian, after the beneficiary
turns 18 years of age, will necessitate the authorization of the beneficiary
(or the beneficiary’s legal guardian as appointed by a cognizant
court), before records and information can be released to the parent
or guardian.
(iv) Certification
of accuracy and authorization to release double coverage information.
This signature certifies
to the accuracy of the double coverage information and authorizes
the release of any information related to double coverage. (Refer
to Sec. 199.8 of this part).
(v) Exceptions to beneficiary signature requirement.
(A) Except
as required by paragraph (c)(1)(iii) of this section, the signature
of a spouse, parent, or guardian will be accepted on a claim submitted
for a beneficiary who is 18 years old or older.
(B) When
the institutional provider obtains the signature of the beneficiary
(or the signature of the parent or guardian when the beneficiary
is under 18 years) on a CHAMPUS claim form at admission, the following
participating claims may be submitted without the beneficiary’s
signature.
(1) Claims for laboratory and diagnostic tests
and test interpretations from radiologists, pathologists, neurologists,
and cardiologists.
(2) Claims from
anesthesiologists.
(C) Claims filed by
providers using CHAMPUS-approved signature-on-file and claims submission procedures.
(2) Provider’s signature.
A participating
provider (see paragraph (a)(8) of Sec. 199.6) is required to sign
the CHAMPUS claim form.
(i) Certification.
A participating provider’s
signature on a CHAMPUS claim form:
(A) Certifies that
the specific medical care listed on the claim form was, in fact,
rendered to the specific beneficiary for which benefits are being
claimed, on the specific date or dates indicated, at the level indicated
and by the provider signing the claim unless the claim otherwise
indicates another individual provided the care. For example, if
the claim is signed by a psychiatrist and the care billed was rendered
by a psychologist or licensed social worker, the claim must indicate
both the name and profession of the individual who rendered the
care.
(B) Certifies that the provider has agreed to participate
(providing this agreement has been indicated on the claim form)
and that the CHAMPUS-determined allowable charge or cost will constitute
the full charge or cost for the medical care listed on the specific
claim form; and further agrees to accept the amount paid by CHAMPUS
or the CHAMPUS payment combined with the cost-shared amount paid
by, or on behalf of the beneficiary, as full payment for the covered
medical services or supplies.
(1) Thus, neither
CHAMPUS nor the sponsor is responsible for any additional charges,
whether or not the CHAMPUS-determined charge or cost is less than
the billed amount.
(2) Any provider
who signs and submits a CHAMPUS claim form and then violates this
agreement by billing the beneficiary or sponsor for any difference
between the CHAMPUS-determined charge or cost and the amount billed
is acting in bad faith and is subject to penalties including withdrawal
of CHAMPUS approval as a CHAMPUS provider by administrative action
of the Director, OCHAMPUS, or a designee, and possible legal action
on the part of CHAMPUS, either directly or as a part of a beneficiary action,
to recover monies improperly obtained from CHAMPUS beneficiaries
or sponsors (refer to Sec. 199.6 of this part.)
(ii) Physician or
other authorized individual professional provider.
A physician
or other authorized individual professional provider is liable for
any signature submitted on his or her behalf. Further, a facsimile
signature is not acceptable unless such facsimile signature is on
file with, and has been authorized specifically by, the CHAMPUS
fiscal intermediary serving the state where the physician or other
authorized individual professional provider practices.
(iii) Hospital or
other authorized institutional provider.
The provider signature on
a claim form for institutional services must be that of an authorized
representative of the hospital or other authorized institutional
provider, whose signature is on file with and approved by the appropriate
CHAMPUS fiscal intermediary.
(d) Claims filing deadline.
For all services
provided on or after January 1, 1993, to be considered for benefits,
all claims submitted for benefits must, except as provided in paragraph
(d)(2) of this section, be filed with the appropriate CHAMPUS contractor
no later than one year after the services are provided. Unless the
requirement is waived, failure to file a claim within this deadline
waives all rights to benefits for such services or supplies.
(1) Claims returned
for additional information.
When a claim is submitted initially within
the claim filing time limit, but is returned in whole or in part
for additional information to be considered for benefits, the returned
claim, along with the requested information, must be resubmitted
and received by the appropriate CHAMPUS contractor no later than
the later of:
(i) One year after
the services are provided; or
(ii) 90 days from the
date the claim was returned to the provider or beneficiary.
(2) Exception to
claims filing deadline.
The Director, OCHAMPUS, or a designee, may
grant exceptions to the claims filing deadline requirements.
(i) Types of exception.
(A) Retroactive
eligibility.
Retroactive
CHAMPUS eligibility determinations.
(B) Administrative
error.
Administrative
error (that is, misrepresentation, mistake, or other accountable
action) of an officer or employee of OCHAMPUS (including OCHAMPUSEUR)
or a CHAMPUS fiscal intermediary, performing functions under CHAMPUS
and acting within the scope of that official’s authority.
(C) Mental incompetency.
Mental incompetency
of the beneficiary or guardian or sponsor, in the case of a minor
child (which includes inability to communicate, even if it is the
result of a physical disability).
(D) Delays by other
health insurance.
When not attributable to the beneficiary,
delays in adjudication by other health insurance companies when
double coverage coordination is required before the CHAMPUS benefit
determination.
(E) Other waiver authority.
The Director, OCHAMPUS may
waive the claims filing deadline in other circumstances in which
the Director determines that the waiver is necessary in order to
ensure adequate access for CHAMPUS beneficiaries to health care
services.
(ii) Request for
exception to claims filing deadline.
Beneficiaries who wish to
request an exception to the claims filing deadline may submit such
a request to the CHAMPUS fiscal intermediary having jurisdiction
over the location in which the service was rendered, or as otherwise
designated by the Director, OCHAMPUS.
(A) Such
requests for an exception must include a complete explanation of
the circumstances of the late filing, together with all available
documentation supporting the request, and the specific claim denied
for late filing.
(B) Each request for
an exception to the claims filing deadline is reviewed individually
and considered on its own merits.
(e) Other claims filing
requirements.
Notwithstanding
the claims filing deadline described in paragraph (d) of this section,
to lessen any potential adverse impact on a CHAMPUS beneficiary
or sponsor that could result from a retroactive denial, the following
additional claims filing procedures are recommended or required.
(1) Continuing care.
Except for claims
subject to the CHAMPUS DRG-based payment system, whenever medical
services and supplies are being rendered on a continuing basis,
an appropriate claim or claims should be submitted every 30 days
(monthly) whether submitted directly by the beneficiary or sponsor
or by the provider on behalf of the beneficiary. Such claims may
be submitted more frequently if the beneficiary or provider so elects.
The Director, OCHAMPUS, or a designee, also may require more frequent
claims submission based on dollars. Examples of care that may be
rendered on a continuing basis are outpatient physical therapy,
private duty (special) nursing, or inpatient stays. For claims subject
to the CHAMPUS DRG-based payment system, claims may be submitted
only after the beneficiary has been discharged or transferred from
the hospital.
(2) [Reserved]
(3) Claims involving
the services of marriage and family counselors, pastoral counselors,
and supervised mental health counselors.
CHAMPUS requires that marriage
and family counselors, pastoral counselors, and supervised mental
health counselors make a written report to the referring physician
concerning the CHAMPUS beneficiary’s progress. Therefore, each claim
for reimbursement for services of marriage and family counselors,
pastoral counselors, and supervised mental health counselors must
include certification to the effect that a written communication
has been made or will be made to the referring physician at the
end of treatment, or more frequently, as required by the referring
physician.
(f)
Preauthorization.
When specifically
required in other sections of this part, preauthorization requires
the following:
(1) Preauthorization must be granted before benefits
can be extended.
In those situations requiring preauthorization,
the request for such preauthorization shall be submitted and approved
before benefits may be extended, except as provided in Sec. 199.4(a)(11).
If a claim for services or supplies is submitted without the required
preauthorization, no benefits shall be paid, unless the Director, OCHAMPUS,
or a designee, has granted an exception to the requirement for preauthorization.
(i) Specifically
preauthorized services.
An approved preauthorization specifies the
exact services or supplies for which authorization is being given.
In a preauthorization situation, benefits cannot be extended for
services or supplies provided beyond the specific authorization.
(ii) Time limit on
preauthorization.
Approved preauthorizations are valid for specific
periods of time, appropriate for the circumstances presented and
specified at the time the preauthorization is approved. In general,
preauthorizations are valid for 30 days. If the preauthorized service
or supplies are not obtained or commenced within the specified time
limit, a new preauthorization is required before benefits may be
extended. For organ and stem cell transplants, the preauthorization
shall remain in effect as long as the beneficiary continues to meet
the specific transplant criteria set forth in the TRICARE/CHAMPUS
Policy Manual, or until the approved transplant occurs.
(2) Treatment plan.
Each preauthorization
request shall be accompanied by a proposed medical treatment plan
(for inpatient stays under the Basic Program) which shall include
generally a diagnosis; a detailed summary of complete history and
physical; a detailed statement of the problem; the proposed treatment
modality, including anticipated length of time the proposed modality
will be required; any available test results; consultant’s reports;
and the prognosis. When the preauthorization request involves transfer
from a hospital to another inpatient facility, medical records related
to the inpatient stay also must be provided.
(3) Claims for services
and supplies that have been preauthorized.
Whenever a claim is submitted
for benefits under CHAMPUS involving preauthorized services and
supplies, the date of the approved preauthorization must be indicated
on the claim form and a copy of the written preauthorization must be
attached to the appropriate CHAMPUS claim.
(4) Advance payment
prohibited.
No
CHAMPUS payment shall be made for otherwise authorized services
or items not yet rendered or delivered to the beneficiary.
(g) Claims review.
It is the responsibility
of the CHAMPUS fiscal intermediary (or OCHAMPUS, including OCHAMPUSEUR)
to review each CHAMPUS claim submitted for benefit consideration
to ensure compliance with all applicable definitions, conditions,
limitations, or exclusions specified or enumerated in this part.
It is also required that before any CHAMPUS benefits may be extended,
claims for medical services and supplies will be subject to utilization
review and quality assurance standards, norms, and criteria issued
by the Director, OCHAMPUS, or a designee (see paragraph (a)(1)(v)
of Sec. 199.14 for review standards for claims subject to the CHAMPUS
DRG-based payment system).
(h) Benefit payments.
CHAMPUS benefit
payments are made either directly to the beneficiary or sponsor
or to the provider, depending on the manner in which the CHAMPUS
claim is submitted.
(1) Benefit payments made to beneficiary or sponsor.
When the CHAMPUS
beneficiary or sponsor signs and submits a specific claim form directly
to the appropriate CHAMPUS fiscal intermediary (or OCHAMPUS, including
OCHAMPUSEUR), any CHAMPUS benefit payments due as a result of that specific
claim submission will be made in the name of, and mailed to, the
beneficiary or sponsor. In such circumstances, the beneficiary or
sponsor is responsible to the provider for any amounts billed.
(2) Benefit payments
made to participating provider.
When the authorized provider elects to participate
by signing a CHAMPUS claim form, indicating participation in the
appropriate space on the claim form, and submitting a specific claim
on behalf of the beneficiary to the appropriate CHAMPUS fiscal intermediary,
any CHAMPUS benefit payments due as a result of that claim submission
will be made in the name of and mailed to the participating provider.
Thus, by signing the claim form, the authorized provider agrees
to abide by the CHAMPUS-determined allowable charge or cost, whether
or not lower than the amount billed. Therefore, the beneficiary
or sponsor is responsible only for any required deductible amount
and any cost-sharing portion of the CHAMPUS-determined allowable charge
or cost as may be required under the terms and conditions set forth
in Secs. 199.4 and 199.5 of this part.
(3) CEOB.
(i) When
a CHAMPUS claim is adjudicated, a CEOB is sent to the beneficiary
or sponsor. A copy of the CEOB also is sent to the provider if the
claim was submitted on a participating basis. The CEOB form provides,
at a minimum, the following information: (i) Name and address of
beneficiary.
(ii) Name and address
of provider.
(iii) Services or supplies
covered by claim for which CEOB applies.
(iv) Dates
services or supplies provided.
(v) Amount billed;
CHAMPUS-determined allowable charge or cost; and amount of CHAMPUS payment.
(vi) To
whom payment, if any, was made.
(vii) Reasons for any
denial.
(viii) Recourse available
to beneficiary for review of claim decision (refer to Sec. 199.10
of this part).
Note: The Director, OCHAMPUS, or a designee,
may authorize a CHAMPUS fiscal intermediary to waive a CEOB to protect
the privacy of a CHAMPUS beneficiary.
(4) Benefit under
$1.
If
the CHAMPUS benefit is determined to be under $1, payment is waived.
(i) Extension of the
Active Duty Dependents Dental Plan to areas outside the United States.
The Assistant
Secretary of Defense (Health Affairs) (ASD(HA) may, under the authority
of 10 U.S.C. 1076a(h), extend the Active Duty Dependents Dental
Plan to areas other than those areas specified in paragraph (a)(2)(i)
of this section for the eligible beneficiaries of members of the
Uniformed Services. In extending the program outside the Continental
United States, the ASD(HA), or designee, is authorized to establish
program elements, methods of administration and payment rates and
procedures to providers that are different from those in effect
under this section in the Continental United States to the extent
the ASD(HA), or designee, determines necessary for the effective
and efficient operation of the plan outside the Continental United
States. This includes provisions for preauthorization of care if the
needed services are not available in a Uniformed Service overseas
dental treatment facility and payment by the Department of certain
cost-shares and other portions of a provider’s billed charges. Other
differences may occur based on limitations in the availability and
capabilities of the Uniformed Services overseas dental treatment
facility and a particular nation’s civilian sector providers in
certain areas. Otherwise, rules pertaining to services covered under
the plan and quality of care standards for providers shall be comparable
to those in effect under this section in the Continental United
States and available military guidelines. In addition, all provisions
of 10 U.S.C. 1076a shall remain in effect.
(j) General assignment
of benefits not recognized.
CHAMPUS does not recognize any general assignment
of CHAMPUS benefits to another person. All CHAMPUS benefits are
payable as described in this and other Sections of this part.
[51 FR 24008, Jul 1, 1986, as amended at
52 FR 33007, Sep 1, 1987; 53 FR 5373, Feb 24, 1988; 54 FR 25246,
Jun 14, 1989; 56 FR 28487, Jun 21, 1991; 56 FR 59878, Nov 26, 1991;
58 FR 35408, Jul 1, 1993; 58 FR 51238, Oct 1, 1993; 58 FR 58961,
Nov 5, 1993; 62 FR 35097, Jun 30, 1997; 63 FR 48446, Sep 10, 1998; 64
FR 38576, Jul 19, 1999; 67 FR 42721, Jun 25, 2002; 68 FR 44881,
Jul 31, 2003; 69 FR 44952, Jul 28, 2004; 69 FR 51569, Aug 20, 2004;
70 FR 19265, Apr 13, 2005; 79 FR 41642, Jul 17, 2014; 81 FR 61097,
Sep 2, 2016; 82 FR 45447, Sep 29, 2017]