(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]