(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]