(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]