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case hold such records confidential ex- performed within 90 days of initial recept when:
quest, all pending claims for services (i) Disclosure of such information is and supplies will be denied. A denial of authorized specifically by the bene- payments for services or supplies proficiary;
vided before and related to) the re(ii) Disclosure is necessary to permit
quest for a physical examination is not authorized governmental officials to
subject to reconsideration. The medinvestigate and prosecute criminal ac
ical examination and required benetions, or
ficiary travel related to performing the (iii) Disclosure is authorized or re
requested medical examination will be quired specifically under the terms of
at the expense of CHAMPUS. The medthe Privacy Act or Freedom of Infor
ical examination may be performed by mation Act (refer to $ 199.1(m) of this
a physician in a Uniformed Services part).
medical facility or by an appropriate For the purposes of determining the
civilian physician, as determined and applicability of and implementing the
selected by the Director, OCHAMPUS, provisions of $$199.8, 199.11, and 199.12,
or a designee who is responsible for or any provision of similar purpose of any other medical benefits coverage or
making such arrangements as are necentitlement, OCHAMPUS
essary, including necessary travel arCHAMPUS fiscal intermediaries may
rangements. release, without consent or notice to
(7) Claims filing deadline. For all servany beneficiary or sponsor, to any per
ices provided on or after January 1, son, organization, government agency,
1993, to be considered for benefits, all provider, or other entity any informa
claims submitted for benefits must, extion with respect to any beneficiary cept as provided in $199.7, be filed with when such release constitutes a routine the appropriate CHAMPUS contractor use published in the FEDERAL REGISTER no later than one year after the servin accordance with DoD 5400.11-R (Pri- ices are provided. Unless the requirevacy Act (5 U.S.C. 552a)). Before a per- ment is waived, failure to file a claim son's claim of benefits will be adju- within this deadline waives all rights dicated, the person must furnish to to benefits for such services or supCHAMPUS information that reason- plies. ably may be expected to be in his or (8) Double coverage and third party reher possession and that is necessary to coveries. CHAMPUS claims involving make the benefit determination. Fail
double coverage or the possiblity that ure to provide the requested informa
the United States can recover all or a tion may result in denial of the claim.
part of its expenses from a third party, (6) Physical examinations. The Direc
are specifically subject to the provitor, OCHAMPUS, or a designee, may
sions of $199.8 or $199.12 of this part as require a beneficiary to submit to one
appropriate. or more medical (including psy
(9) Nonavailability Statements within a chiatric) examinations to determine the beneficiary's entitlement to bene
40-mile catchment area. In some geofits for which application has been
graphic locations, it is necessary for made or for otherwise authorized medi
CHAMPUS beneficiaries not enrolled in cally necessary services and supplies
TRICARE Prime to determine whether required in the diagnosis or treatment
the required medical care can be proof an illness or injury (including ma
vided through a Uniformed Services faternity and well-baby care). When a
cility. If the required care cannot be medical examination has been provided, the hospital commander, or quested, CHAMPUS will withhold pay
designee, will issue a Nonavailability ment
any pending claims Statement (DD form 1251). Except for preauthorization requests on that par- emergencies, a Nonavailability Stateticular beneficiary. If the beneficiary ment should be issued before medical refuses to agree to the requested med- care is obtained from a civilian source. ical examination, or unless prevented Failure to secure such a statement by a medical reason acceptable to may waive the beneficiary's rights to OCHAMPUS, the examination is not benefits under CHAMPUS.
(i) Rules applicable to issuance of Nonavailability Statement (NAS) (DD Form 1251).
(A) The ASD(HA) is responsible for issuing rules and regulations regarding Nonavailability Statements.
(B) For CHAMPUS beneficiaries who are not enrolled in TRICARE Prime, an NAS is required for services in connection with non-emergency inpatient hospital care and outpatient and inpatient maternity care if such services are available at a facility of the Uniformed Services located within a 40mile radius of the residence of the beneficiary, except that an NAS is not required for services otherwise available at a facility of the Uniformed Services located within a 40-mile radius of the beneficiary's residence when another insurance plan or program provides the beneficiary primary coverage for the services. For maternity care, an NAS is required for services related to outpatient prenatal, outpatient or inpatient delivery, and outpatient postpartum care subsequent to the visit that confirms the pregnancy. The requirement for an NAS does not apply to beneficiaries enrolled in TRICARE Prime, even when those beneficiaries use the point-of-service option under $199.17(n)(3).
(C) In addition to NAS requirements set forth in paragraph (a)(9) of this section, additional NAS requirements are established
to paragraph (a)(10) of this section in connection with highly specialized care in national or 200-mile catchment areas of military or civilian STS facilities.
(ii) Beneficiary responsibility. A CHAMPUS beneficiary who is not enrolled in TRICARE Prime is responsible for securing information whether or not he or she resides in a geographic area that requires obtaining a Nonavailability Statement. Information concerning current rules and regulations may be obtained from the Offices of the Army, Navy, and Air Force Surgeons General; or a representative of the TRICARE managed care support contractor's staff, or the Director, OCHAMPUS.
(iii) Rules in effect at time civilian medical care is provided apply. The applicable rules and regulations 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 (DD Form 1251) must be filed with applicable claim. When a claim is submitted for CHAMPUS benefits that includes services for which a Nonavailability Statement was issued, a valid Nonavailability Statement authorization must be on DEERS.
(v) Nonavailability Statement (NAS) and Claims Adjudication. A NAS is valid for the adjudication of CHAMPUS claims for all related care otherwise authorized by this part which is received from a civilian source while the beneficiary resided within the Uniformed Service facility catchment area which issued the NAS.
(vi) In the case of any service subject to an NAS requirement under paragraph (a)(9) of this section and also subject to a preadmission (or other preservice) authorization requirement under $199.4 or $199.15, the administrative processes for the NAS and preservice authorization may be combined.
(10) Nonavailability Statements in national or 200-mile catchment areas for highly specialized care available in selected military or civilian Specialized Treatment Service Facilities(i) Specialized Treatment Service Facilities. STS Facilities may be designated for certain high cost, high technology procedures. The purpose of such designations is to concentrate patient referrals for certain highly specialized procedures which are of relatively low incidence and/or relatively high per-case cost and which require patient concentration to permit resource investment and enhance the effectiveness of quality assurance efforts.
(ii) Designation. Selected military treatment facilities and civilian facilities will be designated by the Assistant Secretary of Defense for Health Affairs as STS Facilities for certain procedures. These designations will be based on the highly specialized capabilities of those selected facilities. For each STS designation for which NASs in national or 200-mile catchment areas will be required, there shall be a determination that total government costs associated with providing the service under the Specialized Treatment Services program will in the aggregate be less than the total government cost of that service under the normal operation of CHAMPUS. There shall also be a determination that the Specialized Treatment Services Facility meets a standard of excellence in quality comparable to that prevailing in other highly specialized medical centers in the nation or region that provide the services involved.
(iii) Organ transplants and similar procedures. For organ transplants and procedures of similar extraordinary specialization, military or civilian STS Facilities may be designated for a nationwide catchment area, covering all 50 states, the District of Columbia and Puerto Rico (or, alternatively, for any portion of such a nationwide area).
(iv) Other highly specialized procedures. For other highly specialized procedures, military or civilian STS Facilities will be designated for catchment areas of up to approximately 200 miles radius. The exact geographical area covered for each STS Facility will be identified by reference to State and local governmental jurisdictions, zip code groups or other method to describe an area within an approximate radius of 200 miles from the facility. In paragraph (a)(10) of this section, this catchment area is referred to as a "200-mile catchment area".
(v) NAS requirement. For procedures subject to a nationwide catchment area NAS requirement under paragraph (a)(10)(iii) of this section or a 200-mile catchment
NAS requirement under paragraph (a)(10)(iv) of this section, CHAMPUS cost sharing is not allowed unless the services are obtained from a designated civilian Specialized Treatment Services program (as authorized) or an NAS has been issued. This rule is subject to the exceptions set forth in paragraph (a)(10)(vi) of this section. This NAS requirement is a general requirement of the CHAMPUS program.
(vi) Erceptions. Nationwide catchment areas NASs and 200-mile catchment area NASs are not required in any of the following circumstances:
(A) An emergency.
(B) When another insurance plan or program provides the beneficiary primary coverage for the services.
(C) A case-by-case waiver is granted based on a medical judgment made by the commander of the STS Facility (or other person designated for this purpose) that, although the care is available at the facility, it would be medically inappropriate because of a delay in the treatment or other special reason to require that the STS Facility be used; or
(D) A case-by-case waiver is granted by the commander of the STS Facility (or other person designated for this purpose) that, although the care is available at the facility, use of the facility would impose exceptional hardship on the beneficiary or the beneficiary's family.
(E) The beneficiary is enrolled in TRICARE Prime.
(vii) Waiver process. A process shall be established for beneficiaries to request a case-by-case waiver under paragraphs (a)(10)(vi) (C) and (D) of this section. This process shall include:
(A) An opportunity for the beneficiary (and/or the beneficiary's physician) to submit information the beneficiary believes justifies a waiver.
(B) A written decision from a person designated for the purpose on the request for a waiver, including a statement of the reasons for the decision.
(C) An opportunity for the beneficiary to appeal an unfavorable decision to a designated appeal authority not involved in the initial decision; and
(D) A written decision on the appeal, including a statement of the reasons for the decision.
(viii) Notice. The Assistant Secretary of Defense for Health Affairs will annually publish in the FEDERAL REGISTER a notice of all military and civilian STS Facilities, including a listing of the several procedures subject to nationwide catchment area NASs and the highly specialized procedures subject to 200-mile catchment area NASs.
(ix) Specialized procedures. Highly specialized procedures that may be established as subject to 200-mile catchment area NASs are limited to:
(A) Medical and surgical diagnoses requiring inpatient hospital treatment
of an unusually intensive nature, docu- (11) Quality and Utilization Review mented by a DRG-based payment sys- Peer Review Organization program. All tem weight (pursuant to $ 199.14(a)(1)) benefits under the CHAMPUS program for a single DRG or an aggregated DRG are subject to review under the weight for a category of DRGs of at CHAMPUS Quality and Utilization Releast 2.0 (i.e., treatment is at least two view Peer Review Organization protimes as intensive as the average gram pursuant to $ 199.15. (Utilization CHAMPUS inpatient case).
and quality review of mental health (B) Diagnostic or therapeutic serv- services are also part of the Peer Reices, including outpatient services, re- view Organization program, and are adlated to such inpatient categories of
dressed in paragraph (a)(12) of this sectreatment.
tion.) (C) Other procedures which require
(12) Utilization review, quality assurhighly specialized equipment the cost
ance and reauthorization for inpatient of which exceeds $1,000,000 (e.g.,
mental health services and partial hoslithotriptor, positron emission tomog
pitalization. (i) In general. The Director, raphy equipment) and such equipment
OCHAMPUS shall provide, either diis underutilized in the area; and
rectly or through contract, a program (D) Other comparable highly special
of utilization and quality review for all
mental health care services. Among ized procedures as determined by the Assistant Secretary of Defense for
other things, this program shall inHealth Affairs.
clude mandatory preadmission author
ization before nonemergency inpatient (x) Quality standards. Any facility
mental health services may be prodesignated as a military or civilian
vided and mandatory approval of conSTS Facility under paragraph (a)(10) of
tinuation of inpatient services within this section shall be required to meet
72 hours of emergency admissions. This quality standards established by the
program shall also include requireAssistant Secretary of Defense for
ments for other pretreatment authorHealth Affairs. In the development of
ization procedures, concurrent review such standards, the Assistant Sec
of continuing inpatient and partial retary shall consult with relevant med
hospitalization, retrospective review, ical specialty societies and other ap
and other such procedures as deterpropriate parties. To the extent fea
mined appropriate by the Director, sible, quality standards shall be based
OCHAMPUS. The provisions of paraon nationally recognized standards.
graph (h) of this section and $199.15(f) (xi) NAS procedures. The provisions of
shall apply to this program. The Direcparagraphs (a)(9)(ii) through (a)(9)(v) of
tor, OCHAMPUS, shall establish, purthis section regarding procedures ap- suant to that $ 199.15(f), procedures subplicable to NASs shall apply to ex
stantially comparable to requirements panded catchment area NASs required
of paragraph (h) of this section and by paragraph (a)(10) of this section.
$199.15. If the utilization and quality (xii) Travel and lodging expenses. In review program for mental health care accordance with guidelines issued by services is provided by contract, the the Assistant Secretary of Defense for contractor(s) need not be the same conHealth Affairs, certain travel and lodg- tractor(s) as are engaged under $199.15 ing expenses associated with services in connection with the review of other under the Specialized Treatment Serv- services. ices program may be fully or partially (ii) Preadmission authorization. (A) reimbursed.
This section generally requires (xiii) Preference for military facility preadmission authorization for all nonuse. In any case in which services sub
emergency inpatient mental health ject to an NAS requirement under services and prompt continued stay auparagraph (a)(10) of this section are thorization after emergency admisavailable in both a military STS Facil- sions. It also requires preadmission auity and from a civilian STS Facility, thorization for all admissions to a parthe military Facility must be used un- tial hospitalization program, without less use of the civilian Facility is spe- exception, as the concept of an emercifically authorized.
gency admission does not pertain to a partial hospitalization level of care. services and supplies must be provided This section generally requires and billed for by a hospital or other aupreadmission authorization for all non- thorized institutional provider. Such emergency inpatient mental health billings must be fully itemized and sufservices and prompt continued stay au- ficiently descriptive to permit thorization after emergency admis- CHAMPUS to determine whether benesions. Institutional services for which fits are authorized by this part. Depayment would otherwise be author- pending on the individual cirized, but which were provided without cumstances, teaching physician servcompliance with preadmission author- ices may be considered an institutional ization requirements, do not qualify for benefit in accordance with $199.4(b) or the same payment that would be pro- a professional benefit under $199.4(C). vided if the preadmission requirements See paragraph (c)(3)(xiii) of this section had been met.
for the CHAMPUS requirements re(B) In cases of noncompliance with garding teaching physicians. In the preauthorization requirements, a pay- case of continuous care, claims shall be ment reduction shall be made in ac- submitted
to the appropriate cordance with $199.15(b)(4)(iii).
CHAMPUS fiscal intermediary at least (C) For purposes of paragraph every 30 days either by the beneficiary (a)(12)(ii)(B) of this section, a day of or sponsor or, on a participating basis, services without the appropriate directly by the facility on behalf of the preauthorization is any day of services beneficiary (refer to $ 199.7). provided prior to:
(ii) Successive inpatient admissions. (1) The receipt of an authorization; or Successive inpatient admissions shall
(2) The effective date of an authoriza- be deemed one inpatient confinement tion subsequently received.
for the purpose of computing the active (D) Services for which payment is duty dependent's share of the inpatient disallowed under paragraph institutional charges, provided not (a)(12)(ii)(B) of this section may not be more than 60 days have elapsed bebilled to the patient (or the patient's tween the successive admissions, exfamily).
cept that successive inpatient admis(13) Implementing instructions. The Di- sions related to a single maternity epirector, OCHAMPUS shall issue policies, sode shall be considered one confineprocedures, instructions, guidelines, ment, regardless of the number of days standards and/or criteria to implement between admissions. For the purpose of this section.
applying benefits, successive admis(b) Institutional benefits. (1) General. sions will be determined separately for Services and supplies provided by an maternity admissions and admissions institutional provider authorized as set related to an accidental injury (refer to forth in 199.6 may be cost-shared only $199.4(f)). when such services or supplies: are oth- (iii) Related services and supplies. Coverwise authorized by this part; are ered services and supplies must be renmedically necessary; are ordered, di- dered in connection with and related rected, prescribed, or delivered by an directly to a covered diagnosis or deOCHAMPUS-authorized individual pro- finitive set of symptoms requiring othfessional provider as set forth in 8 199.6 erwise authorized medically necessary or by an employee of the authorized in- treatment. stitutional provider who is otherwise (iv) Inpatient, appropriate level reeligible to be a CHAMPUS authorized quired. For purposes of inpatient care, individual professional provider; are the level of institutional care for which delivered in accordance with generally Basic Program benefits may be exaccepted norms for clinical practice in tended must be at the appropriate level the United States; meet established required to provide the medically necquality standards; and comply with ap- essary treatment except for patients plicable definitions, conditions, limita- requiring skilled nursing facility care. tions, exceptions, or exclusions as oth- For patients for whom skilled nursing erwise set forth in this part.
facility care is adequate, but is not (i) Billing practices. To be considered available in the general locality, benefor benefits under $199.4(b), covered fits may be continued in the higher