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(B) The private duty (special) nursing are better accommodated through the care must be ordered and certified to use of visiting nurses. This allows the be medically necessary by the attend- personal services that are not ing physician.
coverable by CHAMPUS to be obtained (C) The skilled nursing care must be at lesser cost from other than an R.N. rendered by a private duty (special) Skilled nursing services provided by nurse who is neither a member of the visiting nurses are covered under immediate family nor is a member of CHAMPUS. the beneficiary's household.
NOTE: When the services of an R.N. are not (D) Private duty (special) nursing available, benefits may be extended for the care does not, except incidentally, in- otherwise covered services of a L.P.N. or clude providing services that provide or L.V.N. support primarily the essentials of
(xiii) Physicians in a teaching setting. daily living or acting as a companion
(A) Teaching physicians. or sitter.
(1) General. The services of teaching (E) If the private duty (special) nurs
physicians may be reimbursed on an aling care services being performed are
lowable charge basis only when the primarily those that could be rendered
teaching physician has established an by the average adult with minimal instruction or supervision, the services
attending physician relationship be
tween the teaching physician and the would not qualify as covered private
patient or when the teaching physician duty (special) nursing services, regardless of whether performed by an R.N.,
provides distinct, identifiable, personal
services (e.g., services rendered as a regardless of whether or not ordered
consultant, assistant surgeon, etc.). and certified to by the attending physician, and regardless of the condition of
Attending physician services may in
clude both direct patient care services the patient.
or direct supervision of care provided (F) In order for such services to be considered for benefits, a private duty
by a physician in training. In order to
be considered an attending physician, (special) nurse is required to maintain
the teaching physician must: detailed daily nursing notes, whether the case involves inpatient nursing
(i) Review the patient's history and
the record of examinations and tests in service or nursing services rendered in the home setting.
the institution, and make frequent re(G) Claims for continuing private
views of the patient's progress; and duty (special) nursing care shall be
(ii) Personally examine the patient;
and submitted at least every 30 days. Each claim will be reviewed and the nursing
(iiii) Confirm or revise the diagnosis care evaluated whether it continues to
and determine the course of treatment be appropriate and eligible for benefits.
to be followed; and (H) In most situations involving pri
(iv) Either perform the physician's vate duty (special) nursing care ren
services required by the patient or sudered in the home setting, benefits will
pervise the treatment so as to assure be available only for a portion of the that appropriate services are provided care, that is, providing benefits only by physicians in training and that the for that time actually required to per
care meets a proper quality level; and form medically necessary skilled nurs- (v) Be present and ready to perform ing services. If full-time private duty any service performed by an attending (special) nursing services are engaged, physician in a nonteaching setting usually for convenience or to provide when a major surgical procedure or a personal services to the patient,
complex or dangerous medical proceCHAMPUS benefits are payable only dure is performed; and for that portion of the day during (vi) Be personally responsible for the which skilled nursing services are ren- patient's care, at least throughout the dered, but in no event is less than 1 period of hospitalization. hour of nursing care payable in any 24- (2) Direct supervision by an attending hour period during which skilled nurs- physician of care provided by physicians ing services are determined to have in training. Payment on the basis of albeen rendered. Such situations often lowable charges may be made for the
professional services rendered to a beneficiary by his/her attending physician when the attending physician provides personal and identifiable direction to physicians in training who are participating in the care of the patient. It is not necessary that the attending physician be personally present for all services, but the attending physician must be on the provider's premises and available to provide immediate personal assistance and direction if needed.
(3) Individual, personal services. A teaching physician may be reimbursed on an allowable charge basis for any individual, identifiable service rendered to a CHAMPUS beneficiary, so long as the service is a covered service and is normally reimbursed separately, and so long as the patient records substantiate the service.
(4) Who may bill. The services of a teaching physician must be billed by the institutional provider when the physician is employed by the provider or a related entity or under a contract which provides for payment to the physician by the provider or a related entity. Where the teaching physician has no relationship with the provider (except for standard physician privileges to admit patients) and generally treats patients on a fee-for-service basis in the private sector, the teaching physician may submit claims under his/her own provider number.
(B) Physicians in training. Physicians in training in an approved teaching program are considered to be “students” and may not be reimbursed directly by CHAMPUS for services rendered to a beneficiary when their services are provided as part of their employment (either salaried or contractual) by a hospital or other institutional provider. Services of physicians in training may be reimbursed on an allowable charge basis only if:
(1) The physician in training is fully licensed to practice medicine by the state in which the services are performed, and
(2) The services are rendered outside the scope and requirements of the approved training program to which the physician in training is assigned.
(d) Other benefits—(1) General. Benefits may be extended for the allowable charge of those other covered services
and supplies described in paragraph (d) of this section, which are provided in accordance with good medical practice and established standards of quality by those other authorized providers described in $199.6 of this Regulation. Such benefits are subject to all applicable definitions, conditions, limitations, or exclusions as otherwise may be set forth in this or other chapters of this Regulation. To be considered for benefits under paragraph (d) of this section, the described services or supplies must be prescribed and ordered by a physician. Other authorized individual professional providers acting within their scope of licensure may also prescribe and order these services and supplies unless otherwise specified in paragraph (d) of this section. For example, durable medical equipment and cardiorespiratory monitors can only be ordered by a physician.
(2) Billing practices. To be considered for benefits under paragraph (d) of this section, covered services and supplies must be provided and billed for by an authorized provider as set forth in $199.6 of this part. Such billing must be itemized fully and described sufficiently, even when CHAMPUS payment is determined under the CHAMPUS DRG-based payment system, so that CHAMPUS can determine whether benefits are authorized by this part. Except for claims subject to the CHAMPUS DRG-based payment system, whenever continuing charges are involved, claims should be submitted to the appropriate CHAMPUS fiscal intermediary at least every 30 days (monthly) either by the beneficiary or sponsor or directly by the provider. For claims subject to the CHAMPUS DRGbased payment system, claims may be submitted only after the beneficiary has been discharged transferred from the hospital.
(3) Other covered services and supplies—(i) Blood. If whole blood or plasma (or its derivatives) are provided and billed for by an authorized institution in connection with covered treatment, benefits are extended as set forth in paragraph (b) of this section. If blood is billed for directly to a beneficiary, benefits may be extended under paragraph (d) in the same manner as a medical supply.
(ii) Durable medical equipment—(A) (iv) Diagnostic testing otherwise auScope of benefit. Subject to the excep- thorized by this part. tions in paragraphs (B) and (C) below, (C) Basic mobility equipment exception. only durable medical equipment (DME) A wheelchair, or a CHAMPUS-approved which is ordered by a physician for the alternative, which is medically necspecific use of the beneficiary, and essary to provide basic mobility, inwhich complies with the definition of cluding reasonable additional cost for “Durable Medical Equipment” in $ 199.2 medically necessary modifications to of this part, and which is not otherwise accommodate a particular disability, excluded by this Regulation qualifies may be cost-shared as durable medical as a Basic Program benefit.
equipment. (B) Cardiorespiratory monitor excep
(D) Exclusions. DME which is othertion. (1) When prescribed by a physician wise qualified as a benefit is excluded who is otherwise eligible as
as a benefit under the following cirCHAMPUS individual professional pro
cumstances: vider, or who is on active duty with a (1) DME for a beneficiary who is a paUnited States Uniformed Service, an
tient in a type of facility that ordielectronic cardiorespiratory monitor,
narily provides the same type of DME including technical support necessary
item to its patients at no additional for the proper use of the monitor, may charge in the usual course of providing be cost-shared as durable medical
its services. equipment when supervised by the pre
(2) DME which is available to the scribing physician for in-home use by:
beneficiary from a Uniformed Services (i) An infant beneficiary who has had
Medical Treatment Facility. an apparent life-threatening event, as
(3) DME with deluxe, luxury, or imdefined in guidelines issued by the Di
material features which increase the rector, OCHAMPUS, or a designee, or
cost of the item to the government rel(ii) An infant beneficiary who is a
ative to a similar item without those
features. subsequent or multiple birth biological sibling of a victim of sudden infant
(E) Basis for reimbursement. The cost death syndrome (SIDS), or
of DME may be shared by the (iii) An infant beneficiary whose birth
CHAMPUS based upon the price which weight was 1,500 grams or less, or
is most advantageous to the govern
ment taking into consideration the an(iv) An infant beneficiary who is a
ticipated duration of the medically pre-term infant with pathologic apnea,
necessary need for the equipment and as defined in guidelines issued by the
current price information for the type Director, OCHAMPUS, or a designee, or
of item. The cost analysis must include (v) Any beneficiary who has a condi
comparison of the total price of the tion or suspected condition designated
item as a monthly rental charge, a in guidelines issued by the Director,
lease-purchase price, and a lump-sum OCHAMPUS, or a designee, for which
purchase price and a provision for the the in-home use of the cardiorespira
time value of money at the rate detertory monitor otherwise meets Basic
mined by the U.S. Department of the Program requirements.
Treasury. (2) The following types of services
(iii) Medical supplies and dressings and items may be cost-shared when
(consumables). Medical supplies and provided in conjunction with an other
dressings (consumables) are those that wise authorized cardiorespiratory mon- do not withstand prolonged, repeated itor:
use. Such items must be related di(i) Trend-event recorder, including rectly to an appropriate and verif technical support necessary for the covered medical condition of the speproper use of the recorder.
cific beneficiary for whom the item (ii) Analysis of recorded physiological was purchased and obtained from a data associated with monitor alarms. medical supply company, a pharmacy,
(iii) Professional visits for services or authorized institutional provider. otherwise authorized by this part, and Examples of covered medical supplies for family training on how to respond and dressings are disposable syringes to an apparent life threatening event. for a known diabetic, colostomy sets,
irrigation sets, and elastic bandages. An external surgical garment specifically designed for use following a mastectomy is considered a medical supply item.
NOTE: Generally, the allowable charge of a medical supply item will be under $100. Any item over this amount must be reviewed to determine whether it would not qualify as a DME item. If it is, in fact, a medical supply item and does not represent an excessive charge, it can be considered for benefits under paragraph (d)(3)(iii) of this section.
(iv) Oxygen. Oxygen and equipment for its administration are covered. Benefits are limited to providing a tank unit at one location with oxygen limited to a 30-day supply at any one time. Repair and adjustment of CHAMPUSpurchased oxygen equipment also is covered.
(v) Ambulance. Civilian ambulance service is covered when medically necessary in connection with otherwise covered services and supplies and a covered medical condition. Ambulance service is also covered for transfers to a Uniformed Service Medical Treatment Facility (USMTF). For the purpose of CHAMPUS payment, ambulance service is an outpatient service (including in connection with maternity care) with the exception of otherwise covered transfers between hospitals which are cost-shared on an inpatient basis. Ambulance transfers from a hospital based emergency room to another hospital more capable of providing the required care will also be cost-shared on an inpatient basis.
NOTE: The inpatient cost-sharing provisions for ambulance transfers only apply to otherwise covered transfers between hospitals, i.e., acute care, general, and special hospitals; psychiatric hospitals; and longterm hospitals.
(A) Ambulance service is covered for emergency transfers from a beneficiary's place of residence, accident scene, or other location to a USMTF, and for transfer to a USMTF after treatment at, or admission to, a civilian hospital, if ordered by other than a representative of the USMTF.
(B) Ambulance service cannot be used instead of taxi service and is not payable when the patient's condition would have permitted use of regular private transportation; nor is it payable when transport or transfer of a patient is primarily for the purpose of
having the patient nearer to home, family, friends, or personal physician. Except described in paragraph (d)(3)(v)(A) of this section, transport must be to closest appropriate facility by the least costly means.
(C) Vehicles such as medicabs or ambicabs function primarily as public passenger conveyances transporting patients to and from their medical appointments. No actual medical care is provided to the patients in transit. These types of vehicles do not qualify for benefits for the purpose of CHAMPUS payment.
(D) Ambulance services by other than land vehicles (such as a boat or airplane) may be considered only when the pickup point is inaccessible by a land vehicle, or when great distance or other obstacles are involved in transporting the patient to the nearest hospital with appropriate facilities and the patient's medical condition warrants speedy admission or is such that transfer by other means is contraindicated.
(vi) Prescription drugs and medicines. Prescription drugs and medicines that by United States law require a physician's or other authorized individual professional provider's prescription (acting within the scope of their license) and that are ordered or prescribed by a physician or other authorized individual professional provider (except that insulin is covered for a known diabetic, even though a prescription may not be required for its purchase) in connection with an otherwise covered condition or treatment, including Rh immune globulin.
(A) Drugs administered by a physician or other authorized individual professional provider as an integral part of a procedure covered under paragraph (b) or (c) of this section (such as chemotherapy) are not covered under this subparagraph inasmuch as the benefit for the institutional services or the professional services in connection with the procedure itself also includes the drug used.
(B) CHAMPUS benefits may not be extended for drugs not approved by the U.S. Food and Drug Administration for commercial marketing. Drugs grandfathered by the Federal Food, Drug and
Cosmetic Act of 1938 may be covered rector, OCHAMPUS, or a designee, shall under CHAMPUS as if FDA approved. issue guidelines describing the policy on (vii) Prosthetic devices. The purchase
abortion. of prosthetic devices is limited to those
(3) Family planning. The scope of the determined by the Director,
CHAMPUS family planning benefit is OCHAMPUS to be necessary because of
as follows: significant conditions resulting from
(i) Birth control (such as contraceptrauma, congenital anomalies, or dis- tion)-(A) Benefits provided. Benefits ease.
are available for services and supplies (viii) Orthopedic braces and appliances. related to preventing conception, inThe purchase of leg braces (including cluding the following: attached shoes), arm braces, back (1) Surgical inserting, removal, or rebraces, and neck braces is covered, or- placement of intrauterine devices. thopedic shoes, arch supports, shoe in- (2) Measurement for, and purchase of, serts, and other supportive devices for contraceptive diaphragms (and later the feet, including special-ordered, cus- remeasurement and replacement). tom-made built-up shoes or regular (3) Prescription contraceptives. shoes subsequently built up, are not (4) Surgical sterilization (either male covered.
or female). (e) Special benefit information—(1) Gen- (B) Exclusions. The family planning eral. There are certain circumstances, benefit does not include the following: conditions, or limitations that impact (1) Prophylactics (condoms). the extension of benefits and that re- (2) Spermicidal foams, jellies, and quire special emphasis and expla- sprays not requiring a prescription. nation. This paragraph (e) sets forth (3) Services and supplies related to those benefits and limitations recog- noncoital reproductive technologies, nized to be in this category. The bene- including but not limited to artificial fits and limitations herein described
insemination (including any costs realso are subject to all applicable defini- lated to donors or semen banks), intions, conditions, limitations, excep- vitro fertilization and gamete tions, and exclusions as set forth in
intrafallopian transfer. this or other sections of this part, ex- (4) Reversal of a surgical sterilization cept as otherwise may be provided spe- procedure (male or female). cifically in this paragraph (e).
(ii) Genetic testing. Genetic testing es(2) Abortion. The statute under which
sentially is preventive rather than reCHAMPUS operates prohibits payment lated to active medical treatment of an for abortions with one single excep- illness or injury. However, under the tion-where the life of the mother
family planning benefit, genetic testwould be endangered if the fetus were
ing is covered when performed in cercarried to term. Covered abortion serv
tain high risk situations. For the purices are limited to medical services and
pose of CHAMPUS, genetic testing insupplies only. Physician certification
cludes to detect developmental abnoris required attesting that the abortion malities as well as purely genetic dewas performed because the mother's
fects. life would be endangered if the fetus
(A) Benefits provided. Benefits may be were carried to term. Abortions per
extended for genetic testing performed formed for suspected or confirmed fetal
on a pregnant beneficiary under the abnormality (e.g., anencephalic) or for
following prescribed circumstances. mental health reasons (e.g., threatened
The tests must be appropriate to the suicide) do not fall within the excep
specific risk situation and must meet tions permitted within the language of
one of the following criteria: the statute and are not authorized for
(1) The mother-to-be is 35 years old payment under CHAMPUS.
or older; or NOTE: Covered abortion services are lim
(2) The mother- or father-to-be has ited to medical services or supplies only for the single circumstance outlined above and
had a previous child born with a condo not include abortion counseling or refer
genital abnormality; or ral fees. Payment is not allowed for any
(3) Either the mother- or father-to-be services involving preparation for, or normal has a family history of congenital abfollowup to, a noncovered abortion. The Di- normalities; or