« PreviousContinue »
NAVMED 6320/10 are required to adjudicate claims in each instance of Sickness, injury, or maternity care when treatment is received from a non-Federal Source under the provisions of this part. The form should be prepared by a naval medical or dental officer, when practicable, by the senior officer present where a naval medical or dental officer is not on duty, or by the member receiving care when on detached duty where a senior officer is not present. (i) For nonemergency care with prior approval, submit the NAVMED 6320/10 containing the prior approval, after completing blocks 8 through 18. (ii) For emergency care (or nonemergency care without prior approval), submit a NAVMED 6320/10 after completing blocks 1 through 18. Assure that the diagnosis is listed in block 10. If prior approval was not obtained, state in block 11 circumstances necessitating use of non-Federal facilities. (iii) Signature by the member in block 17 inplies agreement for release of information to the responsible adjudication authority receiving the claim for processing. Signature by the cer– tifying officer in block 18 will be conSidered certification that documentation has been entered in the member’s Health Record as directed in article 16– 24 Of MANMED. (2) Itemized bills. The Original and three copies of itemized bills to show: (i) Dates on Or between which Services were rendered or supplies furnished. (ii) Nature of and Charges for each item. (iii) Diagnosis. (iv) Acknowledgment of receipt of the services or Supplies on the face of the bill or by separate certificate. The acknowledgment must include the Statement. “Services were received and were Satisfactory.” (3) Claims for reimbursement. To effect reimbursement, also submit the original and three copies of paid receipts and an SF 1164. Claim for Reimbursement for Expenditures on Official Business, completed per paragraphs 046377– 2 a. and b of the Naval Comptroller Manual (NAVCOMPT MAN).
(4) Notice of eligibility (NOE) and line of duty (LOD) determination. When a reServist claims benefits for care received totally after the completion of either an active duty or active duty for training period, the claim should also include: (i) An NOE issued per SECNAVINST 1770.8. (ii) An LOD determination from the member’s commanding officer. (b) Adjudicating authority’s responsibility. Reviewing and processing properly Completed claims and forwarding approved claims to the appropriate disbursing office should be completed within 30 days of receipt. Advice may be requested from COMNAVMEDCOM (MEDCOM-333 (A/V 294–1127)) for medical or MEDCOM-06 (A/V 294–1250)) for dental on unusual or questionable instances of Care. Advise claimants of any delay experienced in processing claims. (1) Review. The receiving adjudication authority will carefully review each claim Submitted for payment or reimbursement to verify whether: (i) Claimant was entitled to benefits (i.e., was on active duty, active duty for training, inactive duty training, Was not an unauthorized absentee, etc.). As required by part 728 of this chapter, a Defense Enrollment Eligibility Reporting System (DEERS) eligibility check must be performed on claims to all claimants required to be enrolled in DEERS. (ii) Care rendered was due to a bona, fide emergency. (NOTE: When questions arise as to the emergency nature of Care, forward the claim and all supporting documentation to the appropriate clinical specialist at the nearest naval hospital for review.) (iii) Prior approval was granted if a. bona fide emergency did not exist. (NOTE: If prior approval was not obtained and the condition treated is determined to have been nonemergent, the claim may be denied.) Consideration should always be given to cases that would have received prior approval but, due to lack of knowledge of the program, the member did not submit a request. (iv) Care rendered was authorized under the provisions Of this part.
(v) Care rendered was appropriate for the specific condition treated. (NOTE: When questions arise regarding appropriateness of care, forward all documentation to a clinical Specialist at the nearest naval hospital for review. If care is determined to have been inappropriate, the claim may be denied to the extent the member was negligent.) (vi) Claimed benefits did not result from a referral by a USMTF. If the member was an inpatient Or an outpatient in a USMTF immediately prior to being referred to a civilian Source of care, the civilian care is supplemental and may be the responsibility of the referring USMTF. See $732.11(p) for the definition of supplemental care. (2) Dispproval. If a determination is made to disapprove a claim, provide the member (and provider of care, when applicable) a prompt and courteous letter stating the reason for the disapproval and the appropriate avenues of appeal as outlined in $732.24. (3) Processing. Subpart C contains the chargeable accounting classifications and Standard Document Numbers (SDN) to be cited on the NAVCOMPT 2277, Voucher for Disbursement and/or Collection, on an SF 1164 submitted per paragraph (a)(3) of this Section, and On supporting documents of approved claims before submission to disbursing Offices. (i) For payment to providers of care, a NAV COMPT 2277 will be prepared and certified approved for payment by the adjudicating authority. This form must accompany the NAVMED 6320/10
and supporting documentation per paragraph 046393–1 Of the NAVCOMPTMAN.
(ii) Where reimbursement is requested, the SF 1164 submitted per §732.19(a)(3) will be completed, per paragraph 046377 Of the NAVCOMPTMAN, and certified ap
proved for payment by the adjudicating authority. This form must accompany the NAVMED 6320/10 and supporting documentation. (c) Amount payable. Amounts payable are those considered reasonable after taking into consideration all facts. Normally, payment should be approved at rates generally prevailing within the geographic area where services or Supplies were furnished. Although rates
Specially established by the Veterans Administration, CHAMPUS, or those used in Medicare are not controlling, they should be considered along with Other facts. (1) Eaccessive charges. If any charge is excessive, the adjudication authority will advise the provider of care of the conclusion reached and afford the provider an opportunity to voluntarily reduce the amount of the claim. If this does not result in a proper reduction and the claim is that of a physician Or dentist, refer the difference in Opinions to the grievance committee of the provider’s professional group for an opinion of the reasonableness of the charge. If Satisfactory settlement of any claim cannot thus be made, forward all documentation t;O COMNAVMEDCOM (MEDCOM-333) for decision. Charges determined to be above the allowed annount or charges for unauthorized services are the responsibility of the Service member. (2) Third party payment. Do not withhold payment while seeking funds from health benefit plans or from insurance policies for which premiums are paid privately by service members (see §732.22 for possible recovery of payments action). (3) No-fault insurance. In States with no-fault automobile insurance requirements, adjudication authorities will notify the insurance carrier identified in item 16 of the NAVMED 6320/10 that, Federal payment of the benefits in this part is secondary to any no-fault insurance coverage available to the potentially covered member. (d) Duplicate payments. Adjudication authorities and disbursing activities should take precautions against dupliCate payments per paragraph 046073 of the NAVCOMPTMAN.
§ 732.20 Adjudication authorities.
(a) General. Controlling activities for medical care in the United States are designated as “offices of medical affairs” (OMA) and for dental care, “offices of dental affairs” (ODA). NAVMEDCOMINST 6010.3 delineates responsibilities and functional tasks of OMAS and ODAs, including monthly reporting of receipt of claims and claims payment. Commanders of geographic naval medical commands must Communicate with all activities in their regions to ensure that messages and medical cognizance reports are properly furnished per higher authority directives. (b) Within the United States (less Hawaii). For the 48 contiguous United States, the District of Columbia, and Alaska, the following six regions are responsible for care rendered or to be rendered within their areas of responSibility. (1) Northeast Region. The States of Connecticut, Delaware, Illinois, Indiana, Iowa, Kentucky, Maine, Massachusetts, Michigan, Minnesota, MisSouri, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, Rhode Island, Vermont, and Wisconsin are served by 1 ODA and 1 OMA: (i) Responsibility for dental matters for States in the Northeast Region is vested in: Commander, Naval Medical Command, Northeast Region, Office of Dental Affairs, Great Lakes, IL 60088, Tele: (A/V) 792–3940 or (C) (312) 688–3940. (ii) Responsibility for medical matters for States in the Northeast Region is vested in: Commander, Naval Medical Command, Northeast Region, Office of Medical Affairs, Great Lakes, IL 60088, Tele: (A/V) 792–3950 or (C) (312) 688–3950. (2) National Capital Region. For the States of Maryland and West Virginia; the Virginia, counties of Arlington, Fairfax, Loudoun, and Prince William; the Virginia, cities of Alexandria, Falls Church, and Fairfax; and the District of Columbia, responsibility for medical and dental matters is vested in: Commander, Naval Medical Command, National Capital Region, Office of Medical Affairs, Bethesda, MD 20814, Tele: (A/V) 295–5322 or (C) (301) 295–5322. (3) Mid-Atlantic Region. For the States of North Carolina, South Carolina, and all areas of Virginia, South and west of Prince William and Loudoun counties, responsibility for medical and dental matters is vested in: Commander, Naval Medical Command, Mid-Atlantic Region, 6500 Hampton Boulevard, Norfolk, VA 23502, Attn: Office of Medical/Dental Affairs, Tele: (A/V) 565–1074/1075 or (C) (804) 445–1074 Or 1075.
(4) Southeast Region. For the States of Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Oklahoma, Tennessee, and Texas, medical and dental responsibilities are vested in: Commanding Officer, Naval Medical Clinic, Code O1A, New Orleans, LA 70146, Tele: (A/V) 485–2406/7/8 or (C) (504) 361–2406 2407 Or 2408.
(5) Southwest Region. For the States of Arizona and New Mexico; the counties of Kern, San Bernadino, San Luis Obispo, Santa Barbara, and all other California, counties south thereof; the community of Bridgeport, California. (Marine Corps cold-weather training site); and Nevada, except for NAS Fallon and its inmediate area; medical and dental responsibilities are vested in: Commander, Naval Medical Command, Southwest Region, Office of Medical Affairs, San Diego, CA 92.134– 7000, Tele: (A/V) 987–2611 or (C) 233–2611.
(6) Northwest Region. The States of Alaska, Colorado, Idaho, Kansas, Montana, Nebraska, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming; the Counties of Inyo, Kings, Tulare, and all other counties of California, north thereof; and NAS Fallon, Nevada, and its immediate area are served by 2 OMAS and 1 ODA:
(i) Responsibility for dental matters for the area. Of responsibility Of the Northwest Region is vested in: Commander, Naval Medical Command, Northwest Region, Office of Dental Affairs, Oakland, CA 94.267–5025, Tele: (A/ V) 855–6200 or (C) (415) 633–6200.
(ii) Responsibility for medical matters for the States of Colorado, Kansas, and Utah; the California, counties of Inyo, Kings, Tulare, and all other counties of California, north thereof; and NAS Fallon, Nevada, and its immediate area, is vested in: Commander, Naval Medical Command, Northwest Region, Oakland, CA 94627–5025, Attn: Office of Medical Affairs, Tele: (A/V) 855–5705 or (C) (415) 633–5705.
(iii) Responsibility for medical matters for the States of Alaska, Idaho, Montana, Nebraska, North Dakota, Oregon, South Dakota, Washington, and Wyoming is vested in: Commanding Officer, Naval Medical Clinic, Naval Station, Seattle, WA 98115, Attn: Office of Medical Affairs, Tele: (A/V) 941–3823 or (C) (206) 526–3823.
(c) Outside the United States (plus Hawaii). For all areas outside the United States plus Hawaii, the following activities are vested with responsibility for approval or disapproval of requests and claims for maternity, medical, and dental Care: (1) Executive Director, OCHAMPUSEUR, U.S. Army Medical Command, APO New York 09102, for Care rendered within the U.S. European Command, Africa, the Malagasy Republic, and the Middle East. (2) Commanding Officer, U.S. Naval Hospital, FPO San Francisco 96652–1600 (U.S. Naval Hospital, Subic Bay, Luzon, Republic of the Philippines), for care rendered in Afghanistan, Bangladesh, Hong Kong, India, Nepal Pakistan, the Philippines, Southeast Asia, Sri Lanka, and Taiwan. (3) Commanding Officer, U.S. Naval Hospital, FPO Seattle 98765–1600 (U.S. Naval Hospital, Yokosuka, Japan), for care rendered in Japan, Korea, and Okinawa. (4) Commanding Officer, U.S. Naval Hospital, FPO San Francisco 96630–1600 (U.S. Naval Hospital, Guam, Mariana. Islands), for care rendered in New Zealland and Guam. (5) Commanding Officer, U.S. Naval Communications Station, FPO San Francisco 96680–1800 (U.S. Naval Communications Station, Harold E. Holt, Exmouth, Western Australia), for care rendered in Australia. (6) Commanding Officer, U.S. Naval Air Station, FPO New York 09560 (U.S. Naval Air Station, Bermuda), for care rendered in Bermuda. (7) Commanding Officer, U.S. Naval Hospital, FPO Miami 34051 (U.S. Naval Hospital, Roosevelt Roads, Puerto Rico), for maternity and medical care, and Commanding Officer, U.S. Naval Dental Clinic, FPO Miami 34051 (U.S. Naval Dental Clinic, Roosevelt Roads, PR), for dental care rendered in Puerto Rico, the Virgin Islands, and other Caribbean Islands. (8) Commanding Officer, Naval Medical Clinic, Box 121, Pearl Harbor, HI 96860, for maternity and medical care, and Commanding Officer, Naval Dental Clinic, Box 111, Pearl Harbor, HI 96860, for dental care rendered in the State of Hawaii, Midway Island, and the Central Pacific basin.
(9) The OMA for either the Southeast Region or the Southwest Region for Care rendered in Mexico to members Stationed within the respective areas of responsibility of these OMAS. Forward claims for care rendered in Mexico to all other personnel to Commander, Naval Medical Command, Washington, DC 20372–5120 (MEDCOM-333). (10) Commander, Naval Medical Command, Washington, DC 20372–5120 (MEDCOM-333) for inpatient and outpatient emergency and nonemergency Care of active duty Navy and Marine Corps members in Canada and under the circumstances outlined in paragraph (d) of this section. (11) Outside the 50 United States, Commanding officers of operational units may either approve claims and direct payment by the disbursing offiCer Serving the Command Or forward claims to the appropriate naval mediCal Command in paragraphs (b)(1) through (c)(9) of this Section. This is a local policy decision to enhance the maintenance of good public relations. (12) The appropriate Command in paragraphs (b)(1) through (c)(9) of this Section for Care rendered aboard Commercial vessels en route to a location Within the geographic areas listed. (13) The commanding officer authorizing care in geographical areas not Specifically delineated elsewhere in this section. (d) The Commander, Naval Medical Command (MEDCOM-333), Navy Department, Washington, DC 20372–5120. Under the following circumstances, responsibility is vested in COMNAVMEDCOM for adjudication of claims: (1) For reservists who receive treatment, after completion of their active duty or inactive duty training as prescribed in §732.12(b). (2) For care rendered in Mexico to personnel Stationed outside the areas of responsibility of the Southeast and Southwest Regions. (3) For care rendered to members stationed in or passing through countries in Central and South America. (4) For Outpatient Care rendered NATO active duty members. (5) When Departmental level review is required prior to approval, adjudication, or payment. These claims: (i) Will be considered on appeal.
(ii) Must be forwarded by the member through the adjudication authority chain of command (In instances of unusual or controversial denial of claims, the adjudication authority may forWard claims to COMNAVMEDCOM On appeal, via the chain of Command, with notification to the member.).
(6) For all inpatient and outpatient care of active duty Navy and Marine Corps members stationed in the United States who receive care in Canada.
§ 732.21 Medical board.
When adjudication authorities uncover conditions which may be chronic or otherwise potentially disabling, they should make a determination (with help from appropriate clinical specialists) as to the need for a medical board. Chapter 18 of MANMED and Medical Disposition and Physical Standards Notes, available from COMNAVMEDCOM (MEDCOM-25), provide guidance.
(a) Chronic conditions requiring a medical board include (but are not limited to):
(5) Heart disease,
(7) Peptic ulcer disease,
(8) Psychiatric conditions, and
(9) Allergic conditions requiring deSensitization.
(b) Other potentially disabling or chronic conditions may be referred to a medical board by the adjudication authority with the concurrence of an appropriate naval clinical Specialist and the Commander of the regional medical Command.
$732.22 Recovery of medical care payments.
Adjudication authorities must submit evidence of payment to the action JAG designee per chapter 24 of the Manual of the Judge Advocate General (JAGMAN), in each instance of payment where a third party may be legally liable for causing the injury or disease treated, or when a Government claim is possible under workers compensation, no-fault insurance, or under
medical payments insurance (all automobile accident cases). (a) To assist in identifying possible third party liability cases, item 16 of each NAVMED 6320/10 must be completed whenever benefits are received in Connection with a vehicle accident. Adjudication authorities should return for completion, as applicable, any claim received without item 16 completed. (b) The front of a NAVJAG Form 5890/12 (Hospital and Medical Care, 3rd Party Liability Case) must be completed and submitted by adjudication authorities with evidence of payment. Block 4 of this form requires an appended Statement of the patient or an accident report, if available. To ensure that Privacy Act procedures are accomplished and documented, the perSOn Securing Such a Statement from a recipient of care must show the recipient the Privacy Act statement printed at the bottom of the form prior to SeCuring such a statement. The member should be asked to sign his or her name beneath the statement. (c) For Care rendered in States with no-fault insurance laws, comply with procedures outlined in §732.19(c)(3).
§ 732.23 Collection for subsistence.
The Navy Pay and Personnel Procedures Manual provides guidance regarding pay account checkage procedures to liquidate subsistence charges incurred by members entitled to care under the provisions of this part. Such members must also be entitled to basic allowance for subsistence (BAS) while hospitalized at Government expense. The responsible activity (the adjudication authority or the naval MTF to which such a member is transferred) should follow procedures outlined in the Navy Pay and Personnel Procedures Manual when an eligible officer or enlisted member of the naval Service is subsisted at Department of the Navy expense while hospitalized in a nonnaval treatment facility. Subpart C contains the creditable accounting classification for inpatient subsistence Collections.
$732.24 Appeal procedures.
When a claim for Care Or a request for prior approval for nonemergency