Prescribing Document - 32 CFR 199.7

§ 199.7

32 CFR Ch. I (7–1–11 Edition)

not required, be accredited by a qualified accreditation organization, as defined in § 199.2; and
(vi) Has entered into a participation
agreement approved by the Director,
OCHAMPUS, or designee, which at
least complies with the minimum participation agreement requirements of
this section.
(3) Transfer of participation agreement.
In order to provide continuity of care
for beneficiaries when there is a change
of provider ownership, the provider
agreement is automatically assigned to
the new owner, subject to all the terms
and conditions under which the original agreement was made.
(i) The merger of the provider corporation or foundation into another
corporation or foundation, or the consolidation of two or more corporations
or foundations resulting in the creation of a new corporation or foundation, constitutes a change of ownership.
(ii) Transfer of corporate stock or the
merger of another corporation or foundation into the provider corporation or
foundation does not constitute change
of ownership.
(iii) The surviving corporation or
foundation shall notify the Director,
OCHAMPUS, or designee, in writing of
the change of ownership promptly after
the effective date of the transfer or
change in ownership.
(4) Pricing and payment methodology:
The pricing and payment of procedures
rendered by a provider authorized
under this paragraph (f) shall be limited to those methods for pricing and
payment allowed by this part which
the Director, OCHAMPUS, or designee,
determines contribute to the efficient
management of CHAMPUS.
(5) Termination of participation agreement. A provider may terminate a participation agreement upon 45 days
written
notice
to
the
Director,
OCHAMPUS, or designee, and to the
public.
[51 FR 24008, July 1, 1986]
EDITORIAL NOTE: For FEDERAL REGISTER citations affecting § 199.6, see the List of CFR
Sections Affected, which appears in the
Finding Aids section of the printed volume
and at www.fdsys.gov.

§ 199.7 Claims submission, review, and
payment.
(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 § 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

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§ 199.7

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 fiscal
year outpatient deductible, as defined
in § 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 fiscal 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 fiscal 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
§ 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

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.

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§ 199.7

32 CFR Ch. I (7–1–11 Edition)

(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 § 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.).

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§ 199.7

(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 authorization.
(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.

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§ 199.7

32 CFR Ch. I (7–1–11 Edition)

(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 § 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 costsharing 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 addi-

tion, 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
§ 199.1 of this part).
(ii) For the purposes of determining
the applicability of and implementing
the provisions of §§ 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

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§ 199.7

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 § 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
§ 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 CHAMPUSdetermined 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

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§ 199.7

32 CFR Ch. I (7–1–11 Edition)

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 § 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.

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§ 199.7

(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) Inpatient mental health services.
Under most circumstances, the 60-day
inpatient mental health limit applies
to the first 60 days of care paid in a calendar year. The patient will be notified
when the first 30 days of inpatient
mental health benefits have been paid.
The beneficiary is responsible for assuring that all claims for care are submitted sequentially and on a regular
basis. Once payment has been made for
care determined to be medically appropriate and a program benefit, the decision will not be reopened solely on the
basis that previous inpatient mental
health care had been rendered but not
yet billed during the same calendar
year by a different provider.
(3) Claims involving the services of marriage and family counselors, pastoral
counselors, and mental health counselors.
CHAMPUS requires that marriage and
family counselors, pastoral counselors,
and mental health counselors make a
written report to the referring physician concerning the CHAMPUS bene-

ficiary’s progress. Therefore, each
claim for reimbursement for services of
marriage and family counselors, pastoral counselors, and 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 § 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

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§ 199.7

32 CFR Ch. I (7–1–11 Edition)

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 § 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 inter-

mediary (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 costsharing portion of the CHAMPUS-determined allowable charge or cost as
may be required under the terms and
conditions set forth in §§ 199.4 and 199.5
of this part.
(3) CEOB. 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 § 199.10 of this part).
NOTE: The Director, OCHAMPUS, or a designee, may authorize a CHAMPUS fiscal

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Office of the Secretary of Defense

§ 199.8

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, July 1, 1986]
EDITORIAL NOTE: For FEDERAL REGISTER citations affecting § 199.7, see the List of CFR

Sections Affected, which appears in the
Finding Aids section of the printed volume
and at www.fdsys.gov.

§ 199.8

Double coverage.

(a) Introduction. (1) In enacting
TRICARE legislation, Congress clearly
has intended that TRICARE be the secondary payer to all health benefit, insurance and third-party payer plans. 10
U.S.C. 1079(j)(1) specifically provides
that a benefit may not be paid under a
plan (CHAMPUS) covered by this section in the case of a person enrolled in,
or covered by, any other insurance,
medical service, or health plan, including any plan offered by a third-party
payer (as defined in 10 U.S.C. 1095(h)(1))
to the extent that the benefit is also a
benefit under the other plan, except in
the case of a plan administered under
title XIX of the Social Security Act (42
U.S.C. 1396 et seq.).
(2) The provision in paragraph (a)(1)
of this section is made applicable specifically to retired members, dependents, and survivors by 10 U.S.C. 1086(g).
The underlying intent, in addition to
preventing waste of Federal resources,
is to ensure that TRICARE beneficiaries receive maximum benefits
while ensuring that the combined payments of TRICARE and other health
and insurance plans do not exceed the
total charges.
(b) Double coverage plan. A double
coverage plan is one of the following:
(1) Insurance plan. An insurance plan
is any plan or program that is designed
to provide compensation or coverage
for expenses incurred by a beneficiary
for medical services and supplies. It includes plans or programs for which the
beneficiary pays a premium to an
issuing agent as well as those plans or
programs to which the beneficiary is
entitled as a result of employment or
membership in, or association with, an
organization or group.
(2) Medical service or health plan. A
medical service or health plan is any
plan or program of an organized health
care group, corporation, or other entity for the provision of health care to
an individual from plan providers, both
professional and institutional. It includes plans or programs for which the
beneficiary pays a premium to an
issuing agent as well as those plans or

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