DEPARTMENT OF DEFENSE. Office of the Assistant Secretary of Defense. (Health Affairs) Civilian Health and Medical Program of the Uniformed Services

Transcription

1 ~0~ R REPRINT (INCORPORATING CHANGES 1 THROUGH 26) DEPARTMENT OF DEFENSE Office of the Assistant Secretary of Defense (Health Affairs) Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) JULY 1991

2 DEPARTMENT OF DEFENSE PUBLICATION SYSTEM OFFICE OF THE SECRETARY OF DEFENSE DoD R - REPRINT Assistant Secretary of Defense (Health Afflars) July 12,1991 CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED SERVICES (CHAMPUS). DoD 601 O.8-R, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), March 1986, has been been superseded by the attached reprint. This reprint incorporates changes 1 through 26 and is dated July Because of the publication of this reprint, Change no. 26 was not published as a separate change. Change no. 26 issued a new chapter 16 and pages vii, 6-i, 6-3, and 6-5, which were affected by this Change, contain marginal bars. These pages and chapter 16 were effective June 1, EFFECTIVE DATE This reprint is effective immediately. At f. -x& wj S L. ELMER irector Correspondence and Directives WHEN PRESCRIBED ACTION HAS BEEN TAKEN, THIS TRANSMITTAL SHOULD BE FILED WITH THE BASIC DOCUMENT SD FORM 106-2, MAR 81 32/104

3 DOD R Jul 91 DEPARTMENT OF DEFENSE DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENT OF TRANSPORTATION WASHINGTON, D.C. March 10, 1986 FOREWORD This Regulation is issued under the authority of DoD Instruction , Administration of the Civilian Health and Medical Program of the Uniformed. Services (CHAMPUS), October 24, It corrects typographical errors, updates references, and incorporates substantive coordinated or mandated changes issued since its original publication. Its purpose is to prescribe uniform policy for the worldwide operation of CHAMPUS, and t.o provide guidelines for an equitable delivery of authorized health care benefits to all beneficiaries. DoD 601O.8-R, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), January 10, 1977, is hereby canceled. This Regulation applies to the Offj.ce of the Secretary of Defense (OSD), the Military Departments, the Organization of the Joint Chiefs of Staff, the Unified >-..,. and Specified Commands, and the Defense Agencies (hereafter referred to collectively as DoD Components ), the U.S. Coast Guard (CG), the Commissioned CorPs of the U.S. Public Health Service (USPHS), and the Commissioned Corps of the National Oceanic and Atmospheric Administration (NOAA) (hereafter referred to collectively as the other Uniformed Services ). This Regulation is effective immediately and is mandatory for use by DoD Components, CG, USPHS, and NOAA. Forward recommended changes to this Regulation through channels to the Director, OCHAYPUS Aurora, Colorado DoD Components and the other ljrtiformed Services may obtain copies of this. Regulation through their own publication channels. Other Federal agencies and the public may obtain copies from the U.S. Department of Commerce. National Technical Information Service, 5285 Port Royal Road, Springfield,. VA i

4 Records responsibility for this Regulation is assigned to the Department of Defense. This responsibility includes the retirement of records and the publication of changes. AA.4?.L2+?S. xl). William Mayer, M.D. Assistant Secretary of Defense (Health Affairs) $!we.-.q. n ~ L-uG.LY!?/,. 0 Edward N. Brandt, Jr., M.D< Assistant Secretary for Health Department of Health and Human Services 1. \ Adhiral James S. Cracey Commandant, United States Coast Guard \. ii

5 . TABLE OF CONTENTS DoD 601O.8-R Jul 91 I!!%!? Foreword i CHAPTER 1. GENERAL PROVISIONS,,....- A. B. C. E. G. I. J. K. L. M. N. O. P. Q. Purpose Applicability Authority and Responsibility l-l Medical Benefits Program Program Funds Claims Adjudication and Processing Recommendations for Change to Regulation CHAMPUS Claim Forms The CHAMPUS Handbook Program Integrity Role of CHAMPUS Health Benefits Advisor (HBA) Cooperation and Exchange of Information with Other Federal Programs Disclosure of Information to the Public Discretionary Authority Demonstration Projects Military-Civilian Health Services Partnership Program Equality of Benefits CHAPTER 2. DEFINITIONS A. General B. Specific Definitions CHAPTER 3. ELIGIBILITY A. General B. Persons Eligible C. Beginning Dates of Eligibility Dual Coverage E, Changes in and Termination of Eligibility Determination of Eligibility Status G. Evidence of Eligibility Required CHAPTER 4. BASIC PROGRAM BENEFITS A. General B. Institutiona lbenefits C. Professional Services Benefit Other Benefits E. Special Benefit Inf(JrmatiOn Beneficiary or Sponsor Liability G. Exclusions and Limitations b Payment and Liability for Certain Potentially Excludable Services under the Peer Review Organization Program iii

6 CHAPTER 5. PROGRAM FOR THE HANDICAPPED (PFTH) A. B. C. E. G. I. J. K. L. General Cost-Sharing Criteria for Qualifying for PFTH Benefits Mental Retardation.j Serious Physical Handicap Procedures for Obtaining Benefits Use of Public Facilities Covered Services and Supplies Utilization Review and Quality Assurance General Limitations Authority to Determine Eligibility Under PFTH.. Implementing Instructions CHAPTER 6. AUTHORIZED PROVIDERS A. General B. Institutional Providers C. Individual Professional Providers of Care Other Providers E. Implementing Instructions Exclusion CHAPTER 7. CLAIMS SUBMISSION, REVIEW, AND PAYMENT A. B. C. E. G. 1. J. General Information Required to Adjudicate a CHAMPUS Claim Signature on CHAMPUS Claim Form Clainls Filing Deadline Other Claims Filing Requirements Preaut.horization Claims Review Benefit Payments Erroneous Payments and Recoupment General Assignment of Benefits Not Recognized o 7-1o CHAPTER 8. DOUBLE COVERAGE A. Introduction B, Double Coverage Plan C. Application of Double Coverage Provisions Special Considerations E. Implementing Instructions CHAPTER 9. ADMINISTRATIVE REMEDIES FOR FRAUD, ABUSE, AND CONFLICT OF INTEREST A. General B. Abuse C. Fraud Conflict of Interest iv

7 DoD 601O.8-R Jul 91.. Sect ion CHAPTER 10. E. F. G. H. I. J. K. L. Dual Compensation Aclministrative Remedies Period of Exclusion, Suspension, or Termination Procedures for Initia.t.ing and Implementing the Administrative Remedies Evidence Required for Determinations to Invoke Administrative Remedies Suspending Administrative Action Not.ice to Other Agencies Compromise, Settlement, and Resolution Authority APPEAL AND HEARING PROCEDURES A. General Sec:tion B. Reconsideration C. Formal Review Hearing E. Final Decision CHAPTER 11. OVERPAYMENTS RECOVERY A. B: C. E. Sect:i(}n G. I. General Authority Policy Appeal.ahilit.y Delegation Recoupment of Erroneous Payments Compromise, Suspension, or TerminatiC~n of Collection Actions Arising Under the Federal Claims Collection Act Referrals for Collect.ion Claims Involving Indications of Fraucl, Filing of False Claims or Misrepresentation CHAPTER 12. THIRD PARTY RECOVERIES SecU.ion A. Sect..ion B. C. Sectivn E. General Authority Policy ~-1 Appealability s Fede~al Medical Care Recovery Act Claims Aut.omohile or Other Medical. Payment Insurance t No-Fault Insurance, or [Trlinsured Motorist. Insurance W~~rker s Compensation Claims Mixed Claims v

8 CFIAPTER 13. DEPENDENTS DENTAL PLAN A. B. C. Sect.ioll E. Ser tion G. General Provisions Definitions Enrollment and Eligibility Premium Sharing *..,...,..,..,....*... Plan Benefits......,..*..... * Authorized Providers......* Benefit Payment Appeal and Hearing Procedures CHAPTER 14. PROVIDER REIMBURSEMENT METHODS Sect ion A. B. Sect, jon C. Sect ion E. Sec Lion F. S~ction G. 1. J. K. Hospitals * Skilled Nursing Facilities (SNI?S) Reimbursement for Other Than Hospitals & SNFS.. Reimbursement of Freestanding Ambulatory SuL-gic81 Centers Reimbursement of Birthing Centers Reimbursement of Residential Treatment Centers Reimbursement of Individual Health-Care Professionals and Other Non-Institutional Healt.h Care Prciviclers..., Reimbursement Under the Military-Civilian Health Services Partnership Program Accommodation of Discounts Under Provider Reimbursement Methods Outside t.he United States.., Implementing Instructions CHAPTER 15. PEER REVIEW ORGANIZATION PROGRAM A. B. C. E. Sect.iol] G. Sect ion I. J. Sec:t.i(m K, L.!3ection El, General * ,.., Objectives of Rev~. ew System Hospital Cooperatio n Areas of Review Actions as a Result of Review Procedures Regarding Certain Services, In~.lll(lillg Services Not Covered by the DRG-Based Payment System Procedures Regarding Initial Determinat.iuns Procedures Regarding Reconsiderations Appeals and Hearings Acquisition, Prot.ect. ion and Disclosure of peer Review Information Limited Inununit.y from Liability for Participants in PRO Program Additional Provision Regarding Confid.ent.i.ality c~f Records ].5-5 ohligat.ions, Sanctions and Procedures vi

9 DoD 601O.8-R Jul 12, 91 CHAPTER 16. Supplemental HEALTH CARE program FOR ACTIVE DUTY MEMBERS A. PurlJose and Applical}.ility B. Obligation of Hospitals Concerning Payment for Supplemental.Healt.h Care for Active Duty Members section c, General Rule for Payment and Administration Sect.i.on D. Spe~ial Rules and procedures E. Waiver Authority Authorities AF PEFJDIX A. Acronyms A-~ APPENDIX B. References B-1 vii

10 DoD 601O.8-R Jul CHAPTER 1 GENERAL PROVISIONS TABLE OF CONTENTS SECTION A. Purpose. B. Applicability. 1. Geographic. 2. Agency. c. Authority and Responsibility. 1. Legislative authority. a. Joint. regulations. b. Administration. 2. Organizational delegations and assignments. a. Assistant Secretary of Defense (Health Affairs) (ASD(HA)). b. Department of Health and Human Services. c. Department of Transportation. d. Office of CHAMPUS (OCHAMPUS). e. Evidence of eligibility. D. Medical Benefits Program. E. Program Funds. F. Claims Adjudication and Processing. 1. The United States. Contracting out. :: In-house. 2. Outside the United States. a. Special subsidiary office or contracting out. b. Support agreements. G. Recommendations for Change to Regulation H. CHAMPUS Claim Forms. 1-5 I. The CHAMPUS Handbook. 1-5 l-i

11 SECTION J. Program Integrity. K. Role of CHAMPUS Health Benefits Advisor (HBA). L. Cooperation and Exchange of Information with Other Federal Programs. 1. Investigation for fraud. 2. Unnecessary services. M. Disclosure of Information to the Public. ~ N. Discretionary Authority. o. Demonstration Projects. 1. Authority. 2. Procedures. 3. Definition. P. Military-Civilian Health Services Partnership Program. Q. Equality of Benefits. EME l-ii