(a) General. 1 (1) Listing of provider does not guarantee payment of 1 benefits. (2) Outside the United States or emergency situations 1 within the United States. (3) Dual Compensation/Conflict of Interest. 1 (4) [Reserved] 2 (5) Utilization review and quality assurance. 2 (6) Exclusion of beneficiary liability. 2 (7) Provider required. 2 (8) Participating providers. 2 (i) Mandatory participation. 2 (ii) Voluntary participation 3 (A) Total claims participation: The participating provider 3 program. (B) Claim-specific participation. 3 (9) Limitation to authorized institutional provider 3 designation. (10) Authorized provider. 3 (11) Balance billing limits. 3 (i) In general. 3 (ii) Waiver. 4 (iii) Compliance. 4 (12) Medical records. 4 (13) Participation agreements. 4 (14) Implementing instructions. 5 (15) Exclusion. 5 (b) Institutional providers 5 (1) General. 5 (i) Preauthorization. 6 (ii) Billing practices. 6 (2) Nondiscrimination policy. 6 (i) Emergency care. 6 (ii) Care rendered before finding of a violation. 6 (iii) Other facility not available. 6 i
(3) Procedures for qualifying as a CHAMPUS-approved institutional provider. 6 (i) JCAH accreditation status. 6 (ii) Required to comply with criteria. 7 (iii) Notice of peer review rights. 7 (iv) Surveying of facilities. 7 (v) Institutions not in compliance with CHAMPUS 7 standards. (vi) Participation agreements required for some hospitals which are not Medicare-participating. 7 (4) Categories of institutional providers. 7 (i) Hospitals, acute care, general and special. 7 (ii) Liver transplantation centers. 8 (iii) Heart transplantation centers. 9 (iv) Hospitals, psychiatric. 11 (v) Hospitals, long-term (tuberculosis, chronic care, or 12 rehabilitation). (vi) Skilled nursing facility. 12 (vii) Residential treatment centers. 13 (A) Organization and administration. 13 (1) Definition. 13 (2) Eligibility. 14 (3) Governing body. 14 (4) Chief executive officer. 15 (5) Clinical Director. 15 (6) Medical director. 15 (7) Medical or professional staff organization. 15 (8) Personnel policies and records. 15 (9) Staff development. 15 (10) Fiscal accountability. 15 (11) Designated teaching facilities. 15 (12) Emergency reports and records. 15 (B) Treatment services. 16 (1) Staff composition. 16 (2) Staff qualifications. 16 (3) Patient rights. 16 ii
(4) Behavioral management. 16 (5) Admission process. 16 (6) Assessments. 17 (7) Clinical formulation. 17 (8) Treatment planning. 17 (9) Discharge and transition planning. 17 (10) Clinical documentation. 17 (11) Progress notes. 17 (12) Therapeutic services. 17 (13) Ancillary services. 18 (C) Standards for physical plant and environment. 18 (1) Physical environment. 18 (2) Physical plant safety. 18 (3) Disaster planning. 18 (D) Standards for evaluation system. 18 (1) Quality assessment and improvement. 18 (2) Utilization review. 18 (3) Patient records review. 18 (4) Drug utilization review. 19 (5) Risk management. 19 (6) Infection control. 19 (7) Safety. 19 (8) Facility evaluation. 19 (E) Participation agreement requirements. 19 (F) Other requirements applicable to RTCs. 21 (viii) Christian Science sanatoriums. 21 (ix) Infirmaries. 21 (x) Other special institution providers. 21 (A) General. 21 (B) Types of providers. 22 (1) Free-standing ambulatory surgical centers. 22 (2) [Reserved] 23 (xi) Birthing centers. 23 (A) Certification requirements. 23 (B) CHAMPUS birthing center standards. 24 iii
(1) Environment. 24 (2) Policies and procedures. 24 (3) Informed consent. 24 (4) Beneficiary care. 24 (5) Medical direction: 24 (6) Admission and emergency care criteria and 24 procedures. (7) Emergency treatment. 25 (8) Emergency medical transportation. 25 (9) Professional staff. 25 (10) Medical records. 25 (11) Quality assurance. 25 (12) Governance and administration. 25 (xii) Psychiatric partial hospitalization programs. 25 (A) Organization and administration. 25 (1) Definition. 25 (2) Eligibility. 26 (3) Governing body. 26 (4) Chief executive officer. 26 (5) Clinical Director. 27 (6) Medical director. 27 (7) Medical or professional staff organization. 27 (8) Personnel policies and records. 27 (9) Staff development. 27 (10) Fiscal accountability. 27 (11) Designated teaching facilities. 27 (12) Emergency reports and records. 27 (B) Treatment services. 27 (1) Staff composition. 27 (2) Staff qualifications. 28 (3) Patient rights. 28 (4) Behavioral management. 28 (5) Admission process. 28 (6) Assessments. 28 (7) Clinical formulation. 28 iv
(8) Treatment planning. 29 (9) Discharge and transition planning. 29 (10) Clinical documentation. 29 (11) Progress notes. 29 (12) Therapeutic services. 29 (13) Ancillary services. 29 (C) Standards for physical plant and environment. 29 (1) Physical environment. 30 (2) Physical plant safety. 30 (3) Disaster planning. 30 (D) Standards for evaluation system. 30 (1) Quality assessment and improvement. 30 (2) Utilization review. 30 (3) Patient records. 30 (4) Drug utilization review. 30 (5) Risk management. 30 (6) Infection control. 30 (7) Safety. 30 (8) Facility evaluation. 31 (E) Participation agreement requirements. 31 (F) Other requirements applicable to PHPs. 32 (xiii) Hospice programs. 33 (xiv) Substance use disorder rehabilitation facilities. 34 (A) Organization and administration. 34 (1) Definition of inpatient rehabilitation center. 34 (2) Definition of partial hospitalization center for the 35 treatment of substance use disorders. (3) Eligibility. 35 (4) Governing body. 35 (5) Chief executive officer. 36 (6) Clinical Director. 36 (7) Medical director. 36 (8) Medical or professional staff organization. 36 (9) Personnel policies and records. 36 (10) Staff development. 37 v
(11) Fiscal accountability. 37 (12) Designated teaching facilities. 37 (13) Emergency reports and records. 37 (B) Treatment services. 37 (1) Staff composition. 37 (2) Staff qualifications. 37 (3) Patient rights. 37 (4) Behavioral management. 38 (5) Admission process. 38 (6) Assessment. 38 (7) Clinical formulation. 38 (8) Treatment planning. 38 (9) Discharge and transition planning. 38 (10) Clinical documentation. 38 (11) Progress notes. 39 (12) Therapeutic services. 39 (13) Ancillary services. 39 (C) Standards for physical plant and environment. 39 (1) Physical environment. 39 (2) Physical plant safety. 39 (3) Disaster planning. 39 (D) Standards for evaluation system. 39 (1) Quality assessment and improvement. 39 (2) Utilization review. 40 (3) Patient records review. 40 (4) Drug utilization review. 40 (5) Risk management. 40 (6) Infection control. 40 (7) Safety. 40 (8) Facility evaluation. 40 (E) Participation agreement requirements. 40 (F) Other requirements applicable to substance use disorder rehabilitation facilities. 42 (c) Individual professional providers of care 42 (1) General 42 vi
(i) Purpose. 42 (ii) Professional corporation affiliation or association 42 membership permitted. (iii) Scope of practice limitation. 42 (iv) Employee status exclusion. 43 (v) Training status exclusion. 43 (2) Conditions of authorization 43 (i) Professional license requirement. 43 (ii) Professional certification requirement. 43 (iii) Education, training and experience requirement. 43 (iv) Physician referral and supervision. 43 (3) Types of providers. 43 (i) Physicians. 43 (ii) Dentists. 44 (iii) Other allied health professionals. 44 (A) Clinical psychologist. 44 (B) Doctors of Optometry. 44 (C) Doctors of Podiatry or Surgical Chiropody. 44 (D) Certified nurse midwives. 44 (E) Certified nurse practitioner. 44 (F) Certified Clinical Social Worker. 45 (G) Certified psychiatric nurse specialist. 45 (H) Certified physician assistant. 45 (I) Other individual paramedical providers. 46 (iv) Extramedical individual providers. 46 (A) Certified marriage and family therapists. 46 (B) Pastoral counselors. 47 (C) Mental health counselor. 49 (E) Christian Science practitioners and Christian Science nurses. 50 (d) Other providers. 50 (1) Independent laboratory. 50 (2) Suppliers of portable x-ray services. 50 (3) Pharmacies. 50 (4) Ambulance companies. 50 (5) Medical equipment firms, medical supply firms. 50 vii
(6) Mammography suppliers. 50 (e) Program for Persons with Disabilities Providers. 50 (1) General. 50 (2) PFPWD provider categories. 51 (i) PFPWD inpatient care provider. 51 (ii) PFPWD outpatient care provider. 51 (iii) PFPWD vendor. 51 (3) PFPWD provider exclusion or suspension. 51 (f) Corporate services providers. 51 (1) General. 51 (2) Conditions of authorization. 52 (3) Transfer of participation agreement. 53 (4) Pricing and payment methodology: 53 (5) Termination of participation agreement. 54 viii