B\SON OCHAMPUS 6010.48-H PROVIDER HANDBOOK MAY 1990 DEPARTMENT OF DEFENSE • OFFICE OF CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED SERVICES DEPARTMENT OF DEFENSE ..MED Slt..VICitSOFFICE OF CIVILIAN HEALTH AND MEDICAL P"OG.. AM OF THE UN• .., AU ..ORA, COLORADO 10041·1100 BRP May 24, 1990 FQREWORD This Handbook is authorized by OCHAMPUS Instruction 6010.48, "Provider Handbook", May 1, 1986. It is for the use and guidance of health care providers servicing CHAMPUS beneficiaries. Be aware that this Handbook does not cover all of the policies and procedures of CHAMPUS. Regulations and certain benefits change over time. It is important to be in touch with the CHAMPUS claims processor or contractor for the region or with the provider field representative for the area. In several parts of the u.s., CHAMPUS is conducting demonstration projects in order to improve access to health care and to contain costs. These projects may last from one to five years or more and may temporarily change the way CHAMPUS is used. These demonstration projects are not described in this Handbook. The CHAMPUS regulation (DOD 6010.8-R) is the final word on any issue. If there is a discrepancy between this Handbook and the regulation, the regulation determines benefits. The claims processors serve as fiscal intermediaries, processing and paying claims. Comments regarding this Handbook should be sent to: Public Affairs Branch OCHAMPUS Aurora, Colorado 80045-6900 ~¢.~~~ Captain, Dental Corps, United States Navy Director OCHAMPUS 6010.48-H May 24,1990 CONTENTS CHAMPUS OVERVIEW. . . . . . . . . . . . . . . . ..... . . . . . . . . . . . .... . .. . 1 CHAMPVA •••••••••• .... . . . ... . . . . .. . . . . . . . .. . . . . . . . ... . . . . l. COVERED SERVICES ••••• . . . ... . . . . . . . . . . . . . . . . . . ...... . . . . . 2 NON-COVERED SERVICES. .... . . . .. . . .. . . ... . . . . . . . . . . . . . . .. . 2 COVERED ORAL SURGERY. .. . ... . . . . . . . . . . . . . ..... . . .. 3 NON-COVERED DENTAL SERVICES. ..... . .... . . .. . . . ... . . . . . . . . 3 ELIGIBILITY CHAMPUS. .... . .. . . . . . . . ... . . . . . . . .. . . . . . 4 ELIGIBILITY CHAMPVA •••••••• .. . . . . . . .. . . . . . . . . . .. . . . . .. 5 ELIGIBILITY-FORMER SPOUSES •• . . . . . . .. . . . . . . .. . . . .. . . . .. 5 CHANGES AFFECTING ELIGIBILITY. .... . . .. . . . . . ... . . . .. . . . . . 6 CHECKING ELIGIBILITY •••••••.•• ..... . . . . . . . . . . . . . ... . . . . . 7 ELIGIBILITY AND SPECIAL RULES UNDER DRGS •• . . . . . . .. . . . .. . 8 NON-AVAILABILITY STATEMENTS ••••••• ... . . . . . . ... . . . . . . . . 8 COST-SHARES FOR INPATIENT CARE ••• .. . . . . . ... . . . . . . . . . ... 10 DRGS AND HOSPITAL COST-SHARES •••• .. . . . . . .... . ... . . . . . . . 10 PARTICIPATION OR ACCEPTING ASSIGNMENT. 12 AMBULANCE COVERAGE •••••• . . . .. . . ... . . . . . ... . . . . . . . .. . . .. 13 AMBULATORY SURGERY •••••• . . . . ... . . . . . . . . . .. . . . . . . .. . . . . . 14 APPEALS. . . . • • • . . • • • • • . . . . • • . • . • • . • • . . . . • . • . . . • • • . . . • • • • 14 ALLOWABLE CHARGE REVIEWS. . . ...... . . .. . . .. . . . . . . . . . . . . . . 16 BENEFIT AUTHORIZATION. ..... . .. . . . . . . . . . . . . .... . . . . . . . .. 17 BIOFEEDBACK •••••••••••• .. . . . .. . . ... . .. . . . . . . . . . ... . . ... 17 BREAST RECONSTRUCTION •••••••• . . . . . . . . . . . .. . . .. . . . .. . . . . 18 CHAMPUS-AUTHORIZED PROVIDERS. • • • • • • • • • • • • • • • • • • • • • • • • • • 18 ii OCHAMPUS 6010.48-H May 24,1990 CONTENTS CHRONIC RENAL DISEASE (CRD) •••••••••••••••••••••••••••• 19 COST-SHARE. .. . . . . . . . ..... . .... . .. . .... . . .. . ... . . .... . . . 20 CT SCANS .•. .. . ' ....... . . . . . .. . ... . ....... . .. . . . . . . . . . .. 21 DEDUCTIBLE. .. . .. . .. . . ....... . .... . . . . . . . . . .. . . . . . .. 21 DEMONSTRATION PROJECTS • •••••••••••••••••••••••••••••••• 22 DOUBLE COVERAGE •..•.•••••• .... . . . ... . . . .. . . . .. . . . . . .... 22 DURABLE MEDICAL EQUIPMENT (DME) . . . .... . . ... . . . . . .... . .. 23 FRAUD AND ABUSE •••.••••••• 25 FREE-STANDING BIRTHING CENTERS .••••••...••••••.••••.•.• 27 HEART TRANSPIA.NTS ••••••.•••••••••.•...•••.••.•••...•.•. 27 LITHOTRIPSY. • . . • . . • • • • . . • • • . . • • . . . . . . . . . . . • • • . • • . . . . . . . 28 LIVER TRANSPIA.NTS •••••••••• .. . .. . . .. . . . .. . . . . . . . . . . . . .. 28 MAGNETIC RESONANCE IMAGING. .. . .. . . . . .. . . . . .. . . . . .. . . . . . 28 MATERNITY CARE. .... . . . .. . . .. . . . . . . . . . . . . . . .. . .. . . . ... . . 29 MORBID OBESITY. . . .. . .. . .... . ..... . .. . . . . .. . . . . . . .. . . . .. 31 MULTIPLE SURGERIES • •••.•..•••..••••.•••••...•.• 31 PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) .. 32 PRESCRIPTION DRUGS AND MEDICINES. .. . .. . . . .. . .... . . . ... . . 32 PROSTHETIC DEVICES. • • • • • • • • • • • • • • • • • . • • • . • • • • • • • . • • • • • • 33 REIMBURSEMENT •••••• .. . .. . ..... . .. . . . ... . . . . . . . . . .... . . . 33 Filing Claims. .. . . .... . . . . . . . .. . . . . .... . . . . . . . .. . . 35 Claims Filing Jurisdiction. . . . . . .. . . . . .... . .. . .. . . 36 Claim Forms . .............. . . . . . ... . .. . . . . . . . . . . . .. 37 Adequate Medical Documentation. . . . . . . . . . . .... . .. 38 Hospital-employed Providers/DRGs. . . . . . .... . .... . . . 39 Signature on File••••••••••••••.••...••••••.•••••• 39 iii OCHAMPUS 601 0.48-H May 24, 1990 CONTENTS Explanation of Benefits (EOB) ......••.....•..••••• 40 Special Services for Providers ....•........•.••••• 40 PEER REVIEW ORGANIZATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . • • • 41 PROVIDER SANCTIONS.... . . • . . . . . . . • . • . . . . • . . . . . . . . • . • • • • • 41 PROGRAM FOR THE HANDICAPPED. . . . . . . . . . . . . . . . . . . . . . . • • • • • 42 MENTAL HEALTH BENEFITS. . . . . • • . . . . . . . . . . . . . . . . . . . . . . . • • • 45 Pre-payment Certification..•................••..•. 45 Outpatient Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 7 Limits-Inpatient Care....................•.•..•• 47 Waivers........................................... 48 MENTAL HEALTH PROVIDERS. • . . . . . . . . • • . . . . • . . . . . . . . . . . • • • • 48 Hospitals and Daily Rates........••..........••••• 49 Residential Treatment Centers•.............•.•.••• 49 Professional Providers••........•.••.....•...•.••• 51 Psychiatrists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Clinical Psychologists.....•.................••.•• 51 Clinical Social Workers ......•...••.•..•....•••••• 51 Certified Psychiatric Nurse Specialists.......•..• 52 Marriage, Family and Pastoral Counselors....•.•••• 52 Mental Health Counselors.....................••.•• 53 PSYCHIATRIC EMERGENCIES •.....•..................•.••... 55 ALCOHOLISM TREATMENT. . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . • . • • 55 SPECIAL CONSIDERATIONS.... . . . . . . . . . . . . • . . . . . . . . . . . • • . • • 57 Excluded Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Eating Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 iv OCHAMPUS 6010.48-H May 24,1990 CONTENTS APPENDICES GI..OSSARY. • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • A I D CARD EXAMPLES • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • B FORMS • • • • • • • • . • • • • • • • • • • • • • • • • • • • • • • • • . . • • • • • . • • • • • • • • • C DD FORM 2 52 0 ••••••••••••••••• C-1 CHAMPUS FORM 501(HCFA-1500) .... C-5 DD FORM 2532 •• C-7 DD FORM 2533 ••••• C-9 DD FORM 2527 ••• C-11 DD FORM 1251 ••• C-17 UB-82 (HCFA-1450) ..... .... C-19 v OCHAMPUS 6010.48-H May 24, 1990 CHAMPUS CHAMPUS--The Civilian Health and Medical Program of the Uniformed Services--is a cost-sharing program for military families, retirees and their families, some former spouses, and survivors of deceased military members. The uniformed services include the Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Service and the National Oceanic and Atmospheric Administration. CHAMPUS shares the cost of most medical services from civilian providers when beneficiaries can't get care from a military hospital or clinic. Service families are eligible to receive inpatient and outpatient care from uniformed service hospitals and clinics. The types of medical services available at uniformed service hospitals vary by facility, and hospitals serve active-duty ·members first. • The CHAMPUS program supplements the uniformed service hospitals and clinics. CHAMPUS is similar to other third-party payers in that there are some coverage limitations and personal financial responsibilities. Providers should check with the CHAMPUS claims processor for their state if there are questions about coverage of certain types of care. CHAMPVA CHAMPVA is a health benefit for the families of veterans with 100 percent service-connected disability and the surviving spouse or children of a veteran who dies from a service-connected disability. (A surviving spouse of a person who died on active duty may be eligible for CHAMPVA if the survivor remarried and the marriage later ended) . The Department of Veterans Affairs determines who is eligible for CHAMPVA. CHAMPVA beneficiaries, including children, must have a current identification card and be listed in DEERS, the Defense Enrollment Eligibility Reporting System. Generally, the same benefit rules apply for CHAMPUS and CHAMPVA, unless otherwise stated. The same claims processors handle both CHAMPUS and CHAMPVA claims, unless there are special rules. CHAMPUS and CHAMPVA cover medically necessary services and supplies required for diagnosis and treatment of illness or injury, including maternity care. Services and supplies must be provided in accordance with sound medical practice and established quality standards by physicians or other authorized professional providers. 1 OCHAMPUS 6010.48-H May 24, 1990 COVERED SERVICES NOTE: This is NOT an all-inclusive list. AMBULANCE AMBULATORY SURGERY ANESTHESIA SERVICES BONE MARROW TRANSPLANTS (WITH LIMITATIONS) BREAST RECONSTRUCTION (WITH LIMITATIONS) CHRONIC RENAL DISEASE CONSULTATION SERVICES CT SCANS DURABLE MEDICAL EQUIPMENT FREE-STANDING BIRTHING CENTERS HEART TRANSPLANTS (WITH LIMITATIONS) INPATIENT CARE IN-HOME CARDIO-RESPIRATORY MONITORS LABORATORY AND PATHOLOGY SERVICES LIVER TRANSPLANTS (WITH LIMITATIONS) MAGNETIC RESONANCE IMAGING (WITH LIMITATIONS)MATERNITY CARE MEDICAL SUPPLIES AND DRESSINGS MENTAL HEALTH CARE MORBID OBESITY (WITH LIMITATIONS) OUTPATIENT CARE OXYGEN PERCUTANEOUS LITHOTRIPSY PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY PHYSICAL THERAPY PRESCRIPTION DRUGS AND MEDICINES PROSTHETIC DEVICES SPEECH THERAPY (WITH LIMITATIONS) STERILIZATION RADIATION THERAPY SERVICES SURGERY (PRE-OPERATIVE AND POST-OPERATIVE CARE)WELL BABY CARE (BIRTH TO TWO YEARS) X-RAY SERVICES 1 NON-COVERED SERVICES (examples only) ACUPUNCTURE ANESTHESIA BY ATTENDING PHYSICIAN ARTIFICIAL INSEMINATION , BREAST REDUCTION OR AUGMENTATION (COSMETIC PURPOSES)CHIROPRACTORS AND NATUROPATHS COMFORT ITEMS COSMETIC SURGERY CUSTODIAL CARE DOMICILIARY CARE ELECTROLYSIS 2 OCHAMPUS 6010.48-HMay 24, 1990 EXERCISE PROGRAMS IMMUNIZATIONS (EXCEPT FOR WELL BABY CARE) INVESTIGATIONAL PROCEDURES MAMMOGRAMS (ROUTINE) PAP SMEARS (ROUTINE) PHYSICAL EXAMINATIONS PREVENTIVE MEDICINE ROUTINE FOOT CARE STERILIZATION REVERSAL STOP SMOKING PROGRAMS WEIGHT REDUCTION PROGRAMS COVERED ORAL SURGERY -SURGERY TO CORRECT ACCIDENTAL INJURY -SURGERY OF ACCESSORY SINUSES, SALIVARY GLANDS OR DUCTS -EXCISION OF TUMORS AND CYSTS OF THE JAWS, CHEEKS, LIPS, TONGUE, ROOF AND FLOOR OF THE MOUTH WHEN THE CONDITION REQUIRES A PATHOLOGICAL EXAM -EXTERNAL INCISION AND DRAINAGE OF CELLULITIS -FRACTURES OF FACIAL BONES -ORAL AND FACIAL CANCER -REDUCTION OF DISLOCATIONS AND THE EXCISION OF THE TEMPOROMANDIBULAR JOINTS, WHEN SURGERY IS A NECESSARY PART OF THE REDUCTION -SURGICAL INTERVENTION NECESSITATED BY PHYSICIAN-INDUCED TRAUMA, E.G., FOR GINGIVAL HYPERPLASIA Covered oral surgical procedures that are essentially NOTE: medical rather than dental may not require pre-authorization. NON-COVERED DENTAL SERVICES -preventive, routine, restorative, prosthodontic and emergency dental care • -adding or modifying bridge work and dentures -orthodontics, except when directly related to correction of a cleft palate 3 OCHAMPUS 6010.48-HMay 24, 1990 NOTE: Preauthorization is needed for adjunctive dental care. Providers should contact: Blue Cross/Blue Shield of South CarolinaCHAMPUS/ Adjunctive Dental P.O. Box 6150 Columbia, sc 29260-6150 NOTE: The Delta Dental Insurance Plan for active-duty familymembers is not part of the CHAMPUS program. ELIGIBILITY The. following people are eligible for CHAMPUS/CHAMPVA: CHAMPUS A. Active-duty family 1. Spouse **** 2. Former spouse (providing specific criteria are met) 3. Children (legitimate, illegitimate, adopted) and stepchildren a. to age 21 if unmarried b. to age 23 .if full-time student and unmarried (neednew I.D. card) c. beyond age 21 if disabled and unmarried, and disability occurred prior to the 21st birthday (neednew I.D. card) NOTE: The active-duty member is not eligible. .B. When the sponsor ((military member) is retired or deceased 1. Spouse **** 2. Former spouse (providing specific criteria are met) 3. Children and stepchildren a. to age 21 if unmarried b. to age 23 if full-time student and unmarried (neednew I.D. card) 4 OCHAMPUS 6010.48-HMay 24, 1990 c. beyond age 21 if disabled and unmarried, and disability occurred prior to the 21st birthday (need new I.D. card) 4. Retired sponsor CHAMPVA A. Spouse (veteran sponsor with 100% disability) B. Widow/widower c. Children and stepchildren 1. to age 18 if unmarried 2. to age 23 if full-time student and unmarried (need new I.D. card) 3. beyond age 18 if disabled and unmarried, and disability occurred prior to the 18th birthday (new I.D. card required) but NOTE: The disabled sponsor is NOT eligible for CHAMPVA, is eligible for care from the Dept. of Veterans Affairs. The following are not eligible for CHAMPUS or CHAMPVA: active-duty members, dependent parents, grandchildren, and those entitled to Part A Medicare, except for active-duty dependents. CHAMPVA beneficiaries who exhaust their Medicare lifetime reserve may be covered again by CHAMPVA. **** ELIGIBILITY RULES FOR FORMER SPOUSES Some former spouses, i.e., those who have been married to activeduty or retired military members, may be eligible for CHAMPUS benefits. The rules governing their eligibility have been spelled out in federal law. Since each of the military branches of service determines eligibility, providers should be aware that not all former spouses are eligible, nor are they necessarily eligible indefinitely. Providers should check for a valid ID card or authorization letter, check the expiration date, and make a copy of both sides of the ID card. Providers who have questions about the specifics of former spouse eligibility should contact the appropriate claim processor's field representative. 5 OCHAMPUS 6010.48-HMay 24, 1990 CHANGES AFFECTING.ELIGIBI~TY A. Separation and divorce 1. Spouse maintains eligibility through separation; afterdivorce, eligibility may continue as a former spouseunder certain circumstances. 2. Children maintain eligibility after divorce.Stepchildren are eligible only if they are adopted bythe sponsor. B. Death of sponsor 1. Spouse a. Does not change eligibility unless spouseremarries; eligibility ends with remarriage,unless remarriage is to an active-duty or retired sponsor. b. For CHAMPVA ONLY, benefits can be regained upontermination of the second marriage. 2. Children--does not affect eligibility. C. Medicare 1. Medicare is always first payor. 2 0 Eligibility for Medicare is assumed to begin at age 65unless disallowance can be shown. 3 0 Retired members and their dependents who are eligiblefor Medicare Part. A, based on disability, age orchronic renal disease, lose eligibility for CHAMPUS. Dependents of active-duty members .remain eligible forCHAMPUS, but Medicare is primary. • . •. NOTE: Eligibility for Medicare affects only the individualrecipient; it does~not affect other family members. D. Adoption An adopted child becomes eligible when the adoption is final. NOTE: Grandchildren, grandparents, parents and parents-in-laware NOT eligible for CHAMPUS/CHAMPVA benefits. 6 OCHAMPUS 6010.48-HMay 24, 1990 CHECKING ELIGIBILITY The Department of Defense uses an enrollment system, like all other third-party health plans, to check who is eligible for CHAMPUS benefits. DEERS--the Defense Enrollment Eligibility Reporting System--is a world-wide data base of military families, retirees and others covered by CHAMPUS and CHAMPVA. The Defense Department developed the enrollment system at the direction of Congress to make it easier to plan and allocate resources and to establish a method of eliminating fraudulent use of military benefits. In the United States, most eligibles are already enrolled in DEERS. Active-duty and retired military personnel are automatically enrolled in the system, but their family members must be registered by their sponsor with DEERS to ensure that they are correctly entered into the system. Military sponsors and family members should report any changes in status or location to their nearest service personnel office immediately to ensure their DEERS information is current. Those family members who are not enrolled should contact the nearest personnel office of any uniformed service for assistance. Claims will be denied if patient/sponsor eligibility information is not available to the claims processor through the DEERS data bank. Providers should ask CHAMPUS and CHAMPVA patients whether they are enrolled in DEERS. Patients can verify their enrollment by calling the nearest personnel office of any service, or by calling the DEERS center (U.S: 1-800-538-9552; CA only: 1-800 -334-4162; HI/AK: 1-800-527-5602). CHAMPUS and the services frequently remind people to keep their DEERS information up-to-date with changes in family status and location. However, since new people join the military every day, their family members may not be enrolled. A valid ID card may be the only means of checking eligibility. Providers should check the effective and expiration dates on the card. Children under the age of 10 will probably not have an ID card. In these cases, providers should check the parent's ID card. CHAMPUS recommends that providers make a copy of both sides of the ID card and retain it on file for future reference. NOTE: SEE APPENDIX B FOR EXAMPLES OF ID CARDS NOTE: Family members lose their eligibility at midnight on the day the active-duty sponsor is discharged from service. 7 OCHAMPUS 6010.48-HMay 24, 1990 NOTE: Active-duty service members are not covered by CHAMPUS.The service member's branch of service provides forthe care of active-duty service members, or isresponsible for paying for any civilian emergency carerequired by active-duty members. All claims foractive-duty members must be referred to the member'sbranch of service. Bills should include a copy of the narrative summary or a copy of the outpatient record of the visit. SPECIAL ELIGIBILITY RULES UNDER DIAGNOSIS RELATED GROUPS (DRGS) Under the new CHAMPUS DRG payment system, if a patient loses or gains eligibility during a period of hospitalization, the DRG hospital will be paid as if the patient were eligible during the entire confinement. If the patient loses CHAMPUS eligibility because of gaining Medicare eligibility, CHAMPUS becomes the secondary payor. However, if a patient loses eligibility during hospitalization, there will be no payment for cost or length-of stay outliers. The patient's cost-share will be based on the status of the sponsor (active-duty or retired) at the time of admission. For all other providers, including DRG-exempt hospitals, CHAMPUS will share the cost of only that portion of the services or supplies that were rendered before eligibility ceased. INPATIENT CARE AND NON-AVAILABILITY STATEMENTS CHAMPUS patients who live within the health care zone (zip codezone) around a uniformed service hospital need a non-availabilitystatement issued by the hospital before getting non-emergency inpatient civilian care. However, CHAMPUS will share the cost of non-emergency inpatient care without a non-availabilitystatement when the patient has a non-CHAMPUS health plan that is first payor. Families who are eligible for CHAMPUS, but who live outside the zip code zone of the nearest uniformed servicehospital, don't have to get non-availability statements for inpatient civilian health care. NOTE: CHAMPVA patients never need non-availability statements. Providers should be aware that the issuance of a non-availability statement by a military hospital does NOT guarantee payment nordoes it authorize the service as a CHAMPUS benefit. CHAMPUS does not require non-availability statements foremergency treatment, but the attending physician must certifythat the episode was a true emergency. The claims processor willcheck the diagnosis to verify the emergency. On the UB-82, Code 1 must be inserted in locator 17. 8 OCHAMPUS 6010.48-HMay 24, 1990 If a patient received emergency treatment in one hospital and is transferred to another for the same diagnosis because the first hospital was unable to treat him or her, the services by the transferring hospital can be cost-shared as inpatient services. An emergency is defined as the sudden and unexpected onset of a medical condition, a severe injury, or an acute exacerbation of a chronic condition which is threatening to life, limb or sight, requiring immediate treatment. Additionally, it may involve painful symptoms requiring immediate palliative efforts to relieve suffering. Providers should direct questions about the definition of an emergency to the appropriate claims processor. The following services do not, at present, require a nonavailability statement: -ambulatory surgery for active-duty family members -inpatient services in specialized treatment facilities, skilled nursing facilities, student infirmaries and residential treatment centers -inpatient care under the Program for the Handicapped outpatient care maternity care and birthing services at a CHAMPUSauthorized birthing center -providers participating in the military-civilianHealth Services Partnership Program It is possible that some ambulatory surgery and other outpatient services may, in the future, require non-availability statements. Providers should encourage patients to contact their Health Benefits Advisor about current rules. Non-availability statements remain valid for admissions occurring within 30 days of issuance and for 15 days after discharge for any additional inpatient treatment directly related to the original admission. With maternity care, the date of admission is the date the patient enters a prenatal program with a civilian provider. The non-availability statement remains valid until 42 days following the termination of the pregnancy. If a newborn remains in the hospital continuously after discharge of the mother, the mother's non-availability statement remains valid for up to 15 days after the mother's discharge. 9 OCHAMPUS 6010.48-HMay 24, 1990 .After that, a non-availability statement in the baby's name must /accompany the claim for nonemergency care. If the newborn is the child of an active-duty mother, a non availability statement is required on the fourth day of care. The same rule applies to the illegitimate newborn of an active duty or retiree father and an ineligible mother. COST-SHARES FOR INPATIENT CARE(Professional providers) CHAMPUS pays an allowable charge for professional fees. The allowable charge is the maximum amount CHAMPUS will pay for medical and other services furnished by physicians and other individual professional providers, medical groups, independent laboratories, suppliers of ambulance services, suppliers of durable medical equipment, medical supplies and prostheses. The CHAMPUS claims processors determine the allowable charges using data on prevailing charges in a state. The allowable charge, the amount CHAMPUS will pay prior to the reduction for any beneficiary cost-share or deductible, is the lowest of thebilled charge, the prevailing charge or the prevailing chargeadjusted by the Medicare Economic Index. Specific information onallowable charges is available from the claims processors. For active-duty family members, no cost-share is taken forprofessional services rendered in conjunction with the inpatientstay. All others pay 25 percent of the allowable charge. See RTC section, p. 49, on professional provider fees. COST-SHARES FOR HOSPITALS AND DRGS CHAMPUS uses a diagnosis-related group (DRG) payment system formost admissions to acute-care, short-term hospitals in 49 states,the District of Columbia and Puerto Rico. Maryland is exempt from DRGs. Hospitals should continue to bill as they have in the past andshouldn't attempt to assign a DRG on the claim. The claimsprocessors assign DRGs. Claims MUST NOT be submitted bybeneficiaries. Hospitals must use the UB-82. The cost-share provision under DRGs is different forbeneficiaries who are other than active-duty family members.The beneficiary cost-share for these patients is the lesser ofthe per diem rate of $235 (FY,l990) or 25 percent of the billedcharge, not to exceed the DRG amount. CHAMPUS' use of DRGs has not affected the way cost-shares are calculated for active-duty dependents. 10 OCHAMPUS 6010.48-HMay 24, 1990 ~, \ For exempt hospitals unless subject to an alternative CHAMPUS reimbursement system, the cost-share will remain the same as it has been in the past, i.e., 25 percent of the allowable charge. EXEMPT HOSPITALS AND SERVICES -kidney acquisition costs -heart and liver transplants -pediatric cases involving AIDS, cystic fibrosis and bone marrow transplants -psychiatric and substance abuse hospitals -long-term care hospitals -rehabilitation hospitals -cancer hospitals -sole community hospitals (Medicare-exempt) -Christian Science sanitoria -distinct parts of a hospital providing psychiatric, rehabilitation or substance abuse services NEONATES There are 34 DRGs for neonates, based on birth weight, operating room procedures and the presence of complications. In paying neonate claims, CHAMPUS has distinct outlier thresholds which are set so that more cases qualify as outliers and outlier payment is higher than in non-neonatal cases. Birth weight is required on all neonatal claims. In all other respects, claims submission is routine. EXEMPTIONS Professional providers, including nurse anesthetists, employed by hospitals are exempt from DRGs. Hospitals must bill separately for their services, but must participate on these claims. The UB-82 claim form may not be used for billing on these claims. The CHAMPUS Form 501 (HCFA-1500} or the DD Form 2520 should be used. BILLING In situations where the DRG-based payment amount is less than the billed amount, the hospital may not bill beneficiaries for the 11 OCHAMPUS 6010.48-H May 24, 1990 remaining balance after the DRG-based payment amount and the patient's cost-share. The hospital may bill for non-covered items, such as telephones and television. CHAMPUS will pay on a lump-sum basis for hospital capital costs and direct medical education costs. Hospitals should contact the appropriate claims processor to determine the specific information required for payment of these costs. CHAMPUS uses a grouper program similar to Medicare's. There is no uniform pricer program. DRG weights and rates are routinely published in the Federal Register. Questions about billing practices and claims submission under the DRG payment system should be addressed to the appropriate claims processor. NOTE: See section on COST-SHARE for outpatient care, p. 20. PARTICIPATION OR ACCEPTING ASSIGNMENT PROFESSIONAL PROVIDERS CHAMPUS encourages providers to participate (accept assignment of benefits). This means that the provider agrees to accept the CHAMPUS-determined allowable charge as the full fee, even if it is less than the billed amount. CHAMPUS pays the allowable charge, less the patient cost-share and outpatient deductible. The provider also agrees to make no attempt to charge the beneficiary for .more than the allowed amount. However,providers may charge patients for services not covered by CHAMPUS. Providers collect the cost-share and deductible from the patient. Participation facilitates cash flow and payment due will ensures be made to the provider, rather than to the beneficiary. Most CHAMPUS claims are processed within 21 days of receipt by the claims processor. When providers file the claims and participate, they are paid directly. In addition, when providersfill out the claims, there is less likelihood of error and subsequent delay in payment. Providers may participate on a case-by-case basis. However,CHAMPUS does encourage families to seek medical care from providers who are willing to participate. When a provider chooses to participate, "yes" must be checked on the claim form and the provider must sign the form so that payment will be mailed to the provider. Participating providers may file appeals (see APPEALS) and have 12 OCHAMPUS 6010.48-HMay 24, 1990 a right to information on participating claims. HOSPITALS Federal law requires hospitals participating in Medicare to also participate in CHAMPUS for inpatient services. Hospitals that are subject to the CHAMPUS DRG payment system, but not Medicare's DRGs, are required to sign participationagreements with CHAMPUS. AMBULANCE COVERAGE BASIC AMBULANCE SERVICE CHAMPUS shares the cost of ambulance service as an outpatient service under CHAMPUS rules. Ambulance transportation must be medically necessary (patient would otherwise be at risk); the patient's illness or injury must be covered under CHAMPUS; and the ambulance must be licensed under state or local law. Taxis, medicabs and ambicabs do not qualify as ambulances. CHAMPUS will not cover ambulance transportation for the convenience of the patient. Boats and airplanes can qualify as ambulances when the pick-up point is a long distance from a hospital or when the patient's condition requires speedy hospital admission. CHAMPUS will share the cost of ambulances from a civilian hospital to a uniformed service facility. However, CHAMPUS cannot pay for the ambulance if the service facility orders it, or if the service facility is the pick-up point. ADVANCED LIFE SUPPORT AMBULANCES CHAMPUS now covers advanced life support (ALS) ambulance service, which has complex, specialized, life-sustaining equipment and equipment for radio andjor telephone contact with a physician or hospital, e.g., mobile coronary care units and neonatal transport units. The ambulance must have staff trained and authorized to administer IVs, provide anti-shock trousers, establish and maintain the patient's airway, defibrillate the heart, relieve pneumothorax conditions and perform other advanced life support procedures or services, such as EKG monitoring. ALS ambulance use must be justified on the claim. Otherwise, CHAMPUS will reimburse for basic ambulance service only. 13 OCHAMPUS 6010.48-H May 24, 1990 Reusable devices and equipment must be included in the charge for the ambulance trip. ALS ambulance providers may chargeseparately for non-reusable items and disposable supplies, based on actual quantities used. CHAMPUS will not pay for separate charges for basic ALS ambulance personnel. AMBULATORY SURGERY Surgery performed on an outpatient basis at a freestanding ambulatory surgical center must meet all of the fo.llowing conditions to be payable under CHAMPUS: 1. A physician prescribes, provides or supervises the treatment. 2. The center provides the type and level of care and services authorized by CHAMPUS rules. 3. The center meets all licensing and certification requirements of the jurisdiction where the facility is located. 4. The center is approved by Medicare, accredited by Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Accreditation Association for AmbulatoryHealth Care, or meets other such standards as authorized by CHAMPUS. Ambulatory surgery is cost-shared as inpatient care for activeduty family members. A non-availability statement is not needed. It is possible that some ambulatory surgery and other outpatientservices may, in the future, require non-availability statements. Providers should encourage patients to contact their Health Benefits Advisor about current rules. CHAMPUS cannot share the cost'of professional services providedby employees salaried by or contracted with non-approved centers. CHAMPUS can also share the cost of ambulatory surgery in a hospital-based facility. APPEALS Participating providers may appeal certain decisions made by the claims processor, contractor or by CHAMPUS headquarters.Generally, providers who do no~ participate may not appeal, but CHAMPUS patients, parents of pa'tients under 18, or guardians of incompetent beneficiaries, may' file appeals. Generally,providers who do not participate may not re~eive any information 14 OCHAMPUS 6010.48-H May 24, 1990 regarding claims without the signed authorization of the patient or the patient's parent or guardian. The proper appealing party may appoint someone to represent him or her in the appeal. Providers who request approval as CHAMPUS-authorized providers but are denied approval by either CHAMPUS or the contractor may appeal those decisions, as well. However, providers who are excluded because of fraud and abuse by another federal or federally funded program, e.g., Medicare or Medicaid, may not appeal through the CHAMPUS system. Appealable matters include the following: -Denials or partial denials of requests for pre-authorization for certain services or supplies -Notification that CHAMPUS will not pay for services after a certain date -Disagreements such as those regarding medical necessity, inappropriate care, level of care, investigational procedures Non-appealable matters include: A specific exclusion of law or regulation -Allowable charges for a particular service -Decisions by the CHAMPUS contractor to ask for additional information on a particular case PEER REVIEW ORGANIZATIONS AND APPEALS When a peer review organization (PRO) makes an initial or determination that services are medically unnecessary inappropriate, the beneficiary or provider may ask for a reconsideration from the PRO within 90 days of the initial determination. If the PRO's initial determination is unchanged after reconsideration, the beneficiary may appeal the PRO reconsideration to OCHAMPUS within 60 days of the date of the a reconsideration and obtain a hearing. A provider may appeal PRO reconsideration to OCHAMPUS within 60 days of the date of the if there is reason to reconsideration and obtain a hearing ONLY believe that the provider did not know nor could reasonably have been expected to know that the services were excluded. MENTAL HEALTH AND APPEALS • Under the new CHAMPUS program for managing mental health utilization (CHAMP-MH), CHAMPUS requires certain kinds of mental 15 OCHAMPUS 6010.48-H May 24, 1990 health care be certified by the contractor, Health Management Strategies International, Inc., (HMS) before payment is made. (See Mental Health section of this handbook for details.) If certification is denied, HMS will notify the provider and the patient in writing of the denial and explain the right to reconsideration of the denial decision. Requests for reconsideration must be made in writing to HMS within 90 days of the date of the denial decision. Mental health providers may contact HMS at 1-800-242-6764 to request details on reconsiderations. Following a reconsideration that upholds the contractor's initial determination, a participating provider or a beneficiary mayrequest an appeal with the Office of CHAMPUS within 60 days of the reconsideration decision. DEMONSTRATION AREAS Specifics on appeal limits and details on how to appeal in demonstration project areas are available from the appropriate contractors or claims processors. PROVIDER SANCTIONS AND APPEALS Providers who have had sanctions imposed against them, i.e.,exclusion, suspension or termination as CHAMPUS-authorized providers may seek administrative appeal through the organizationthat imposed the sanctions. Providers with questions about the details of appealing sanctions should contact the appropriate contractor or claims processor. ALLOWABLE CHARGE REVIEWS Disagreements regarding the amount allowed for a particular claim may be reviewed, upon written request, by the claims processor.Requests for review must be sent to the claims processor for the state where services were provided and must be postmarked within 90 days of the date on the Explanation of Benefits. If the provider still does not agree with the claims processor's decision concerning the amount allowed, he or she may ask (inwriting) the Benefit Services Branch at the CHAMPUS headquarters to review the decision. The decision of the Office of CHAMPUS is final. However, if the allowed amount is for hospital services paid under the CHAMPUS DRG reimbursement system, only the state peerreview organization (PRO) may change the DRG and the allowed amount. 16 OCHAMPUS 6010.48-H May 24, 1990 ELIGIBILITY AND NON-AVAILABILITY DECISIONS Disagreements regarding CHAMPUS eligibility should be referred to the appropriate uniformed service of the patient's sponsor. Problems with CHAMPVA eligibility should be referred to the CHAMPVA Registry Center, 4500 Cherry Creek Drive, South, Box 64, Denver, CO 80222. Disagreements regarding the issuance or denial of non-avail ability statements should be referred to the appropriate uniformed service hospital. There is an appeal system within the uniformed service hospitals for denial of non-availability statements. The Health Benefits Advisor at military bases should provide the information to the appealing party.. CHAMPUS cannot issue non-availability statements. \BENEFIT AUTHORIZATION CHAMPUS requires prior approval of all care under the CHAMPUS Program for the Handicapped. Providers may contact the claims processor for their state. CHAMPUS does not provide pre-authorization for cosmetic, plastic or reconstructive surgery. However, providers should be aware that CHAMPUS does not pay for surgery of this type unless the purpose is clearly for restoration of function, to correct a serious birth defect, to restore body form after an accidental injury, to improve appearance after severe disfigurement or or extensive scarring from surgery for cancer, for breast reconstruction after a mastectomy. Documentation establishing medical necessity must accompany claims. Many types of mental health care require pre-payment certification. See Mental Health section. Adjunctive dental care requires pre-authorization. See section on Dental Services, p. 3. BIOFEEDBACK On Feb. 6, 1989, CHAMPUS began sharing the cost of services and supplies when used in connection with electrothermal, electromyograph and electrodermal biofeedback therapy for 17 OCHAMPUS 6010.48-H May 24, 1990 patients who haven't responded to more conventional treatment. Coverage requires physician evaluation and referral of patients to CHAMPUS-authorized providers. Coverage is limited to adjunctive treatment for the following conditions: --Raynaud's Syndrome --muscle re-education of specific muscle groups, treatment of pathological muscle abnormalities of spasticity or incapacitating muscle spasm or weakness Excluded is biofeedback for treatment of ordinary muscle tension states, for migraine or tension headache, psychosomaticconditions, bladder-control or hypertension. CHAMPUS also excludes payment for the rental or purchase of biofeedback equipment. CHAMPUS limits treatment to 20 sessions (inpatient and outpatient) in a calendar year for each patient, excluding the initial evaluation. Claims must document physician referral, appropriate medical evaluation and previous attempts at conventional treatment and indicate whether the patient's condition is expected to improvewith the therapy. BREAST RECONSTRUCTION CHAMPUS covers breast reconstructive surgery following a medically necessary mastectomy' (cancer, fibrocystic disease, non-cancerous tumors or serious injury) . There is no time limitation between the mastect?my and reconstruction. Any implant material used must be approved for use in humans bythe Food and Drug Administrati?n· BREAST CONSTRUCTION CHAMPUS will share the cost of constructive breast surgery when the absence of a breast is due to a congenital anomaly.Documentation must show that a,congenital anomaly existed which resulted in agenesis of the breast, i.e., Poland's syndrome.Reconstr.uctive surgery for an incomplete or underdeveloped breast is not covered. · CHAMPUS-AUTHORIZED PROVIDERS A CHAMPUS-authorized provider ' is one who meets certain educational, licensing and operational requirements. 18 OCHAMPUS 6010.48-H May 24, 1990 • Institutional providers include hospitals, special treatment facilities, skilled nursing facilities, residential treatment centers, Christian Science sanatoria, and infirmaries. The term does not include professional corporations or associations. Generally, institutional providers must be Medicare or JCAHO approved, or meet other established CHAMPUS standards for the specific institution. For more information, contact the appropriate claims processor. Individual professional providers of care include those who bill on a fee-for-service basis and are not employed or contracted with an institutional provider. This category includes physicians, dentists, clinical psychologists, optometrists,podiatrists and chiropodists, certified nurse midwives, certified nurse practitioners, clinical social workers, nurse anesthetists, independent laboratories, pharmacies, portable X-ray suppliers,ambulance and medical equipment suppliers, marriage and familycounselors and others. CHAMPUS requires that some professional providers be supervisedby a physician and that patients be referred by a physician. These include, among others, marriage, family and pastoral counselors, mental health counselors, licensed registered nurses, nurse anesthetists, audiologists, speech therapists, physicaltherapists, and occupational therapists. Providers must be licensed for their particular professions in the jurisdiction where the service is given. If licensure is not offered in the jurisdiction, the provider must be certified or prove eligibility for membership in the appropriate national or professional association that sets standards for the profession. NOTE: occupational therapists may not bill CHAMPUS directly, but must bill through a CHAMPUS-authorized institutional provider that employs them. CHRONIC RENAL DISEASE (CRD) Chronic or end stage renal disease that requires a continuing course of dialysis or a kidney transplantation to ameliorate uremic symptoms and maintain life is covered under CHAMPUS until Medicare entitlement has been established. However, benefits for active-duty family members only must be coordinated with Medicare for proper reimbursement. The patient may bill CHAMPUS onlyafter sending the claim to Medicare and receiving reimbursement. CHAMPUS will pay any deductible, cost-share or uncovered services that are not covered under Medicare. CHAMPUS picks up what Medicare doesn't pay. A copy of the Medicare Explanation of Benefits (EOB) must accompany the CHAMPUS claim form. 19 OCHAMPUS 6010.48-H May 24, 1990 Patients who are not active-duty family members are not eligible for CRD coverage under CHAMPUS after attaining Medicare entitlement. COST-SHARE This is the amount of money for which the CHAMPUS beneficiary or sponsor is responsible. The patient cost-share is payable to the provider, along with any deductible required for outpatient care. Other health plans use the terms "co-payment" or "co-insurance". Active-duty families are responsible for payment of the following cost-share: Outpatient -Twenty percent of the CHAMPUS-determined allowable charge, in addition to the annual fiscal year deductible. Inpatient -The amount per day required in a military facility or $25 for each admission, whichever is greater. Retirees, retiree families, former spouses, family members of deceased active-duty and deceased retirees, and CHAMPVA families are responsible for the following cost-share: Inpatientjoutpatient -Twenty-five percent of the CHAMPUS-determined allowable charge in addition to the annual fiscal year deductible for outpatient care. CHAMPUS-eligible families are protected from certain catastrophic medical expenses by a limit or "cap" on covered medical bills for care each fiscal year. The limit for active-duty families is $1,000; for all others (non-active duty and CHAMPVA), the limit is $10,000. The cap applies only to the amount of money required to meet the family's annual deductibles and cost-shares based on CHAMPUS allowable charges for medical care received in each fiscal year. Cost-shares and deductibles paid under the Program for the Handicapped, charges in excess of the CHAMPUS allowable charges and charges for non-covered treatment are not subject to the cap. Providers should be aware that when the cap is reached for care in a fiscal year, CHAMPUS will reimburse for covered care provided in the remainder of that year at 100% of the CHAMPUS allowable charge. When providers file claims for beneficiaries who have met the catastrophic cap, a note to that effect attached to the claim should help speed proper payment. NOTE: In DRG hospitals, the cost-share for beneficiaries who are other than active-duty family members is the lesser 20 OCHAMPUS 6010.48-H May 24, 1990 of 25 percent of the billed charge or the 1990 fiscal year per diem rate of $235. Active-duty family members' cost-share is unaffected by DRGs. (See section on DRGs, p. 10) NOTE: The provider may not waive the patient's cost-share. CT SCANS Medically necessary computerized tomography of the head and body is covered when all of the following are met: 1. A physician refers the patient for the diagnostic procedure. 2. The CT scan procedure is consistent with the preliminary diagnosis or symptoms. 3. Other non-invasive and less costly means of diagnosis have been attempted or are not appropriate. 4. The CT scan equipment is licensed or registered by the appropriate state agency responsible for licensing or registering medical equipment that emits ionizing radiation. 5. A physician supervises and directs the operation of the CT scan equipment. 6. A physician interprets the results of the CT scan. Claims for CT scan procedures must include the following information documenting medical necessity: 1. Patient's preliminary diagnosis or symptoms 2. Referring physician's name 3. Physician's name who interpreted results, if other than the referring physician CT scans performed by mobile units are subject to the same coverage requirements that apply to stationary units. DEDUCTIBLE The CHAMPUS beneficiary must pay a deductible for outpatient services ($50 for an individual, $100 for a family) each fiscal year, based on allowable charges. The fiscal year begins on October 1 and ends on September 30. 21 OCHAMPUS 6010.48-H May 24, 1990 If a CHAMPUS beneficiary has another insurance plan, the deductible for that other plan may also be used as the deductible for CHAMPUS. If the CHAMPUS beneficiary has met the deductible in the region of one claims processor, the beneficiary must get a copy of the CHAMPUS Explanation of Benefits (CEOB) and attach it to any claim sent to a processor in another region. This will prevent the payment of duplicate deductibles. DEMONSTRATION PROJECTS CHAMPUS has initiated several demonstration projects in various regions. These projects involve managed care, preferred provider organizations and other tests of cost-saving measures. CHAMPUS coverage in demonstration areas may differ from usual CHAMPUS policy. Providers should contact the appropriate claims processor for the state to find out about any demonstration projects affecting their area. DOUBLE COVERAGE When a CHAMPUS patient has another health plan, CHAMPUS is always the secondary coverage. Double coverage rules apply to Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) . Medicaid is not considered a double coverage plan, so CHAMPUS is the primary payor in these cases. Many CHAMPUS beneficiaries have supplemental CHAMPUS insurance policies that pay for their deductibles and cost-shares. In these cases, CHAMPUS remains primary payor. Beneficiaries may not waive benefits due from their double coverage plan. If double coverage exists, a claim must be filed with the other plan first. If beneficiaries refuse to claim benefits from the other plan, CHAMPUS will deny payment. CHAMPUS will pay benefits only for charges remaining unpaid after all other health coverage has paid benefits. Some limitations on CHAMPUS as secondary payor include: -CHAMPUS will not pay more as a secondary payor than it would have in the absence of other coverage. -Benefits cannot be paid for services provided prior to CHAMPUS eligibility. 22 OCHAMPUS 6010.48-H May 24, 1990 • -Services must be covered by CHAMPUS. When providers are awar~ that double coverage exists, the provider may annotate the amount paid by the other health insurance on the claim form. On beneficiary-submitted claims, the claim form must be accompanied by evidence of processing bythe other health plan, e.g., a copy of the Explanation of Benefits, work-sheet or letter. If services provided are not covered by the other plan, a copy of the pertinent pages from the insurance policy or benefits handbook should be sent with the claim. Providers should be aware that CHAMPUS will not pay for work related illness or injury that is covered under Worker's Compensation. If the patient fails to apply for Worker's Compensation, CHAMPUS will not cover the costs of health care. However, CHAMPUS benefits are available upon evidence that compensation benefits have been exhausted. In possible third-party liability cases, DO Form 2527, which replaces the old CHAMPUS Form 691, must be completed and sent to the claims processor before a claim is paid. If a claim is sent in and the diagnosis falls in the diagnostic range 800-999 (ICD- 9-CM), the claims processor will send a DO Form 2527 to the person who filed the claim. If the form is not returned within 35 days of the processor's request, the claim and all related claims will be denied. Providers may request copies of DO Form 2527 from the claims processor. NOTE: A dependent child may be eligible for some other coverage, in addition to CHAMPUS, through a stepparent. A step-parent's coverage is primary payor even if the other health insurance plan contains a provision stating that the natural parent's coverage is primary. DURABLE MEDICAL EQUIPMENT (DME) CHAMPUS patients may rent, lease/purchase or simply purchasedurable medical equipment if the following criteria are met: -The allowable charge must exceed $100. -It must be medically necessary in treating a covered illness or injury. -It must improve the function of a malformed, diseased or injured body part or retard further deterioration of the patient's physical condition. -It must be person-specific and be provided on a one-at-a 23 OCHAMPUS 6010.48-H May 24, 1990 time basis only. -It must be primarily and customarily used to serve a medical purpose. DME is not covered if used primarily for transportation, comfort or convenience. Wheelchairs do qualify as DME since they provide mobility and retard deterioration. Cart-like vehicles may also qualify. -It must withstand repeated use. -It must be other than eyeglasses, contact lenses, hearing aids or other communication devices and must be other than exercise equipment, spas, whirlpools, hot tubs, swimming pools or similar items. -It cannot be beyond the medically appropriate level of performance and quality required under the circumstances. Luxury or deluxe items do not qualify. Special fitting of equipment to accommodate a particular disability (one-armed wheelchair) is covered. -It is not for a patient in a facility that provides or can provide the equipment. -It is not available from a local uniformed service medical facility. -Excluding the Program for the Handicapped, DME may be purchased, rented or leased by the month, depending on the cost and period of medical necessity. The claims processor will determine the most cost-advantageous position for the government. Patients may request cost~sharing over a oneto-six month period. NOTE: CHAMPUS regulations exclude air conditioners, humidifiers, dehumidifiers and purifiers (including electronic air filters), regardless of the patient's diagnosis. The denial of these items is not appealable. CHAMPUS will share the cost of repair of DME that is already owned by a patient, subject to the following criteria: -Repairs are limited to those required to make the equipment serviceable. -The physician must state that the equipment continues to be medically necessary. -The repair cost must be less than the rental or leasejpurchase of a new unit. 24 OCHAMPUS 6010.48-H May 24, 1990 -The need for repair must not be due to willful or malicious conduct on the part of the patient. The attending physician must send a signed and dated statement with the claim for repair including: -Patient's diagnosis -Nature of the repair required -Estimated length of medical necessity for the equipment CHAMPUS will share the cost of repair if the need for the equipment is indefinite or permanent, and the cost of repair is less than the purchase cost. When the attending physician specifies the number of months of medical necessity, the cost of repair will be compared with the monthly rental allowance for the item, multiplied by the number of months of medical necessity. If the repair costs less than the estimated replacement, CHAMPUS will allow payment. ADDITIONAL DME COVERAGE CHAMPUS now covers the following: -continuous passive motion (CPM) devices for patients who have received total knee replacements. Use must beginwithin two days following surgery and the maximum coverageperiod is three weeks following surgery. -blood glucose level monitors, when precise mgjdl blood glucose levels are medically necessary for diabetes management. -nasal continuous positive airway pressure (CPAP), when used in adult patients with moderate or severe obstructive sleep apnea. These patients must have failed to obtain relief from other non-invasive therapies and the only other therapeutic alternative would be surgery. -in-home cardio-respiratory monitors for certain infants. Providers should contact the regional claims processor for detailed information on coverage of these monitors. FRAUD AND ABUSE CHAMPUS has a specific office to oversee the fraud and abuse program for the agency. The Office of Program Integrity,established in 1981, analyzes and reviews cases of potentialfraud (intent to deceive or misrepresent to secure unlawful gain). Some examples of fraud are: 25 OCHAMPUS 6010.48-H May 24, 1990 -Billing for services, supplies or equipment not furnished or used by the beneficiary -Billing for costs of non-covered or non-chargeable services, supplies or equipment disguised as covered items -Violation of the participation agreement which results in the beneficiary being billed for amounts that exceed the CHAMPUS allowable charge or cost -Duplicate billings, i.e., billing more than once for the same service, billing CHAMPUS and the beneficiary for the same services, submitting claims to both CHAMPUS and other third parties without making full disclosure of relevant facts or immediate full refunds in the case of overpayment by CHAMPUS -Misrepresentations of dates, frequency, duration or description of services rendered, or the identity of the recipient of the service or who provided the service -Reciprocal billing, i.e., billing or claiming services furnished by another provider or furnished by the billing provider in a capacity other than billed or claimed -Practicing with a revoked license, since a revocation of licensure in any state or territory of the United States will result in a loss of authorized provider status under CHAMPUS The Office of Program Integrity also reviews cases of potential abuse (practices inconsistent with sound fiscal, business or medical procedures and services not considered to be reasonable and necessary). Such cases often result in inappropriate claims for CHAMPUS payment. Some examples of abuse are: -A pattern of waiver of beneficiary (patient) cost-share or deductible -Charging CHAMPUS beneficiaries rates for services and supplies that are in excess of those charges the general public, e.g., commercial insurance carriers -A pattern of claims for services that are not medically necessary, or if necessary, not to the extent rendered -care of inferior quality -Failure to maintain adequate clinical or financial records -Unauthorized use of the term "CHAMPUS" in private business 26 OCHAMPUS 6010.48-H May 24, 1990 Fraudulent actions can result in criminal or civil penalties. Either fraudulent or abusive activities may result in administrative sanctions of suspension or exclusion as an authorized provider. The Office of General Counsel works in conjunction with the Office of Program Integrity in dealing with fraud and abuse. The Defense Department's inspector general investigates CHAMPUS fraud. FREESTANDING BIRTHING CENTERS CHAMPUS shares the cost of maternity care provided by CHAMPUSauthorized freestanding or institution-affiliated birthing centers that provide a planned course of outpatient prenatal care and outpatient childbirth service limited to low-risk pregnancies. Only natural childbirth procedures are covered. CHAMPUS does not require a non-availability statement for birthing center services. Reimbursement for all-inclusive maternity care and childbirth services furnished by an authorized birthing center is limited to the lower of the CHAMPUS-established all-inclusive rate or the cen~er's most-favored all-inclusive rate. Educational supplies and prenatal education services, Codes 99071 and 99078, are excluded from coverage. CHAMPUS will not share the cost of childbirth service provided by a CHAMPUS-approved, free-standing ambulatory surgical center unless the surgical center is also a CHAMPUS-approved birthing center. Questions regarding certification of birthing centers as CHAMPUSauthorized providers should be directed to the appropriate claims processor. HEART TRANSPLANTS CHAMPUS shares the cost of heart transplants, with certain limitations, for bel'}eficiaries who meet CHAMPUS standards for the transplants, and when the surgery is performed at a CHAMPUSapproved heart transplant center. Providers who have questions about heart transplant coverage or who want to request CHAMPUS approval of heart transplantation centers should contact the appropriate claims processor. 27 OCHAMPUS 6010.48-H May 24, 1990 LITHOTRIPSY CHAMPUS covers the following lithotripsy techniques for the treatment of kidney stones: -extracorporeal shock wave lithotripsy (ESWL) for use in the treatment of upper urinary tract stones -percutaneous lithotripsy, or nephrolithotomy, byultrasound or by the related techniques of electrohydraulic or mechanical lithotripsy -transurethral ureteroscopic lithotripsy, or transurethral nephrolithotomy, using either ultrasound, electrohydraulictechniques, or mechanical means LIVER TRANSPLANTS CHAMPUS will share the cost of liver transplants for beneficiaries who meet CHAMPUS requirements, when the surgery and related services are performed at a CHAMPUS-approved liver transplantation facility. Providers who have questions about the details of CHAMPUS coverage should contact the appropriate ·claims processor. MAGNETIC RESONANCE IMAGING Magnetic Resonance Imaging (MRI) coverage is limited to medically necessary and appropriate use of the procedure on soft-tissue areas within the body, using only MRI equipment that has been given approval by FDA and that is used within FDA guidelines. Claims processors may reimburse for claims without medical review for MRI of the posterior fossa (cerebellum and brain stem), high cervical cord (Cl through C3), and for demyelinatingdiseases of the white matter of the brain, considering the patient's symptoms and preliminary diagnosis. All other MRI claims will require documentation of medical necessity and appropriateness and will be referred to medical review. Claims for both CT and MRI scans for the same body area will also require documentation of need and will be reviewed for medical appropriateness. 28 OCHAMPUS 6010.48-H May 24, 1990 A physician's statement justifying the need for MRI will aid in processing the claim faster. Providers should refer questions about coverage of MRI, such as contraindications and investigational uses, to the claims processor for their state. MATERNITY CARE Maternity care includes the entire episode of pregnancy, through delivery and up to the first six weeks after the baby is born. CHAMPUS bases its payment for maternity care on where the patient plans to deliver, i.e., plans an inpatient or outpatient delivery. Inpatient delivery If the patient lives in the designated zip code zone near a military hospital, she must have a non-availability statement from that military hospital before receiving any civilian care. For patients who deliver in CHAMPUS-approved birthing centers, CHAMPUS can share the cost on an inpatient basis, even if patients don't stay for 24 hours. However, a non-availability statement is not required for birthing centers. Outpatient delivery If the patient plans to deliver at home and. lives in the designated zip code zone around a military hospital, she should get a non-availability statement BEFORE delivery in case the need for hospital delivery arises. If the patient has an outpatient delivery, she is responsible for the deductible and corresponding cost-share. All admissions related to the same maternity episode or birth are considered to be a single admission for cost-sharing purposes, regardless of the number of days between admissions and even when the patient is admitted to more than one hospital. A non-availability statement issued for maternity care is good from the time the patient starts prenatal care until 42 days after the delivery. If the newborn remains hospitalized after the mother is released, a separate non-availability statement is not needed unless the hospital stay is longer than 15 days. However, for active-duty families, a non-availability statement is required for newborns on the 4th day. 29 OCHAMPUS 6010.48-H May 24, 1990 Beyond this 15-day limit, a valid non-availability statement in the child's name must accompany a claim. MATERNITY AND NEWBORN CARE UNDER DRGS Under the CHAMPUS DRG-based payment system, separate claims are always required for the mother and the newborn, whether or not the newborn care is considered routine. When the date of birth and the date of admission are the same, the claims processor will handle the newborn claim with no cost-share applied to the first three days of the inpatient stay. The claims processor will apply the cost-share for any days beyond the first three. If the newborn's claim shows a date of admission different from the date of birth, the cost-share will be applied to all inpatient days. Providers should bill separately for pregnancy testing and electronic fetal monitoring to avoid confusion and delay in claims processing. NOTE: CHAMPUS does NOT cover the children of unmarried dependents. Any claims for newborn care of such children will be denied. MATERNITY CARE AUTHORIZED!PROVIDERS Generally, hospitals and physicians that provide maternity care are CHAMPUS-authorized. Certified nurse midwives may furnish care to CHAMPUS patientsindependent of physician referral or sup~rvision. They must be licensed in the area where care is provided, if licensing is offered, and must be certified l?Y the American College of Nurse Midwives. Registered nurses who are NOT certified as midwives are authorized ONLY if the patient is referred to the nurse by a physician and care is supervised by a physician. NOTE: CHAMPUS does NOT cover the services of lay midwives. LOSS OF ELIGIBILITY If the husband of a maternity patient leaves active duty for any reason other than death or retirement, the patient loses eligibility. CHAMPUS will share the cost of only that portionof the maternity care episode that occurred before eligibilityceased. If the maternity !patient is in the hospital when she loses eligibility, and the hospital is subject to the CHAMPUS DRG reimbursement system, the rules described in the ELIGIBILITY section apply. 30 OCHAMPUS 6010.48-H May 24, 1990 MORBID OBESITY CHAMPUS covers three surgical procedures for life-threatening overweight conditions--gastric bypass, gastric stapling and gastroplasty, including vertical banded gastroplasty. One of the following conditions must exist for CHAMPUS to share the cost of these procedures: 1. The patient must be 100 pounds overweight for height and body structure, with a life-threatening medical condition related to morbid obesity, such as: a. diabetes mellitus b. hypertension c. cholecystitis d. narcolepsy e. pickwickian syndrome or other severe respiratory disease f. hypothalamic disorders g. severe arthritis of the weight-bearing joints 2. The patient is 200 percent of ideal body weight for height and body structure, even without a related medical condition. 3. The patient has had an intestinal bypass or other surgery for obesity and requires a second surgery because of complications. The previous surgery need not have been covered by CHAMPUS. CHAMPUS does NOT cover the non-surgical treatment of obesity, to include the gastric balloon. MULTIPLE SURGERIES Multiple surgeries are those procedures performed during the same session. CHAMPUS makes no distinction between "related" and "unrelated" procedures. Reimbursement will be the lower of the total billed charges for all procedures performed OR the sum of 100 percent of the allowable charges for the major (higher allowable) surgical 31 OCHAMPUS 6010.48-H May 24, 1990 procedure plus 50 percent of the allowable charge for all other covered surgical procedures. When the surgical procedures involve fingers, toes or excision or biopsies of multiple lesions, reimbursement will be 100 percent of the allowable charge of the first procedure, 50 percent of the allowable for the second procedure and 25 percent of the allowable for the third and all subsequent procedures. No reimbursement will be made for incidental procedures performed during the same operative session where other covered surgical procedures were performed. Providers should contact the CHAMPUS field representatives for a list of incidental procedures. PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY CHAMPUS will cost-share for multi-vessel percutaneous transluminal coronary angioplasty (PTCA) for treatment of stenotic lesions in patients for whom the likely alternative is coronary bypass surgery. The patient must have the following characteristics: -angina refractory to optimal medical management -objective evidence of myocardial ischemia -lesions amenable to angioplasty PRESCRIPTION DRUGS AND MEDICINES Drugs and medicines must be approved by the Food and Drug Administration for general use by humans. CHAMPUS covers legend drugs; insulin is covered for diabetic patients, regardless of whether a prescription is required by state law. Claims for drugs and medicines must have the bottom half of the claim form completed and signed by the pharmacist or a bill must be attached to the claim. The following information, which may be a copy of the prescription drug label or an itemized statement from the pharmacist, is required for reimbursement: 1. Name of patient/beneficiary 2. Name, strength and quantity of each drug 3. Prescription number of each drug 4. Date prescription was filled 32 OCHAMPUS 6010.48-H May 24, 1990 5. Cost of each drug 6. Name and address of pharmacy 7. Name and address of prescribing physician Prescription drug claims containing more than one controlled drug AND meeting one of the following conditions must contain the diagnosis or diagnoses: 1. More than 20 prescriptions on the claim 2. More than $250 in drug charges on the claim 3. More than $150 in drug charges for any one month 4. More than a $50 charge for an single prescription 5. More than two different controlled drugs in a given month 6. More than four prescriptions for the same controlled drug in a given month 7. More than $750 in accumulated drug charges in one year Vitamins are not generally covered under CHAMPUS. Oral vitamins, even if prescribed for vitamin deficiency or prenatal care, are not reimbursable. Vitamin injections may be reimbursable if a documentation shows that they are necessary in treating specific medical condition and the patient cannot take oral vitamins. CHAMPUS cannot pay for prescriptions written by pharmacists, despite state laws that permit the practice. PROSTHETIC DEVICES CHAMPUS covers the purchase of artificial limbs and eyes and items that are surgically inserted into the body as an essential and integral part of an otherwise covered surgical procedure. REIMBURSEMENT The CHAMPUS allowable charge is the maximum amount CHAMPUS will pay for care given by physicians and other providers. CHAMPUS claims processors determine the allowable charge by examining the actual billed charge, the prevailing charge and the charge established by application of the Medicare Economic Index (MEI) . The allowable charge is the lowest of the three. 33 OCHAMPUS 6010.48-H May 24, 1990 Prevailing charges for CHAMPUS professional providers are updated annually. The prevailing charges are calculated at the 80th percentile of all of the actual charges made to CHAMPUS for a service or procedure in a state. All charges are procedure-code specific, using CPT-4. All the actual charges for each service or procedure are listed in ascending order, and the lowest charge which is high enough to include 80 percent of the actual charges is the prevailing charge. Separate prevailing charges are developed for different classes of providers, e.g., physicians and non-physicians. In calculating the prevailing charge, CHAMPUS claims processors use the CHAMPUS charges for services and supplies provided during the 12-month period ending six months prior to the update. Congress established the MEI, which limits annual increases in prevailing charges based on updates in the MEI. CHAMPUS applies the MEI limitation to physicians' and other individual professional providers' services. CHAMPUS follows the Medicare procedures, subject to changes based on differences in the CHAMPUS and Medicare programs. EXAMPLE OF CALCULATION PROVIDER CHARGE # OF SERVICES A $12.00 21 $13.00 16 $15.00 35 B $12.00 17 $13.50 65 c $11.00 3 $13.00 54 $15.00 11 D $12.00 32 E $12.50 18 $13.50 22 $13.50 22 CHARGE # OF SERVICES CUMULATIVE SERVICES $11.00 3 3 $12.00 70 73 $12.50 18 91 $13.00 70 161 $13.50 87 248 $15.00 46 294 In the example, 80 percent of the total of 294 services equals 235.2 services. The prevailing charge is, therefore, the 236th charge or $13.50. Calculations are rounded to the next highest 34 OCHAMPUS 6010.48-HMay 24, 1990 • number. Reimbursement of Technical/Professional Components CHAMPUS will share the cost of the technical component on radiology and pathology claims, but the professional component will be cost-shared only if the provider actually renders a service, i.e., as attending physician or consultant. CHAMPUS cannot pay a pathologist who merely operates a laboratory, but will reimburse a pathologist who prepares a written lab report for an attending physician, e.g., on a biopsy or frozen section. Providers who wish to know the prevailing charge for a specific service or procedure may write to the CHAMPUS claims processor for the state where care is given. FILING CLAIMS Providers may file claims even when they do not choose to participate (accept assignment). However, in these cases, the claims processor will reimburse the patient. The timely filing is essential to good business practice. Even though the claims filing deadline is Decemrer 31 of the calendar year immediately following the year in which care is given, it is best to file claims as soon as possible. Claims received after the filing deadline must be denied unless there is sufficient evidence to grant an exception. Some of the exceptions to the deadline are: -retroactive eligibility where the uniformed service or the Dept. of Veterans Affairs has made the determination. A copy of the decision must accompany the claim. -administrative error on the part of the claims processor or CHAMPUS. A statement from the claimant detailing the circumstances and a copy of a letter, report or statement from CHAMPUS or the claims processor reflecting the error must accompany the claim. -mental incompetency of the patient when no one is legally responsible for managing the affairs of the patient. A physician's statement including diagnosis and treatment attesting to the mental incompetency must accompany the claim. -provider billings. Participating providers must 35 OCHAMPUS 6010.48-H May 24, 1990 submit a request for an exception to the claims filingdeadline. -other health insurance when the patient submitted a claim to a primary health insurance and the other plan delayedadjudication past the CHAMPUS deadline. A statement indicating the original date of submission to the other plan, and date of adjudication by the other plan with anyrelevant correspondence and an Explanation of Benefits must be submitted. The claim form must be submitted to the CHAMPUS claims processor within 90 days from the date of the other health insurance plan's adjudication. Proper completion of the CHAMPUS claim form facilitates pr~mpt reimbursement. Providers should verify the social security number for CHAMPUS claims or the VA ID number or social security number, whichever appears on the CHAMPVA card, for CHAMPVA claims. When a provider does not participate and the beneficiary files a claim, the provider should give the beneficiary his or her correct provider number to facilitate claim processing. CLAIMS FILING JURISDICTION Generally, claims for medical services should be sent to the claims processor that has jurisdiction for the geographiclocation of the provider's office. If a provider maintains offices in more than one claim processor's jurisdiction, the location of the office where the services or supplies were actually provided determines where to send the claim. Claims for supplies, durable medical equipment and mail-order drugs should be sent to the claims processor having jurisdiction for the state where the provider is located. In no case will the jurisdiction be based on the location of a billing office when it is in a different location from the supplying office. NOTE: When a provider has a mailing address that differs from the street address, it is best to use the street address on the HCFA Form 1500. Special claims processors have been assigned to process all claims for adjunctive dental care and Christian Science services. Adjunctive dental claims should be sent to: Blue Cross and Blue Shield of South Carolina PO Box 6150 Columbia, sc 29260-6150 36 OCHAMPUS 6010.48-HMay 24, 1990 Christian Science claims should be sent to: US BPI PO Box 3063 Columbus, IN 47202 NOTE: Certain regions of the United States are exempt from the above jurisdictional requirement due to CHAMPUS' and military services' demonstration projects. ClAIM FORMS The CHAMPUS Form 501 (HCFA Form-1500) and the DO Form 2520 are used when submitting bills for professional services. However, the preferred form for provider submissions is the Form 501. Payment is made directly to the provider when he or she chooses to participate (accept assignment). If not, the patient receives payment. For claims payable to the patient, items #1 through #18 on the DO Form 2520 (yellow) must be completed. Providers may fill out items #19 through #33, even if they choose not to participate or accept assignment. The provider may attach an itemized bill which includes: -the name and address of the source of care -the name of the patient -the diagnosis (ICD9-CM) or a description of the nature of the illness -the date, charge and description of each service -the name, strength and quantity of drugs and injections -related dates of hospitalization -surgical procedure and duration of anesthesia -and, for maternity care, include the estimated or actual date of delivery NOTE: It is extremely helpful to the claims processor when the sponsor's Social Security Number is included on the bill. Billing statements showing only total charges, cancelled checks, cash register receipts or other receipts are not accepted as 37 OCHAMPUS 6010.48-H May 24, 1990 itemized statements. For prescription drugs, the statement must contain the name of the patient; name, strength and quantity of each drug; prescription number; name and address of pharmacy; name and address of the prescribing physician. If items #19 through #33 are completed, and the provider wishes to participate (accept assignment), item #32 (or the comparable item on CHAMPUS Form 501) must be checked "yes". The claims processor will then make payment directly to the provider. If the provider is filing the claim, the provider an or authorized representative must sign item #33 (or the comparable item on the CHAMPUS Form 501) on the claim form, regardless of whether the provider agrees to participate (accept assignment). If a provider indicates participation on the claim form, but the form is not signed by the provider or a designated representative, the claim will be held and developed for signature. However, if the signature is not received within the specified time, the claim will be processed as a beneficiary claim. ADEQUATE MEDICAL DOCUMENTATION Before authorizing claims payment, the government is entitled to receive information from providers documenting the services or supplies given to beneficiaries. Providers and beneficiaries who file claims are responsible for supplying all necessaryinformation to the claims processor. Failure to furnish requested information may result in denial of the claim. Providers have certain obligations to furnish services or supplies under CHAMPUS that are: -furnished at the appropriate level and only when and to the extent medically necessary as determined under CHAMPUS rules; -of a quality that meets professionally recognized standards of health care; and -supported by adequate medical documentation as may reasonably be required to establish the medical necessity and quality of services furnished, as well as the appropriateness of the level of care. If a provider fails to maintain and furnish, upon request,adequate medical documentation, the claim may be denied and there may be sanctions against the provider for fraud and abuse. CHAMPUS requires that mental health treatment records substantiate the medical or psychological necessity of the specific care. Since measuring severity of illness is less 38 OCHAMPUS 6010.48-H May 24, 1990 exact in the mental health field, evaluations, treatment plans, progress notes and discharge summaries are critical to medical review. HOSPITAL-EMPLOYED PROFESSIONAL PROVIDERS AND DRGS Hospitals subject to DRGs or the mental health per diem reimbursement system may continue to use the UB-82 claim form to bill for inpatient care, but claims for professional providers who are employed by the hospitals must be submitted on either the DD Form 2520 or the Form 501 (HCFA-1500). In addition, bills for emergency services must be billed separately, since the admission itself triggers the DRG payment. Hospitals exempt from DRGs or hospitals with exempt units may bill for all services, including those of hospital-employed professional providers, on the UB-82. ERROR-FREE CLAIMS If the claim form is incomplete or in error, the claims processor will either call or write to the provider or the patient filing the claim to request additional information• • Prompt, cooperative response from providers will result in speedy processing of claims. SIGNATURE ON FILE If the provider has an approved "signature-on-file" agreement, it will satisfy the signature requirement for claims submitted to the claims processor. The "agreement" may be a patient signature on a DO Form 2520 maintained by the provider, or a signature on a form used by the provider in the normal course of doing business. The form must contain the appropriate wording to comply with CHAMPUS rules and the Privacy Act. When providers wish to submit claim forms without the patient's signature, they must agree in writing to: -verify the patient's eligibility at the time the episode of treatment begins -obtain and retain the patient's signature on a claim form or a provider-designed form. If the patient is under 18 or is incompetent, the signature of a parent or guardian is required. {This is not required if the treatment involves venereal disease or alcohol/drug abuse.) -indicate "signature on file" in the patient's signature block on the claim form . 39 OCHAMPUS 6010.48-H May 24, 1990 -cooperate with the claims processor's post-payment audits by supplying requested copies of signatures-on-file within 21 days of request -correct any deficiencies found by the claims processor's audit within 60 days of notification of the deficiency EXPLANATION OF BENEFITS (EOB) For each claim, the claims processor issues an explanation of benefits. When the provider participates (accepts assignment), the EOB is sent to him or her. The patient always receives a copy of the EOB, even if the provider receives payment. The explanation of benefits details the adjudication of the claim. The claim identification number assigned by the claims processor should be included in any inquiry concerning the payment of the claim. REIMBURSEMENT PROBLEMS AND SPECIAL SERVICES FOR PROVIDERS CHAMPUS Provider Relations Providers should direct questions concerning benefits and fiscal matters to the claims processor for the state where care is given. CHAMPUS maintains an Office of Public and Beneficiary Relations to assist providers with questions about the program, but providers should approach the claims processor first. The CHAMPUS claims processors employ provider representatives who visit institutions and individual providers on a regular basis to assist providers with particular problems and to disseminate current information about the CHAMPUS program. The representatives also conduct special meetings and workshops for providers and their office staffs on a regular basis. Providers who need assistance may contact the claims processor for their state to request a visit or call by these representatives. The CHAMPUS medical director and other staff are available to provider representatives or groups of providers to clarify medical, quality assurance and peer review issues. Toll-free telephone lines are also available to ease contact by providers. In addition, some claims processors have providerdedicated telephone lines. The CHAMPUS Public Affairs Branch regularly issues news releases to provider media and prepares feature articles for magazines, newsletters and journals that are of interest to providers. CHAMPUS claims processors also distribute news bulletins 40 OCHAMPUS 6010.48-H May 24, 1990 directly to CHAMPUS providers in their regions. PEER REVIEW ORGANIZATIONS On Oct. 1, 1988, CHAMPUS began using Medicare's peer review organizations (PROs) to review, on a retrospective basis, inpatient care cost-shared under the CHAMPUS DRG-based payment system. CHAMPVA admissions are included in PRO review in several states. On Oct. 1, 1989, CHAMPUS expanded PRO review to include preadmission in many states. PROs are required to provide information to providers regarding those surgical procedures andjor medical admissions subject to pre-admission. The PROs are reviewing to determine reasonableness, necessity and appropriateness of hospital admission; validate the diagnoses and procedure information that determines reimbursement; establish necessity and appropriateness of care for which outlier payment is sought; and ensure that conditions of payment are met, i.e., acknowledgement and attestation statements, informing the patient with "Important Message from CHAMPUS". A PRO denial results in denied services being excluded for CHAMPUS payment, except under certain circumstances. Under the limit of liability regulations, published in the Federal Register on April 8, 1989, CHAMPUS will make payment if neither the provider nor the beneficiary could have reasonably known that the service would be determined to be excluded by the PROs. CHAMPUS will not make payment if the provider and/or the beneficiary had reason to know· that services should be excluded by the PRO for reasons of medical necessity. Additional CHAMPUS regulations related to PRO review were published in the Federal Register on Sept. 15, 1987, effective Oct. 1, 1987, and Jan. 8, 1990, effective Feb. 7, 1990. To speed claims processing for pre-authorized services, hospitals must include the PROs treatment authorization number (TAN) on claims submitted to the claims processor for payments by CHAMPUS. PROVIDER SANCTIONS PROVIDER EXCLUSION AND SUSPENSION A provider is excluded or suspended when he or she is denied status as a CHAMPUS-authorized provider. This means that the provider will not be reimbursed for care rendered to a CHAMPUS beneficiary. Providers are denied status based on the following: -A criminal conviction or civil judgment involving fraud 41 OCHAMPUS 6010.48-H May 24, 1990 -An administrative finding of fraud or abuse under CHAMPUS -An administrative finding that the provider has been excluded or suspended by another agency of the federal government, a state or a local licensing authority -An administrative finding that the provider has knowingly participated in a conflict of interest situation -An administrative finding that it is in the best interests of CHAMPUS or CHAMPUS beneficiaries to exclude or suspend the provider PROVIDER TERMINATION CHAMPUS contractors and the Office of CHAMPUS have authority to terminate providers as authorized under CHAMPUS when it is determined that the providers do not meet CHAMPUS qualifications as spelled out in the CHAMPUS regulation. See APPEALS section for provider sanction appeal procedures. PROGRAM FOR THE HANDICAPPED The CHAMPUS Program for the Handicapped exists for active-duty family members who cannot get specialized training or care through public resources. In some cases, public programs don't have the capacity to provide servces to all who qualify. CHAMPUS cannot share the cost of care under the program when adequate public resources are available to the spouse or child of an active-duty service member. Claims will be denied if the criteria are not met~ Other CHAMPUS beneficiaries (retirees, spouses and children of retirees, and spouses and children of deceased active-duty members or deceased retirees) do not qualify. In addition, CHAMPVA beneficiaries are not eligible. CHAMPUS will share the cost of care from private, non-profit facilities only when a public official issues a written statement (or a CHAMPUS Form 769) stating that no adequate public facilities are available and that no public funds are available to pay any portion of the cost of care from private, non-profit facilities. A public official's statement is valid for one year from the date it is issued. CHAMPUS will not share the cost of any care that is provided by a private facility operating for profit. Active-duty family members who are moderately or severely 42 OCHAMPUS 6010.48-H May 24, 1990 mentally retarded or who have major physical handicaps may qualify for the CHAMPUS Program for the Handicapped. A person is moderately mentally retarded when his or her intelligence quotient is between 36 and 51, severely when it falls below 35. A seriously physically handicapped person is one who: -Is expected to have the handicap at least a year or is expected to die from the handicap; and -The condition keeps the person from engaging in basic productive activities of daily living expected of unimpaired persons in the same age group. Available benefits under the Program for the Handicapped include: Diagnostic services -Durable medical equipment -Prescription drugs and medicines -outpatient treatment -Home treatment -Institutional care -Hearing aids -Special optical devices -Prosthetic devices and orthopedic appliances -Professional services -Special tutoring -Surgery and medical care -Training and special education -Some forms of transportation -Rehabilitation Providers should be aware that benefits under the program are subject to the limits in the CHAMPUS regulations. 43 OCHAMPUS 6010.48-H May 24, 1990 Benefits excluded under the program include: -Dental care -Camping, field trips and similar outings -Alterations to living spaces or vehicles, even when necessary to facilitate entry and exit The CHAMPUS claims processor must authorize any care received or equipment purchased under the program before claims may be paid. Families should send a DD Form 2532 (Request for CHAMPUS Benefits Under the Program for the Handicapped) to the appropriate claims processor for the state. An approved application is valid for 90 days after it is issued. A change of physicians or facilities requires a new form, and if the patient does not obtain the authorized services or supplies within the 90~day period, a new application is required. The supervising physician must prepare a management plan to be sent to the CHAMPUS claims processor with the DD Form 2532 that includes all of the following: -Report of the patient's current physical examination -Patient's diagnosis -Family history -History of the handicapping condition and earlier treatment -Diagnostic test results, including hearing tests or IQ tests, if applicable -Consultant's report, if any -Method and length of care, service or ,~upply planned -Name, address and professional status ,bf provider or supply company providing service or supplies -Prognosis -Monthly cost of care -Make and model of equipment or hearing aid to be provided -Medical records from the present faci]ity, if the patient is requesting approval to change, facilities The supervising physician must sign the management plan. In 44 OCHAMPUS 6010.48-H May 24, 1990 addition, the provider who is performing continuing care under the PFTH may be required by the claims processor to provide information for annual reviews. CHAMPUS payments for all services under the program are limited to $1,000 per month for one individual, with no limit for the second individual. If the cost of care exceeds this amount, the patient's family must make up the difference. There is also a monthly cost-share based on the sponsor's rank. CHAMPUS MENTAL HEALTH BENEFITS CHAMPUS covers the cost of mental health care for those patients who suffer from mental disorders that involve a clinically significant behavioral or psychological pattern--one that not only causes distress but actually impairs the ability to function appropriately for their age. The psychological disorder must also be listed in the Diagnostic and Statistical Manual (DSM-III-R) of the American Psychiatric Association. on Jan. 1, 1990, CHAMPUS began a new program to certify the medical necessity of mental health care for CHAMPUS and CHAMPVA beneficiaries nationwide. The utilization review program is called CHAMP-MH. The current contractor is Health Management Strategies International, Inc. (HMS). CHAMPUS requires that certain types of mental health care be certified before payment is made. Providers are urged to contact HMS for pre-treatment certification to avoid payment delays and retroactive denials. HMS. staff who are clinically qualified and trained in utilization management will assess medical necessity and level of care, using mental health review criteria (Mental Health Appropriateness Review Criteria or MHARC). The effective date for all services covered under CHAMP-MH is Jan. 1, 1990. This applies to all admissions on or after that date, outpatient psychotherapy sessions exceeding 23 sessions after the start date and 60-day waivers requested after the start date. SERVICES COVERED UNDER CHAMP-MH Inpatient Care * Hospital admissions in DRG-exempt psychiatric hospitals and units within the United States * 60-day waiver requests regardless of when the 60-day limit was reached 45 OCHAMPUS 6010.48-H May 24, 1990 * Inpatient psychotherapy that exceeds five sessions per week * Residential treatment center (RTC) admissions for children and adolescents and continuing care of cases for which the previously issued certification expired on or after Jan. 1, 1990 * Specialized treatment facility (STF) admissions for drug and alcohol abuse NOTE: Mental health care provided in DRG-paid facilities is NOT subject to pre-payment certification by HMS. Those claims should be submitted to the CHAMPUS claims processor for adjudication. The Peer Review Organizations (PROs) are responsible for utilization review and quality assurance of claims paid under DRGs. outpatient Care * Psychotherapy services that exceed 23 sessions in a calendar year * Psychotherapy or psychoanalysis services that exceed two sessions in a week * Admission to a partial hospitalization program for alcohol abuse Providers or their designees may contact HMS by writing or telephone: CHAMP-MH P.O. BOX 26307 ALEXANDRIA, VA 22313 1-800-242-6764 The following are excluded from CHAMP-MH's jurisdiction: * Care rendered outside the United States, unless it includes a 60-day waiver request when the limit was reached in a foreign hospital * Care received in DRG-reimbursed hospitals and substance abuse facilities or units * Care under the jurisdiction of certain demonstration projects. Contact the appropriate claims processor. Providers should call HMS at least two business days prior to a planned admission and within ~wo business days after an emergency admission. 46 OCHAMPUS 601 0.48-H May 24, 1990 If certification is not obtained prior to treatment, HMS will review the case retrospectively. Providers should be aware, however, that there is a risk of retrospective denial. Should certification or continued stay be denied~ the provider or the patient must request reconsideration by HMS in writing within 90 days of the denial decision. Certification does NOT guarantee payment, but it does certify that the treatment is medically necessary and delivered at the appropriate level according to CHAMPUS rules and definitions. The CHAMPUS claims processors continue to be responsible for determining a patient's eligibility and benefit limits as well as assuring that claims filing requirements are met. Details on pre-treatment certification, including essential information for utilization management, are available in the CHAMP-MH Newsletter, which is published quarterly by HMS. Providers should be aware that the claims processor for the outpatient psychotherapy session day, to two particular state continues to certify providers. the care. HMS certifies OUTPATIENT CARE For outpatient care, CHAMPUS will share the cost for a maximum of one a up sessions in a seven-day period, unless more are justified as medically or psychologically necessary through certification by HMS. This certification must accompany the claim. Crisis intervention allows for coverage up to two hours in or out of the hospital. Conjoint or family therapy can be covered for payment up to a one and one-half hour session a day. CHAMPUS covers collateral visits, both inpatient and outpatient, that are medically or psychologically necessary for the patient's treatment. A collateral visit is defined as a session between an authorized, individual professional provider and a significant person in the patient's life, but not treatment. The significant person may be someone other than a relative. A collateral visit is counted as a session of psychotherapy. INPATIENT CARE (Limits) If the care is in a hospital, CHAMPUS will cover a maximvm of five psychotherapy sessions in a seven-day period, or more, if medically necessary and certified by HMS. Federal law restricts the use of CHAMPUS funds for inpatient mental health care to a maximum of 60 days in any calendar year, 47 OCHAMPUS 6010.48-H May 24, 1990 unless a waiver is granted. The limitation does not apply to inpatient care in a CHAMPUS-certified residential treatment facility, the Program for the Handicapped, partial inpatient care for alcoholism, or admission before Jan. 1, 1983. NOTE: care in multiple facilities is still subject to the 60-day limit. HMS may grant waivers to this limitation. Providers or beneficiaries should notify HMS by telephone or in writing two weeks before the anticipated date on which the beneficiary meets the 60-day limit. Providers should call HMS at 1-800-242-6764 between 8:00 a.m. and 6:00p.m., Eastern Time. Any request for additional coverage must document that: -The patient is suffering from an acute mental disorder or an acute exacerbation of a chronic mental disorder that results in the patient being put at significant risk to self or of becoming a danger to others, and the patient requires a type, level and intensity of care that can only be provided in an inpatient setting; OR -The patient has, in addition to a mental disorder, a medical condition and requires a type, level and intensity of care that can only be provided in an inpatient setting. If the case has been under HMS review since the beginning of the hospital stay, the HMS staff will advise the provider of what additional documentation is necessary. NOTE: Waivers are granted only infrequently. Providers may not appeal the denial of claims for inpatient care that exceeds 60 days, but they may appeal a denial of a request for a waiver. MENTAL HEALTH PROVIDERS All psychiatric hospitals, in,order to be CHAMPUS-approved, must be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) . Hospitals may be granted interim approval if they have not been in operation long enough for JCAHO accreditation, but they must have Medicare approval. 48 OCHAMPUS 6010.48-HMay 24, 1990 On Jan. 1, 1989, CHAMPUS began using a new payment method, based on patient volume and hospital charges, for inpatient mental health care in all specialty psychiatric hospitals and psychiatric units that are exempt from the CHAMPUS diagnosisrelated group (DRG) payment system. The new payment system affects mental health care in all 50 states, the District of Columbia and Puerto Rico. CHAMPUS pays a pre-determined rate for each day of care provided. For high-volume hospitals (25 or more CHAMPUS discharges in a federal fiscal year), daily rates are hospital-specific, reflecting average, allowed daily charges. For low-volume hospitals and units (those with fewer than 25 CHAMPUS discharges in a federal fiscal year), daily rates are based on the hospital's federal census region and calculated on the basis of claims paid during the base period. Rates are updated each year, based on Medicare's update factor for its Prospective Payment System exempt facilities. Questions about the mental health daily rates should be addressed to the appropriate claims processor. RESIDENTIAL TREATMENT CENTERS CHAMPUS shares the cost of care in residential treatment centers (RTCs) that are separate institutions or distinct units of institutions. These facilities exist specifically for 24-hour, psychiatric treatment of children and adolescents. The RTC must be organized and professionally staffed by CHAMPUS authorized mental health professionals to provide residential treatment of mental disorders to children and adolescents up to age 21 who have sufficient intellectual potential to respond to active treatment. Some important things to remember about RTC care include: -The patient must be suffering from a mental disorder that involves a clinically significant behavioral or psychological pattern--one that not only causes distress but actually impairs the patient's ability to function. -The disorder must be one listed in the Diagnostic and Statistical Manual (DSM-III-R) of the American Psychiatric Association. -The patient must be admitted by a psychiatrist, another physician or a CHAMPUS-recognized clinical psychologist. 49 OCHAMPUS 6010.48-H May 24, 1990 -A psychiatrist or a clinical psychologist must direct the development of the treatment plan. -Inpatient treatment must be required, i.e.,outpatient treatment would not be appropriate. -A protected and structured environment must be medically or psychologically necessary. -CHAMPUS will not share the cost of any care ordered by a court unless the care would have been medically or psychologically necessary, even if the court had not ordered it. -CHAMPUS may not pay for RTC care that has not been certified by the mental health contractor, HMS. Providers should call HMS two business days prior to the patient's admission. RTCs must be accredited by the JCAHO under the Consolidated Standards Manual. They must submit an application for authorization and are subject to an on-site survey before CHAMPUS can grant authorized provider status. Beginning Jan. 1, 1991, HMS will handle provider certification for RTCs. RTCs must sign participation agreements with CHAMPUS to be authorized CHAMPUS providers. CHAMPUS cannot share the cost of any care provided before the date the participation agreement issigned by the CHAMPUS office. The agreement requires the RTC to accept the CHAMPUS determined rate as payment in full and collectfrom the beneficiary or his/her family only the beneficiary cost share and non-covered charges, e.g., education. Participationagreements include the specific rate established for each RTC and the billing number that must be used for claims filing. The Program Initiatives Branch, OCHAMPUS, is responsible forhandling these agreements. · The daily rates are all-inclusive and are established based upon data provided by each RTC. The per diem rate includes the RTC'sdaily charge for all inpatient care and all mental health treatment determined necessary and rendered as part of the patient's treatment plan authorized by the mental health review contractor. The care includes all ind{vidual and group therapy, familytherapy for parents within 250 miles of th~ facility, collateral visits with others and ancillary services. The only allowed charges outside the all-inclusive rate are for: 50 OCHAMPUS 6010.48-H May 24, 1990 • *geographically distant family therapy, i.e., more than 250 miles from the facility * educational services when local or state agencies refuse to pay for them * non-mental health services CHAMPUS will not share the cost of services rendered by independent mental health providers to RTC patients. These providers must look to the RTC for their payment. PROFESSIONAL PROVIDERS Psychiatrists must be Doctors of Medicine or Doctors of Osteopathy and be licensed in the jurisdiction where care is provided. Clinical psychologists must be licensed for independent practice in the state where services are provided: -Have a doctoral degree in psychology from a regionally accredited university and a m1n1mum of two years of supervised clinical experience in psychological health services, of which at least one year is post-doctoral and one year is in an organized psychological health service training program; OR -Be listed in the National Register of Health Service Providers in Psychology, published by the council for the National Register of Health Service Providers in Psychology. Clinical social workers must: -Be licensed or certified at the master's level as clinical social workers by the state where care is provided; and NOTE: For the state of New Jersey, CHAMPUS will accept ACSWlevel certification in the National Association of Social Workers or the diplomate status granted by the American Board of Examiners in Clinical Social Work; and -Have a master's degree in social work from a graduate school of social work accredited by the Council on Social Work Education; and -Have a minimum of two years or three thousand hours 51 OCHAMPUS 6010.48-H May 24, 1990 of post-master's degree clinical social work practiceunder the supervision of a master's degree level social worker in an accredited hospital, a mental health center, or other appropriate clinical setting. Certified psychiatric nurse specialists must: -Be licensed, registered nurses; and -Have at least a master's degree in nursing with a specialization in psychiatric and mental health nursing; and -Have at least two years of post-master's degreepractice in the field of psychiatric and mental health nursing, including an average of eight hours of direct patient contact per week; OR -Be listed in a CHAMPUS-recognized, professionallysanctioned listing of clinical specialists in psychiatric and mental health nursing. Certified psychiatric nurse specialists may provide covered care independent of physician referral and supervision. MARRIAGE, FAMILY AND PASTORAL COUNSELORS CHAMPUS rules require physician referral and coordination with marriage and family therapists. While marriage and familycounseling is not covered under CHAMPUS rules, CHAMPUS will help pay for psychotherapy by individuals who fall in the general category of marriage and family counselors. (For CHAMPUS purposes, the category in6ludes pastoral counselors.) Patients must be receiving psychotherapy fo~ a valid mental disorder listed in DSM-III-R. All referrals are subject to quality-assurance procedures under CHAMPUS rules. Reviews by HMS. for outpatient care take place at the 24th session in a calendar year. The educational and experience requirements for counselors are: -A recognized graduate professional education with the minimum of an earned master's degree from an accredited educational institution in an appropriate behavioral science field, mental health discipline; and -EITHER 200 hours of approved supervision in the practice of marriage and family counseling or pastoralcounseling, ordinarily to be completed in a two-to three-year period. At least 100 hours must be in individual supervision. CHAMPUS prefers that the 52 OCHAMPUS 6010.48-H May 24, 1990 experience be with more than one supervisor and include a continuous process of supervision with at least three cases; and -1,000 hours of clinical experience in the practice of marriage and family counseling or pastoral counseling under approved supervision, involving at least 50 different cases; OR -150 hours of approved supervision of the practice of psychotherapy, ordinarily to be completed in a twoto-three year period, of which at least 50 hours must be individual supervision; plus, at least 50 hours of approved individual supervision of the practice of marriage and family counseling, ordinarily to be completed within a period of not less than one or more than two years; and -750 hours of clinical experience in the practice of psychotherapy under approved supervision involving at least 30 cases; plus, at least 250 hours of clinical practice of marriage and family counseling under approved supervision, involving at least 20 cases; and as -Possession of a valid state license or certificate a marriage and family counselor or pastoral counselor, or hold a license or certificate that allows the individual to provide marriage and family counseling in states that require such licensing or certification; even if licensing is voluntary, CHAMPUS requires licensing for reimbursement. In those states that do not offer licensure, the marriage and family counselor must, in addition to meeting the other requirements listed in this section, be, or be eligible to become, a full clinical member of the American Association of Marriage and Family Therapy. Pastoral counselors must have, or be eligible for, membership at the certification level of the American Association of Pastoral Counselors. NOTE: All professional staff providing mental health services who are employed by institutions must meet the standards of individual authorized providers, as described above. MENTAL HEALTH COUNSELORS CHAMPUS now shares the cost of covered psychotherapy provided by mental health counselors who meet CHAMPUS requirements. Mental health counselors may provide psychotherapy for patients who have 53 OCHAMPUS 6010.48-H May 24, 1990 a medically diagnosed mental disorder, subject to the referral and supervision of a physician. HMS will review all outpatient mental health services in excess of 23 sessions in a calendar year. The appropriate claims processor is responsible for certifyingmental health counselors as authorized CHAMPUS providers. The educational and experience requirements for mental health counselors are: -A master's degree in mental health counseling or an allied health field from a regionally accredited institution, and -Two years of post-master's experience that includes 3,000 hours of clinical work and 100 hours of face-to~ face supervision, and -A state license or certificate to practice as a mental health counselor; if the state does not offer licensure or certification, the counselor must be certified by, or be eligible for, membership in the National Academy of Certified Clinical Mental Health Counselors (NACCMHC) . Membership in the NACCMHC may be verified by checking the association's register or by calling the association at 1-703823-9800, extension 384. PHYSICIAN REFERRAL AND SUPERVISION CHAMPUS requires physician referral and supervision of marriage,family and pastoral counselors and mental health counselors. The requirements are: -The physician must refer a patient to a mental health counselor for the treatment of a medically diagnosedcondition. The physician must actually see the patient, do an evaluation and arrive at an initial diagnostic impression prior to ref~rral. Documentation of the examination, diagnostic impression and referral 1 must be submitted with the initial claim for services. -The referring physician must provide oversight and supervision of the episode of treatment. overall case management rests with the physician. The mental health counselor must maintain ongoing co~rdination with the physician and certify on each claici that written coordination has b~en made or will :be made to the 54 OCHAMPUS 6010.48-H May 24, 1990 • referring physician at the end of the treatment, or more frequently, as the physician requires. PSYCHIATRIC EMERGENCIES Normally, psychiatric admissions do not qualify as emergencies under CHAMPUS rules. Exceptional cases, in order to qualify as emergencies, must meet all of the following criteria: -The patient's diagnosis must be listed in DSM-III-R. -The patient must be suffering from significant distress. and dysfunction. -The patient must be a real and present significant risk to himself or herself or a danger to others. A life threatening situation must exist. A suicide threat alone does not constitute significant risk. However, if the patient is threatening suicide and would carry out the threat if he or she were not put under immediate surveillance, the situation does meet CHAMPUS criteria. Any CHAMPUS claim for a psychiatric emergency must be accompanied by a statement from the attending physician certifying as to the life threatening condition that existed at the time of the admission. Providers should contact HMS within two business days after an emergency admission, since all admissions require prepayment certification by HMS. ALCOHOLISM TREATMENT CHAMPUS covers alcoholism-treatment centers, whether they are hospital-based or free-standing. All alcoholism therapy must take place in an alcohol-treatment center and must be prescribed by a physician or another qualified mental health provider. Providers should contact the mental health contractor, HMS, two business days before admission to obtain pre-certification for inpatient detoxification and rehabilitation treatment for alcohol abuse in settings not covered by DRGs. Certification is also required for rehabilitative treatment for alcohol abuse in a partial hospitalization program, not covered by DRGs. For both inpatient and outpatient care, CHAMPUS does not cover more than 21 days. 55 OCHAMPUS 6010.48-H May 24, 1990 CHAMPUS rules limit alcohol rehabilitation to three lifetime episodes. A benefit period begins with the first date of CHAMPUS-covered treatment and ends 365 days later, whether or not other alcohol benefits are actually used later during the year. Unused benefits cannot be carried over to the next period. Patients may receive any or all of the following services during a benefit period: -Detoxification in an authorized alcohol-treatment center limited to seven days. -Hospital detoxification will be covered only if medical review affirms that hospital-level care is medically necessary. Benefits are paid the same as for any medically necessary inpatient care. Hospital detoxification is not covered beyond seven days, unless medical review affirms that more is medically necessary. -Rehabilitation on a residential or part-time (day or night program) basis, not beyond 21 days. -Outpatient care in an authorized alcoholism treatment center, not beyond 60 visits; and -Family therapy, not beyond 15 visits. CHAMPUS will share the cost of prescriptions for Disulfiram (Antabuse). However, CHAMPUS will not cover hospital bills if the patient is admitted only to receive Disulfiram. The following are NOT covered under CHAMPUS: -Halfway houses; -Academic, vocational or other counseling that is not medically or psychologically necessary. The services of alcoholism counselors are covered as part of alcohol rehabilitation, but must be billed for by the authorized alcdhol treatment cen~er and included in the facility's CHAMPUS-determined al~owable cost rate. -Aversion therapy using drugs or other physical means. This is currently considered investigational under CHAMPUS rules. Any alcoholism inpatient treatment, includtng detoxification, counts toward the 60-day inpatient psychiatric limit. All DSM-III diagnoses, including drug abuse treatment, involving inpatient care count toward the 60-day limit. 56 OCHAMPUS 6010.48-H May 24, 1990 Partial hospitalization does not count toward the 60-day limit. In order to be CHAMPUS-authorized, alcohol treatment centers, including partial-day free-standing centers, must be: -Accredited by the Joint Commission on the Accreditation of Healthcare Organizations {JCAHO). -Meet all licensing and certification requirements of the state or locality. SUBSTANCE ABUSE (OTHER THAN ALCOHOL) In cases of substance abuse other than alcohol, the 60-day limit applies. However, the other limits that apply to alcohol treatment do not apply. SPECIAL CONSIDERATIONS Pervasive developmental disorders, as defined by DSM-III-R, and attention deficit disorders are covered. Specific developmental disorders, e.g., dyslexia, developmental arithmetic disorders, developmental language disorders, developmental articulation disorders and mixed disorders are not covered, with the exception of diagnostic and evaluative services required to arrive at a differential diagnosis. Special education of any type is excluded. Services that are medically or psychologically necessary to or treat attention deficit disorders are covered when diagnose rendered by CHAMPUS-authorized providers. Such services include: -Diagnostic testing and assessment, including neurological evaluation; -Medication; -Psychotherapy, particularly behavioral and family therapy. Psychoanalysis is payable only after pre-payment review by HMS. Chemotherapy management is covered only as an independent procedure and is considered as part of the allowable charge if provided by the same individual who is providing psychotherapy. Charges are not payable if the provider billing for such services is not qualified by state licensure to prescribe psychotropic drugs. Electroconvulsive therapy is covered. 57 OCHAMPUS 6010.48-H May 24, 1990 EXCLUDED SERVICES Psychosurgery is not covered. Surgery for the relief of movement disorders, electroshock treatments and surgery to interrupt the transmission of pain along sensory pathways are not considered psychosurgery. Mental health services and supplies related solely to obesity andjor weight reduction are not CHAMPUS benefits. The following therapies and procedures are not CHAMPUS benefits: -Environmental ecological treatments -Megavitamin or orthomolecular therapy -Transcendental meditation -Rolfing -z therapy -EST -Primal therapy -Bioenergetic therapy -Carbon dioxide therapy Guided imagery -Sedative action electrostimulation therapy -Aversion therapy (includes electric shock for alcoholism) -Narcotherapy with LSD -Marathon therapy -Hemodialysis for schizophrenia -Training analysis -Filial therapy In addition, CHAMPUS does not cover personality enhancement sessions, such as assertiveness training or any therapy that is given as part of an educational program. 58 OCHAMPUS 6010.48-H May 24, 1990 EATING DISORDERS CHAMPUS covers some treatment for so-called "eating disorders," but the diagnosis must be specific, and must be one of the following DSM-III-R disorders: -Anorexia Nervosa -Bulimia -Pica -Rumination Disorder of Infancy -Atypical Eating Disorder CHAMPUS does not cover free-standing "eating-disorder programs." In addition, CHAMPUS will not pay for services provided by a health professional who is employed by, or is under contract to, a free-standing eating disorder program. CHAMPUS may, however, share the cost of individual services and supplies that are medically necessary appropriate treatment of an eating disorder provided by hospitals, or by psychiatrists, psychologists, clinical social workers or psychiatric nurse practitioners, if they are CHAMPUS-authorized providers. If a CHAMPUS-authorized institution provides otherwise authorized care within the context of an eating-disorder program, claims will not be denied solely because the service was provided in a treatment program. CHAMPUS claims processors will adjudicate all eating disorder claims as mental health claims, subject to pre-payment certification by HMS. This includes all inpatient claims and selected outpatient-treatment claims. 59 OCHAMPUS 601 0.48-H Appendix A GLOSSARY ACCEPTING ASSIGNMENT A provider who accepts CHAMPUS assignment (participates) agrees to accept the CHAMPUS allowable charge as the full fee and cannot charge the patient the difference between the provider's charge and the allowable charge. ACTIVE-DUTY SERVICE MEMBER A person who is serving full-time in a uniformed service under orders that do not specify 30 days or less. ADJUNCTIVE DENTAL CARE Dental care that is medically necessary for the treatment of an otherwise covered medical and not dental condition, e.g., intraoral abscesses, cellulitis, loss of jaw substance. ADOPTED CHILD A child taken into a family through a legal adoption process. CHAMPUS eligibility begins at 12:01 a.m. on the day of the final adoption decree. A child is not covered during the waiting period. ATTENDING PHYSICIAN One who has primary responsibility for the medical diagnosis and treatment of the patient. AUTHORIZED PROVIDER A hospital, institution, physician or another professional who meets the licensing and certification requirements of the CHAMPUS regulation and is practicing within the scope of that license. BENEFICIARY A person who is eligible for CHAMPUS or CHAMPVA. CHAMPUS The Civilian Health and Medical Program of the Uniformed Services. CHAMPVA The Civilian Health and Medical Program of the Veterans Administration. CLAIMS PROCESSOR The contractor that processes CHAMPUS claims (fiscal intermediary). COOPERATIVE CARE A program that supplements the military medical system when A-1 OCHAMPUS 6010.48-H Appendix A the military facility does not release the medical management of the patient to a civilian provider. COORDINATION OF BENEFITS The coordination of the payment of CHAMPUS benefits with the payment of benefits made by the double coverage plan so that there is no duplication of benefits paid between the double coverage plan and CHAMPUS. COST-SHARE The patient's share of,the cost for authorized care, depending on the sponsor's military status. CUSTODIAL CARE Care that primarily supports and maintains the patient's condition without active or aggressive medical treatment. The patient is mentally or physically disabled, and the disability is expected to continue and be prolonged. DEERS The Defense Enrollment Eligibility Reporting System, a data base used to verify beneficiary eligibility. DEPENDENT Any spouse or child of an active-duty, retired or deceased active-duty or retired person of the uniformed services. DME Durable medical equipment that costs more than $100, withstands repeated use, improves function or retards any further deterioration of a physical condition, and primarily provides a medical function and not simply transportation. DOUBLE COVERAGE The patient also has entitlement to insurance, medical service, health and medical plan, or other government program through employment, law, membership in an organization or as a student (including entitlement by reason of being retired from an organization or group), which in whole or in part duplicates CHAMPUS benefits. This does not include entitlement to receive care from the Uniformed services Medical Care System. EOB Explanation of benefits. A statement issued by the claims processor explaining how a claim was handled, e.g., what was paid. FISCAL YEAR The federal government's twelve-month accounting period running from October 1 to September ~0 of the following year. A-2 OCHAMPUS 6010.48-H Appendix A HBA Health benefits advisor. Military bases employ HBAs to help beneficiaries with questions about benefits and claims filing. ID CARDS cards issued by the uniformed services and the Dept. of Veterans Affairs showing a person is eligible for CHAMPUS and other benefits. JUDGE ADVOCATE The legal officer at a military base who is responsible for collecting CHAMPUS money in third-party liability cases, e.g., auto accident insurance payments. MATERNITY CARE The total episode of pregnancy, including all prenatal,delivery and postnatal care at six weeks and two days; also includes treatment of complications. MEDICALLY NECESSARY The frequency, extent and types of services or supplies that represent appropriate medical care and are generallyaccepted by qualified professionals as reasonable and adequate for the diagnosis and treatment of illness, injury, or maternity and well-baby care. MILITARY-CIVILIAN HEALTH SERVICES PARTNERSHIP PROGRAM A resource-sharing program that allows CHAMPUS beneficiaries to receive inpatient and outpatient services through CHAMPUS from civilian personnel providing health care services in military hospitals and clinics and from uniformed services professional providers in civilian hospitals and clinics. NON-AVAILABILITY STATEMENT Statement issued by a uniformed service hospital when medical care can't be provided there and the patient must use civilian care, Patients who live outside of the designated zip code zone surrounding the service hospital do not need a non-availability statement. NON-PARTICIPATING PROVIDER One who decides not to accept the CHAMPUS-determined allowable charge as the full fee for care. Payment goesdirectly to the patient in this case, and the patient must pay the bill in full. PARTICIPATING PROVIDER One who accepts CHAMPUS assignment (See acceptingassignment). Payment in this case goes directly to the provider. The patient must still pay the cost-share, A-3 OCHAMPUS 6010.48-H Appendix A outpatient deductible·and the cost of care not covered by CHAMPUS. PROVIDER Person or institution rendering medical services to the patient. RECOUPMENT A formal request for refund of money paid by CHAMPUS in error. RETIREE A former member of the uniformed services who is entitled to retired, retainer or equivalent pay based on duty. SPONSOR The member of the family who is or was in one of the uniformed services. CHAMPUS/CHAMPVA uses the Social Security Number or authorization number of the sponsor or the veteran to identify claims. UNIFORMED SERVICE HOSPITALS Includes all military hospitals and designated uniformed services treatment facilities, some of which are former Public Health Service hospitals. WELL-BABY CARE Preventive and routine care to assess the general health of children up to the second birthday (includes immunizations). A-4 OCHAMPUS 6010.48-H APPENDIX 8 ID CARD EXAMPLES OCHAMPUS 6010.48-H Appendix 8 ACTIVE DUTY GREEN) ISSUING AUIIIORIIIU Will PitIN r IICCII'ItNI''I SUIINAN( ll[lll l'llll)te fO UQUI'IIIIOHIN'l -CIUAl I'HOIOGRAPH SAMPLE AC11VI UPIAAIION DAti DD FORM 2A ARMY. 2AF AIR FORCE, 2CG COAST GUARD, 2MC MARINES, 2N NAVY IDINMCAtiOH fOI PUDOSIS Of THI OlHIVA CONVIN110N IILAIIYI TO TIIATMOO Of PIISOHIIS Of WAI Of AUGUST 12. 1f•t. , co .....At 0) 8 WARNING: For ol&cial ue of the pcnoa idcali&cd hcrcoa. U• 01 pouculon uccpt 11 pracdbcd Ia anlaw(ul, and will make the oft'ca4• 0 liable to hcny penalty, 18USC 499, 506 and 701. " ,_•• PliAII ,_,L, .... ,. POSTMASTER: .......,..-·- '"'.............-··........,. """".,.. AFMPC/Df'MD .. PUCI ta IC&allf 1.1........ • ... ft •• STATII GOVIRNMENT 8-1 OCHAMPUS 6010.48-H Appendix B ACTIVE DUTY (GREEN) ..•.,.....,,......... IIIU. ,..., IICIPIIan ............ ...._. .. • .., ... , ..... acr-. ...,...... PHS 1888-1 (COMMISSIONED CORPS ONLY) PROfiCII1'Y OP' UNITID STATES GOVERNMENT IDENTifiCATION POl PUIPOSU 01 THI GINIVA CONVIN110NI IILAnvl 10 liiAtMENT Of PIISONIIS Of WAI Of AUGUST 12, lf4f. 1..,. .....,. W-T ......., -o ---- :c ~IW&I 114.000 ,... :~::.~·INT en co DAII W IIIUC IIONAIW'!I W 1MUIM WPICIIII _,., SAMPLE (X) WARNING: For olliclal 11M o( 1h1 penon lclcael&ccl hcrcun. U11 or 0 pnsacuioa uctpl 11 pracribccl Ia anlawtul. ad will make 1hc oft"CAdW 0 liable ro hcn1 ~na1111 18USC 499. * aad 701. 0 W r-e. PLIAII .....Pn.l ...... ff POITMAST&R1 ,•._ ,.,.....,...,... '"' .,,..,., •••• ,_u ••ttAUAr... •at•• ,. .. PLICII• ..UIIf 1.1..... ML AI'MPC/DPMD .,..... PROPERn O' UNITED ITATII GOVUNMINT " B-2 OCHAMPUS 601 0.48-H Appendix 8 • ACTIVE DUTY (GREEN) IIIUIIIG AUIIIO.IIIfl WIU r•tllf •l(tPII.I't 1ua11a•• Ml •• •••o• tO •••u•strto•••4iPIIOIO(o.UII "''""' SAMPLE ...... ·······IOit""'' )t.ol ••• 'll .,........ . . ... .. ... . ···-.. DD FORM 2 NOAA (COMMISSIONED CORPS ONLY) IDINTIPICAIIOH POl PUIPOI!S Of THI GeNEVA CONVIN1lON IILATIVI YO tiiAfMENT Of PIISOHIII Of WAI OP AUGUSt 12, ...... , co ...... (X) 0 WARNING: For otRclal uac o( ahc pcraoa ldcallic4 hcrcua. U• 010 poucuion nccpc •• prncribc4 le nlaw(ul, an• will ~nake ahe of'cader0 liable lo hcaw1 pcnah7, l8USC 499, ~and 701. " •-•· rua11 ,_,"' •n•• •• POSTMASTERI .,... ,.,.._,.., , ....UUI &IMII '-'CCI 11111u.Af... IUIIAII fla .. •~au '" • 11111 •·•· ..... IlL STATU GOVIRNMINT 8-3 OCHAMPUS 6010.48-HAppendix B RETIRED BLUE/GRAY -·----- DD FORM 2 (BLUE OR GRAY) (INCLUDES NOAA AND PHS) &"'\:.-c~~--c~ ~\....\..-c'-:."L~~\)..J.__\...~~~"'\.~~"\..."\_~'"\-.~_ ;:ll'Q:__ x~~! DATI M IIATH WEIGHT HEIGHT COLOII tWI' COl. IVU SIGNATURI 01 188UING OFFICER DATI QIIUUI MEDICAL ...-,.,.. OI'NIA&. Ull 01 ,.. MOUIIII oe-. 110 CIW .... CAM AUfNCWPM ·~ MAYID .....ON. Ull CIA ........ IICaPf 4I'IIIICIIIeiD 18 ~MID -.&. MM8 rtll ~LIA&a TO MUW ,_,1¥-11 lA & C. AIITIII --MIMt. CMD-. SAMPLE 276888 MONRYY 0. n.-UNITID ITATU POSTIIA8TIR: Rll'UAN TO ~.II I'OUND. DAOP * DIPAII'TIIDT OP .,.,..... lfiMDT u. .. 111M. lOX WAIHINGTON. D. C. ..... C\_').:;\...\:..\...l:..\...\...\...~\...""'Q-\...~~""\.~~"\:.~1-~'"\-\'}._'}_~'illl~'"\-12 "0 -~) B-4 OCHAMPUS 6010.48-H Appendix B FAMILY MEMBER (ORANGE) ,..,.. SAMPLE DD FORM 1173 1&. llCDeCAL CAM IIIACIUftU A 2 0 .....Q.IDMIMI:. t• GMI.AIUI·~--........... ~l Ill z .:. z J ...~--• s ~ 0 •.. 2 0 • .....,..,._ •Ill J ... • ~ SAMPLE •~ 1: I a l"nND ....AliMa ..... Ill 3 ' ... ii i ~· :1 ,. lfJI'OUND· ....... Ull MTN11~1101liYonea ' CJIIOIIiN IMf' MAL _,. TMM IIIMOII IWIID TNUfQIL CMt AWl {Ill· • •~ a t VIGUftON or NO\llllOM 01-DUI.NOUfff' MIDit CAL CAM ltf:F 01 ltNIIDIOUI UID UAIU fCM ~•IIP\IIIN TO •a '• ~ NOIICU'nON UJ10U AMJCAIU'I!IDI..., ~ OC"MTM&Hf Of' ....... I'UfMIINI TO 'AUIITMIIIIJIJI.IIIIII/: IMIJ WAaMIHCnOH. 0. C. anDI 0 • t= ~'1 JUHifORMID SEIMCE5, IOEN\VICAliOif AND MIVUGI CARO • ___ &. B-5 OCHAMPUS 6010.48-H Appendix B VETERANS ADMINISTRATION (CHAMPVA) (WHITE) POSTMUTER: RETURN TO: CENrRAL CHAMPVA REGISTRY CENTER VAle DENVER. CO 10220 DU£NDENT OR SURVIVOR BENEFICIARY Of VA IDENTIFICATION CAN) SIGNATURE OF BENEFICIARY (1/ .,, U 01 ol*r) SAilPL. >c: C I I I ..... co ·-~..5 tl"E • M ~ ... ~ :Set Cl) _8<"; O"U t 01 co; e:t: ~ >-"' c: 0 ~ ·• c·-~ ,_., 0 :s u "" " -5 0 c~u..,. 0 :::> > .:. S·;::X: ~ O< a: ·-·~~..c:~> :! -§: u u: .:. % ~~~:s t "" z - a: . ~~ II) ~ >< '><. >< "" .:. i5 X ,.,u. U• ~ >< u. - u. ~ "' ...... ·-1-~ ~ ~ 0 ~ Q 0 Q >< j ct ~ul") ><' :> ~ l "" . -.. ..c: I") !:) >< "':1 .:. "' ...... ..: .. .wu~ .. 8 "' ~ ~ >< '>c: >< z 0 Q >c: ~ )< ~ ')< - :> )< ~ g< ~ g:;op ... r-1 ~::S ;> ~·a u ~ .; • B-6 OCHAMPUS 6010.48-H Appendix C APPENDIXC FORMS OCHAMPUS 6010.48-HAppendix C INSTRUCTIONS FOR COMPLETING DO FORM 2520 Tur off this inst111ction sheer before submitting daim. This claim form is to be used when submitting a claim WHERE TO FILE CLAIM requesting payment for inpatient or outpatient Send the original claim form to the appropr~atemedical services or supplies provided to eligible CHAMPUS contractor processing claims for the state orbeneficiaries under the CHAMPUS and CHAMPVA country whert the services/supplies were provided.programs, when provided by civilian sources of medical Contact your CHAMPUS Advisor or OCHAMPUS for thecare. Those include physicians, pharmacies, medical name and address of the appropriate contractor.suppliers, medical equipment suppliers, ambulance (Exception • When entitled to other medical benefiu companies, laboratories. or other authorized coverage. See Item 14 below.) providers. Important: All information in Items I through 18 isWHO FILLS OUT CLAIM FORM required to process the claim. Double check the form, especially Item 8 on Social Security Number or VA File The beneficiary/patient, sponsor (or other parent) of a Number; Item 5 on Identification Card Number; andchild under 18, or the guardian for the individual Item 18, your signature. Beneficiary/patient's name,patient, is required to complete the PatientiSponsor sponsor's name, and sponsor's Social Security NumberInformation Section, Items 1 through 18 at the top of or VA File Number must also be on all attachmentsthe form. The beneficiary/patient (or sponsor) fills out Incomplete forms will be returned fot missingthat section regardless of who submiu the claim • the information. Retain the -copy of the claim formbeneficiary/patient (or sponsor) or the provider of m11ked patient's copy and a copy of a// attachmentsmedical services/supplies. for your recants. When the claim is submitted by a physician or other Special Instructions: provider, the lower part of the form (Physician/Other Provider Information, Items 19 through 33) must be e Submit 1 separate claim form for eac:h completed by the provider. Item 32, Agreement to benefic:iary/patient.Participate, must be checked "Yes "or "No.• If a provider does not choose to participate but completes e File no later than December 31 of the yearthe form, an authoriud 5ignature must still appear in following the year in which the serv1ces wereltem33. provided. If a daim is returned for additional When the claim is submitted by the beneficiary/patient information, it must be resubm•tted by the or sponsor for direct reimbursement, an itemized regular filing deadline. or within 90 days of the natement listing the services/supplies must be notice of the returned form • whichever date 1s attached. The lower section of the form for later.Physician/Other Provider Information may bt left PATIENT/SPONSOR INFORMATION REQUIRED blank. Following are explanations of some of the items ITEMIZED STATEMENTS required on the claim form. For a more detailed If Items 19 through 33 of the claim form have not been explanation of all the items, refer to Fact Sheet 12, completed by the physician or other provider, an "How to File a CHAMPUS Oaim,• available from your itemized statement must be attached. An itemized nearest Uniformed Services medical facility, your statement must contain: CHAMPUS contractor, or from OCHAMPUS. Aurora, Colorado 80045·6900. a. the beneficiary/patient's name b. date the servictslsupplies wert provided Item 5: Identification Card Information. Enter card c. description ofeach service/supply number from spac:t 1 of the Identification Card (DO Form 1173). If an utive duty member uws hislher card d. c:harge for eac:h servic:e/supply for dependenu under ljle 10. use Card Number of DOThe itemized statement must be on the provider's Form 2A, with letters AD" indicating Active Duty,billing letterhead, containing the provider's nam" and after the card number.address. Item 1: Sponsor's Social Security Number. EnterFor prescription drugs, the itemized statement must sponsor's Social Security Number. Enter sponsor'scontain: former Service Number only if the sponsor dotl not a. name of the beneficiary/patient have a Social Security Number. b. name, strength and quantity of each drug If CHAMPVA beneficiary. enter veteran's VA Filec. prescription number of the drug Number. d. name and address of the pharmacy e. name and address ofthe prescribing physician If a NATO beneficiary, enter "NATO" in this space. Not acceptable as itemized statements are billing If a sponsor is an active duty security agent, enter statements showing only total charges, canceled "Security.· checks, cash register receipts (or similar type receipU). DO Form 2520 Instructions, JUN 88 C-1 OCHAMPUS 6010.48-H AppendixC Items 9: VA Station Num!Mr (CHAMPVA only). Enter the three digit number of the VA Station which issued the identification card. Item 14: Do You Have Other Health Insurance? If you are covered under another medical benefits plan or health insurance coverage, check "yes" and supply the name and address of the other health insurer, and what pl•n or program you h•ve from that insurer. CHAMPUS will not duplicate benefits of •ny other health insurance plan or program. e All Beneficiaries must first submit a claim for reimbursement to the other medical care insurer, except if the other coverage is Medicaid. If Medicaid, first submit to CHAMPUS. After receiving an Explanation of Benefits (EOB) or a work sheet from the other health insurer, fill out and file the CHAMPUSJCHAMPVA claim form, attaching a copy of the EOB or work sheet, being sure to complete Items 1 through 18 of the CHAMPUSICHAMPVA claim form. Item 16: Inpatient/Outpatient Care. Check appropriate sp•ce according to the following explanations: e Outpatient. All eligible CHAMPUSICHAMPVA beneficiaries may choose Outpatient care from either civilian, Military or Public Health Services facilities. A Nonavailability Statement (DD Form 1251) is not required for outpatient care. e Inpatient. For admi55ion to a civilian hospital, a Non•vail<~bility Statement (DO Form 12S1) is required by •II !Mneficiaries (except CHAMPVA) who live within the catchment area of a Military Treatment Facility or a Uniformed Services Treat· ment Facility (formerly Public Health Services Facility). A copy of the Nonavailability Statement must be attached to each claim relating to the inpatient stay; i.e., attach a copy to the surgeon's claim, to the anesthesiologist's claim, etc. A Non•vail<~bility St•tement is issued by the Military Hospital Commander before medical c•r• is provided. e Emergency Admission. In the case of a bona fide medical emergency, a Nonavailability Statement is not required for an inpatient admi55ion. • Outside Catchment Arll. A NonavailabilityStatement is not required for •dmission to a civilian hospital when the beneficiary/patient lives outside the Clt ... , I. UON\OI'HOCOAUICUOOTY NO OOVA IOU NO 0 MALl 0 fiMALI 11. SIOtt\QA"J OUTV STAJIOM 0A AOOlllU f()A MTtAlU II. =~AILAIION'"" TO 8 IlL' 8WOW II PHONI NO (lftdurft .,...«IIl -OA -~~' 0 Yll 0 1111 AliT_. ACCIDlMT AtLATIDT llo ---·SrAM0 ACfiVI 1111n 0 O(TootO 0 OIU&IIO O•n01111 &OOMII con na.n "' ,._ T\'11 Of COVliVl<'"' • AN IIUUAY. NOll MOW o MAIIl"lO 0 l-OYMIMTCGIOUII 0 MIDICAID 0 ITUOlMTIUN I • OIICllll ---MOICJt Willi MQIVIO IMA IIINT 0 ...VATICTION-OTIIIA' 0 ...-0 l t6& lfJICTIVI DATI MONTM ' DAY I ,,•• IOc, OTMlOIOINTifU,_ NIIIINO an.a. t•o,......, DAft !Q,&fllHf llli"lD, _~(Jtiltftl1ttllroutUiarewa.com,....lllrt~~tJIIraldlnO.ot~Mt~• • II. NAMl. AOOAISS &NO -""' Of OlllMING '"'"ClAN 14 OOoGHOSII. "M"CIM Ol NATUM Of ILLNIII OA lfiiUOY. AILATI OIOGNOSII TO IAOCIOUIII Ill CCO.-"0" IY OI'IIIPICI TO --I, I. I. 111 OX COOl I. l. J, IS.. ISO. OOAG~ OA TU Of liAVIO Atfs ,.OCID~ COOl COOl MOIOA'riV(AI MlllVtCl ID(Ntft: 31. ,.fllNT' ACCOU"T NO. s A. AlillliiiiMT TO 'AATICII'Ofl 1--ol ..... - II. •oovootR'J -IICUIIIT'I' NO Ovn Ooo 11-IAOVIOIA'J lM...OriR LO. NO \lGhiD IOOVIDIA NO. IlLI ••OIHMot•T LA.IOUlOft..u.a Of SIIIVICl CDOII Otllll "IOICAl lUIIGICAI. JACII.II'f I UMI • "'OATIIMT HOVITAI. IIIIDIN'IIAI. TIIATIII•T CINTtl 1m t$111 IHAIIIIIl -AI. DD Form 2520, JUN 88 C-3 OCHAMPUS 6010.48-H Appendix C PRIVACY ACT DATA REQUIRED IY THE PRIVACY ACT OF 1974: Legll 1uthoroty for the pal'10nll onform1toon, oncludong the Soco1l Securoty NumtMr. requored on thos form os 4' USC JIOI. 41 CfiiiOI elleq., 10 USC 1079 1nd 1086; lnd EO 9J97, NovemtMr 194J (SSNI. The proncopal purpose of thosonformatoon is to evaluate eligoboloty for Clvoloan health benefits authorozed by 10 USC. Chapter 55. and to inue peyment upon elllbloshment of elogobility 1nd determtnetoon that the medical cart received is authorized by lew. The informatoon os subject to verofoutoon with the eppropnall Uniformed Service. The Office of the Civililn Heelth end Medical Program of the Unotormld Services end CHAMPUS Contracton use the onformatoon to control 1nd proc111 mldiell cl1ims lor payment; lor control end 1pprovel of mldicel treetmenu end interfece woth provoders of mldicel care; to control end accomplish reviews of utilizetion; for revoew of cleims related to possible third party liebolity cases and onollatoon of recovery 1ctoon1; lor referrel to P11r llevoew Commott.or 11molar prof1110on1l tev-orgenozltoona to ~trot and revoew provoden medical care; for dilcloaure to third party contacts, without the consent of the individual to whom the informetoon peruina. in sotuations whete the perty to 1M contlctld h11, or is eapectld to have, information neceSMry to est1blosh the velidity of evodence or to verify the accureq of informltion pr-nted by the individual concerning the individuel's eligobility for tMnefits under CHAMPUSI CHAMPVA, "" emount of benefit peymena. 1ny revoew of suspactld 1bu11 or freud, or 1ny concern for progrem ontegroty or quality appr1111l; for the iuuence of deductoble certoficatll; to respond to inquoroes from Congreuoonel offices mede at thl request of the individuel covered by the system; for referral to the Secretery of the Department of Health and Human Servic11 1nd/or to the ·Administretor of the Veterens' Admon11tratoon consistent woth theor st'etutory edmon11t11tive responsobolities under CHAMPUS/ CHAMPVA; for referral to the Department of Justoce and/or for11gn lew anforcement egencoes for onvestogotoon ond pouoble crominol pr011cution; end, for referrel to the Department of Justoce for repre~enlltoon of the Swetery of Defense on Clvolectoons. The onformation must 1M provided if the benefic11ry/ Pllotnt (or sponsor) d11ir11 to hne 1 portoon of the cherges peod by the government. feilure to provode informetoon wdl result on deniel of or delay on payment of the ClAim. PATIENT/SPONSOR INFORMATION • ITEMS 1·18 Items I through II must be completed end the certifiutt llgned by the tMnefitierytpatoent if hllshl iS II yeen of age or older. If the tMnefict~ryipatient is uneble to "'I" on hilllllr own blholf, refer to fact Shlet12, "How to File 1 CHAM PUS Cleim. • Thuponr.or may 119n for eny bt114ficilrylpatoent under II yeen of age, or in the ebstnce of the sponsor, the other perent, the benefic11ry1 petient or benefict~ryipatoent'J guerdian mey "II"· (NOTE: For proviCJ '"sons, 1 tMneficoarylpatient under II y"n of 1111 may sign hillher own cl1om form.) IENEFIOARYIPATIENTCERnFICATION • ITEM 11 ly .. gninlllllm 11 of this CHAMPUSICHAMPVA cleom form, I certofy th1t to the best of my knowledge 1nd belief the informetion provodld in Items I thrOUIIh I 7 il complete arlit correct. 1 further authOroll 1111 release of any medoCII onformatoon ntc111arr tO ldiUdOCIII and proceu th11 claom to the Federal Government ondudingthe CHAMPUS Contrector. 11110 euthorlll the reltlll of. or obteinone of. mediCI I and/or other covtrtlll onforrn.toon 10 1"11 from another orQino&atoon wrth whoch 1 heve the other mldocal btnefia plan or h11lth ona~rance coverege. If I am s~bmottong thit claom for direct reombunement to me, my 1'9ftlt\lre further certifies that the apecofic mldocal aervociiiii~PPIIII for which 1 em cl11mi"9 bell4fitl were actuallr rendered to me on the dltll ollllicettclanel thet the llllched otlmoaed stellment repr-ntl aleeal obligatiOn to PlY· (NOTi: Tile ebove 111110 certofied of otem II •• soenld by theiiiQnsor. other parent or e~ard..n.) PROVIDER PARTIOPATION ·ITEM U lr checking "Yes" in Item U (and ••en•n11 on Item Ul of thl CHAMPUSICHAMPVA daom form, I 1grn to sullmot thol cllom to the appropriell CHAMPUS Contractor 11 1 pertocopetonll provoder. I undenllnd that I 1gr11 to 1ccept the CHAMPUS·determoned re110111ble charge 11 the 10111 chlre• for medocal llrvoctl/lupphtt listed on the ClAim form. I will ICCIPt the CHAMPUS-determonld re110neble c/lare• 1111n of it 11 1111 than the bollld emount, end 1110 egr11 to accept the emount ptid by CHAMPUS. comllonld woth the cost-shered emount 11111 deductoble. of eny. paod by or on tMhelf of till btMficilrylpatllnt, II full peyment for the mediCII llfVICIII/Iupploet. 1 will mate no attempt to collect from the benefocoarylpltllnt (or sponsor) •mouna over the CHAMPUS-determoned reasonable cherge CHAMPUS 111r111 to make eny' tMnefill pay1bl1 dirlctly to me, of 1 submot 1 d11m 111 pertocopetong ,provider (Anr tltlretlorl of th11 atltement by the provoder mar result on the cleim beoniJ returned or proctllld 11 1 non·partocopatone claom woth payment m1d1to the tMneficiary.) PROVIDER CERTIFICATION· ITEM U I certify thet lhlservoctslhown on thll form were mldocally ondoclted arlit ntct~Wry for the h11lth of the patoent and were personally rtndlred by me or were rencltrld incodlnt to my proftssoon11 Mrvoct by my employn under immediell penontl ..,.,.,.,.,on. except u othlrwiSI eaprtuly permitted by CHAMPUS regulatoons For servocn to 1M consodered 11 'incident' to 1 phfi!C•en·a proltss•ona• service. 1) ther mUll 1M rendered wnder the physocotn'a ommedoatt personal super-.tiiOn by h•llher elnptoyH, 2J ther must be •n '"'~'•1. elthough oncldentll, part of• covered phfi!Coan'sllrvoce. 11 thtr mwn be of killlll commonly f~rnolhed in phfi!C•tn'a offoces. and 4) thl MfVICII Of nonphJIICOinl lftWR 1M oncluded in the physocoan'l boll I further certify thet I 1111 not In ontern, resodtnt. or otherw•M '" 1 treinong !IIIIlS for whoch I em receovone compan11toon for serw•ce• lilted on this cleim. 1 further ctrtofy thlt I em not Ill 1n ectovl dwtr memDer of the Unrformed Servoc11; Ill 1 covolo1n employll of the Un•ted St•te• Government; or (3) 1 contract emptor11 of the Unotld Slues Government. eother covolian or molotery (refer to 5 USC SU6l. IMPORTANT· READ CAREFULLY Feder11 Llws(11 USC Zl7 1nd 1001) provide for uiminal peneltoes for knowingly a~bmotton11 or matong anr fa111, foctotooua or freudultnt llltement or deim on •nr matllr within the jurlleliction of any department or 1gtnq of the Unoted States. bemples of fraud onclude sotuationaon which ineligoblt persona knowingly use '" uneuthorozld ldentolicltion Clrd on toling of a CHAMPUSICHAMPVA claom; or wnere providen IUbmot claima for treatment, supplies or equipment not rendered to, or ulld for CHAMPUSICHAMPVA bentfic..roes; or wnere a partocop1tong provodtr billa the beneficilry/patitnt(or IIIQnaor) for emountl over the CHAMPUS-dltermoned reasonable charee; or where 1 bentficllryipatoent (or spontor) ftols to dilciOII other medicll benefits or h11lth insurance coverege. INCOMPLETE CLAIM FORMS WILL BE RETURNED. DD Form 2520 Reverse, JUN 88 C-4 OCHAMPUS 6010.48-HAppendix( PLEASE 00 NOT STAPLE IN THIS AREA HEALTH INSURANCE CLAIM FORM .. [] ::.\~... []::.'.=.... [Jf=~\,,... [] ~.-:~.7:.0. [J ~:.:.:.k_,••.,.. [] =~-:.\':.~···... PAnENT AND INSURED (SUBSCRIBER) INFORMATION J •IWAIOI ••......., ..... , .., ............,..., ........" ........... 'N.ltl•niiUtlf\MtiJIMII,I-fM.I........'*'I I I t ......,..,.,.o..o ••o• ._....,..,_.•..,., .c•.,...,., I ..I..Nf"llla • H.fiiNrl.......tltAIII. Cft'Y. ltAfl....CODII ..... o o ........ "''"'... rM'htllt'l.......,.,...,.•au••• t ..,.,.,otoaov•..o .ocao•Chlll..-toet~cac,.,...o, o ·-•v•,••••.,...,wuw....,.con••"••••-..w•t~ a 0 0 0 .......... ""... .......................... fl IIIIUIII.IAeel*tll·lhl&ll 11n tlatt '"'"'' I 5\iacY::Cii:F=•\r~~~=:;==IIOltC'fMCkM• A llllNMI...IoI..._Oftll.l o ... ,.,.,,.,.,,u.. ~ ... I acc.oe•• ",._• ._,, I_,..MIII I w•oO !§5:0\"1 c:::JW•o•MOII..ICA..II-0 Oa'"'" ••••ve I • ' ....... •t li'AIIhll"l o• AUIMO..IIO "U0.'8 M.afiiAI ••tAO lACK 11'011111 .........01 .,:.:.~=:;...&:~:.=..--.::::~:::.;.::;a~::r.::..... ~:~:.1:.-:'U::t-:~t.-.•:,•:.=;.-::~~.-::~-:i:~o:\'b'I::,U?~-:~·.~~:.\We=.~~;:,·:.~,::· ..................g ......~,.....1011. -·· .... PHYSICIAN OR SUPPLIER INFORMATION II D&flf••lf~IIOIOY...,... tl '' ••t•t•t MA\tuO lUllI ~ 1,.• •-u.a• ........ ,...U.. ........~•••~....,.,... "... a.... I CO.OitiOII • II .....01 fOtM. N•llllft' 0.11101•..•·-........... .IKJ.. I IMitOYQfl • ::.,·,~:::l!~~·,~·u~;,-:.,_,...,...._ toQlMIItiO rOotc.ttaAOie ~-·..._IIIUII•aa_.. ..,._,._._•.,.,__,lllll:llll--. ....... ........ ......... :::8 8: ;.:;;·-------··---·-···--................. ---... .. . .. ................ O.fl OIMhiCI • 00 ~-----;...-- II•""'MI UIIWtt,aa4 u•-ctiOII C.-c&oltllllto..CII· , ...... ll ,__, tO .. ACCI,., •11.011..1111 IGOWI....IIIf "&1110\ol........ , ......-c..... " ....,o.... ,,...,~, II ~._..,..llf"l IICCOUIII M0 11 •ow••~or•••..o •._,.&CI Of II.'IICI MID"'" Of lllhltCI If 0 I ICOOlI 0111 lacl -108Y loiiA-OIIIIIOIC... HAWICIIIU ........ --·•-11-141 _o_.,.. -~..,,,..., __,.. ---· C-5 OCHAMPUS 6010.48-H AppendixC BECAUSE THIS FORM IS USED 8Y VARIOUS GOVEI'INMENT AND PRIVATE HEALTH PROGRAMS. SEIIEI'ARATI INSTRUCTIONS ISSUED 8Y AI'PI.ICAILII'ROGAAM I'IEFERS TO GOVERNMENT l'ftOGRAMI ONLY MEDICARE AND CHAMPUS PAYMENTS: A paltenltlognature reQuelll lllol oa leN 111an the charge aubmoueo· CHAMPUS oa not a nealln onaur· rhal oavmant be made and authorlJH releaae of med•cal tniOtmehon ance proeram end rendett payment lor neaun blnelota provoded lhtOIIIh necetNry to pay tile claom llotem 1 "cornpletea. llle paloent a 11gna11ore membltlhop and eHoloatoon ••In tile Unolormed Servoc:n lnlormaiiOII 011 aulhon&et rele4t•ne ot the tnlormauon to the inaurer or ageRCy 11\own the patoenl 1 aponaor thOuld bl provoded on lho" •temt cap~oned lnIn Medocare naogned or CHAMPUS. partoc:opatoon cnea. llle pnyaoc:oan euree~··.oe .otemt 3. 1.7. I. I and 11 agreea to accept the Charge determonatOOR or tile Medocare earner or CHAMPUS loocal onlermedoary 11 the lull charge. and rne paltent oe BLACK LUNG AND FECA CLAIMS Tne provodeCI Ill'"' to accept the amount paocl by me Government 11 payment ., lvd See Btac• LUIIIreaponaollle only lor the deducltble. coonaurance. and noncovereCI aervocea Coonaurance and the deductobte are bllecl upon llle charge 'ECA .natruchona ragarCI,ng '"'"reel ptoceau•• ano CS-egno"' cochng eyateme. determonetoon olrne Medocare carroer or CHAMPUS loocalonterrnedoary ol IIQNATUftl OF I'HYIICIAN 01'1 IUI'PUEft (MEOtCAftE, CHAMI'UI, FICA AND ILACK LUNGI I certofy that llle aervoc:ea ahown on 11111 torm were medoc:ally ondoc:ated allllougn oncodenralpart ot 1 covered OIIYIIC•an 1 aervoc:e. 3lllley mutt bl and necnNry lor lhe health of lhe pallenland were peraonally rendered or kindl commonly lurnothed on pnyaocoan • oHocea. and 41 the ..,voc:et by me or were rendered incoclent 10 my prol...iontl aervoc:e by my of nonQIIyaoc:iana mual blonciUded on IM Qllyaocoan a boUt. emploY" under ommedille peraonal aupervitoon. eacept u otnerwiH For CHAMPUS claima. 1 runner cenoty 11111 neotller 1 nor any emPloyeeeapreqly per monad by MediCare or CHAMPUS regulatoona. who rendered lhe ter"•c•• are amoloyna or membera ol IPII Undormed For aervoce1 to bl con10dered a ·incodenr to 1 pllyaocoan 1 prolenoonal Servoc:el (Ieier to , usc ,~311 For BIICh·L .. ng tlaomt I lurlller cetlofy aervtce. 11 they mual be rendered under thl OhVI•t•an 1 •mmed•ate per· lt\11 IPII aerv.eea performed were lor 1 BliCk lung retatecs CJ•torder aonal aupervoaoon lly niainer emPloyee. 21 they mull bl an ontegral. No Pan 8Medicare benelita may bl paod unleNtnoalorm o1 r-oved 11 reQuored ~Y eaoatong law and reg .. tatoonll20 CFR •za 1101. NOTICE. Any one who m•arepreaenta or tala•hea 111enta&J mtormetlon to rec:eute CN,"tmtnt from Federal luncJa reQullll~ o, ltue fOf'm m1~ upon convoc:toon be aub1ect 10 lone and omproaonmenl under apptoubte Federal ItWI NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE. CHAMPU&. FECA. AND BLACK LUNG INFORMATION We are au1norozed lly HCFA. CHAMPUS ana OWCP lo Ilk you lor onlor· Fedlfll IQIRCI" II neceaury tO IOm•n•allr lhe.. Dtotrama f01 matoon noeded on the admonoauaroon oltlle MeCiocare. CHAMPUS. FECA. eaamole. it may be nrteiiN'Y to grama lor relua1ng to auooly •ntormar.on However la•lure to -:IIICI30USCII01 etfumaah 1nformattOn regard•no ana med•cal aerviCel rtnd.,ed or tne amount charged would orevent Davment of ell•"'• unoer thlll oroThe •nformation we obtain 10 comgtete ela•m• ynder tt\eM or09rama 11 grama. Fadure to turn•ah any other •ntormahon. such 11 name or ctaun uaea to identify you and to determone your etogoboloty. II o1 tlto uaed 10 nu111blr. would delay payment or tne ~1aom. decode ol lne aervicel 1nd auppliet you received are covered by ,,.... program& and to inaurtlhll proper payment ia made. II 01 mlndelory 11111 you tell 111 ol you art !Ieong IlealeiS tor 1 woro relltecl tniutY 10 we can datermtnt wnetner wor11era compenuhon will oar tor Tne onlormatoon may alao bl goven to oilier provodera or aervoc:e1. Cit· treatment Sectoon 1877 .tii31 ol the Soco11 Securoty Act prOYodft uera. •ntermed••r•••· mect•cal rev•ew bOardS anCI other organ•ut•on• or Gramtnal Denalt••• for w•thholchngrh•a .ntormat10n MEDICAID I'AYMENTI ll'ftOVIDEft ClftTIFICATIONI 1nerelly agree to keep tucn recorda 11 are necetNry to doactoH lully lhe SIGNATURE OF PHYSICIAN 10R SUPPLIER I I RMATION SPEOFIED IN THE CURRENT WRimN GUIDEUNES I'UILISHED IY OCHAMI'US K>R EACH TREATMENT AREA WHICH REQUIRES CHAMI'US AUTHORIZATION. PART I• 5PON5C:1R INFORMATION :1. RANK AND PAY GIIAOI IJ. IIIANCH Of SERVICI 1. IIAMI Of SPONSOR (Wt, Flnf, ~ln/CMIJ ._ SOCIAL SECURITY 011 SIIIVICI NO. IS. VA PILl NO. CCHAMPVAJ n·TU· Of SPONSOn~ ACTIVE RETIRED flDECEASED 7. COMPUTI MIUTARY AOOIIISS (Sirut. C/fr, $Ute, •tidlip Code) I. ltOMI AOOIIESS ($1tHt. C/fr, St•ll. •tidZip CoOl) , •• TELIPHONI AREA CODE ( EXT TEUPHONI AREA CODE ( l EXT PART II • PADENT INFORMATION NAMI Of PAnENT (Uft. First Middle lrtltMI) 10. DATI Of IIATH (YYAIIMOD} In. RtLAnONSHIP TO SPOIISOII 13. HOMI AOOIIISS (SITHf. C/fr, Sl•ll. •tidlipCOIN) 11. IOINTIIICAnON CAAO NUMIIR (OD 1-117J) MONTH DAY YEAII EFFECTIVE DATE I L L TILIPHONI AREA COOl ( , EXT EXPIRATION DATE I I I 1•. IllQUIST POl DC-~ 1s. ADMISSION DAn cYYMMDDJ I,._ OISCHAIIGI DATI CY\'IIIMifDDInIO-OAY WAIVEII n CIIITIFICATION OfRESIOENTIAL TREATMENT CAlli 17.15TIMATED COST Pll MOIITH 01 TOTAL COST. OISCHAIGIO PIIOFESSIONAA. FACIUT'I' s ' I"AKT Ill• ""~VIDEittNFORMATION 11. NAMI AIIO AOOIIISI Of l'tiOPISSIONAL l'tiOVIDING CAll 11. IIAMI ANO AOOIIUS Of PACILIT't WHEIII CARl IIICIIVIO , TILIPHONI AREA COOl ( TlLIPHONI AlllA COOl ( l ZO. 015QPUIII Of l'tiOPISSIONAL l'tiOVIOING CAlli Qt -~ Z1. PIIISON TO CONTACT AT AIOVI PACIUTYBMEDIQNE R SOCIAL WOIIIC PSYCHOLOGY NURSING U. SIGNATUIII Of SPONSOR. PAniHT, 01 LIGAL1Y IISI'OMSIILI aJ. DATE (YYAAMDD) Ia•. RELA noNsHIP ro PATIINT NilSON CONTACT YOUR HEALTH BENEFITS ADVISOR FOR CORRECT MAIUNG ADDRESS DO Form 2533, Dille; a ,....,. -"1-.,. ollloiiN. - C-9 OCHAMPUS 601 0.48-HAppendix C STATEMENT OF PERSONAL INJURY· POSSIBLE THIRD PARTY LIABILITY CHAMPUS I CHAMPVA Public reporttng burden for th11 collect•on of tnformatton •• est1mated 10 average 57 m1nute1 per responM, oncludong the tome for revoewingonstructoons. Mlrchong e••stn•g d1t1 sources. gatherong and maontlontng the d1t1 needed. and completong and revoew•ng the collect1on of information. Send comments regardiniJ th11 burden esttmate or any other upect of th11 collection of tnformat•on. onclucltng suggest•ons for flduCtniJ thiS burden,IO WashoniJ!On t THUCTIONS The Federal Medical Care Recovery Act. •2 Un1ted Statll Code 2651·U(1970irequllll the Government to Mek reomburMment of the reasonable value of mediul Clrt furnoshed to CHAMPUS or d11ect ure benefocoaroll when the medoCII tare rtsuiU from •n1uro11 uuMd by a negligent third party. For your informatoon, the term "Neghgent Thtrd Party" can onclude any of the followong: (11 Any pertOn who uuMd the onJury. or the person's on11.r1nce compeny; and (21 tht owner of the property wnert the acctdent occurred or the owner's onturance compeny. Other thord perttll from whom tht Un•ted Stltll un collect ondwdt: (1) Any onturance compeny which inswrll your famtly for hospttllllltoon and mediCal e•penMI; and (2) of tht onJury occwrred It 1 work 1111. the Untted St1t11 may collect from Worker's Cornpenllt•on or the employer's onlurance company Thtl form il to ba completed by pertOnl who hiVI rectoved medocal cart It Government e•penM or by 1 responSible f1mliy member. In o.IWIIO--.n_l,_,.._.,__ lfLf _ ITIOCMIUI OTMIA B 8 IIMC*I MO. (llfd&M AIU CDdiJ SECTION II NON-VEHICULAR ACCID!:NTS o. IITI Qf ~~~---cnw. '-11'· ,..., II. 'IIIII 0 &.M 0 o ... 1"DATI ._ """' AIIO -~~Of -~Qf JIIOOIIIY'f WNIII -OCWIIIIO ........ .. I < OIWOSITMIII Qf CAll Itt. -MdS.Af,_.l ,.._ o. MU O'I'MP , ......,a:-q MIMIIAI IIUUUO • 'I'MI ACOOI•n I. IIIIAI fN4I &CQOI•T -IIRATIO' a:·~·---., (t) COMPANY ICAMI loll &OOIIIU-DPCMI ttl COM'"-' NAMI Ul OOU(Y 110. 1•1 AMOUII'fJ ""0 T"fl'll 01 COVIAAGI Ul OOU(Y 100. COl AMOIIOin ""D IYPil Of COVIAAGI 01 OOUC'r 110 141 AMOUIOTI •-0 T"fl'll 01 COviAAGI DD Form 2527, AUG 88 C-12 OCHAMPUS 6010.48-H Appendix C SECTION IJJ VEHICULAR ACCIDENT A CO,Y Of AN OffiCIAL I'OUCI IIIPOIIT MAY II SUISTITUTID POll 'AliT$ 1 THIIOUGH I Of THIS SICTION. OIDICAQ lUIJIC -S. --...roon. ~01 I'IAVIL -TM1 ACGDIIIT • 5miT IIAMIS. 1UffiC Wll -1.l1t. VIHM:U lit WH1C1t YOUWIU· 8 OTMII VIHIO.IISI 8 a; ~ASSPIGEM IH YOU. YIHICU Ne/Vde f1 L IIIAIIIIII _jU ..·.· ·· c.IIUUIID 8: a: 8: 8: ._ CMLIAM oa MtUf4AY 8CMLIAN ""'',..' B""ILIAII Mt\lfAAY BCIVILIAN MILIUoA'f 8"....... M•u'••,. 1. WHAT I'OUCI AGIIICY -UIGAQD Tltl .. -VQ.A-fOil-IICUTI WIU OSWID. MD YO-OSIUID ACGD~m •• , .. srofWCI~y -· ~~~onw• -.J ... -- 0 0 GUVIL ·QDIIlr 0 _.,AL 0 UliHT Ottuww D CUAA 0 fOGGY o .......... 'AVIO 0 oo• 0 WIT OIC'f 0 COIItGUIIO D OHtU ~........, D NAIUIOW 0 'NINOING OSioOWCOVIIID 0 OTHII lf•-J DO Form 2527, AUG 81 C-13 OCHAMPUS 6010.48-H Appendix( .,. TUifiC liGULAnoNS o. JOifiD HGUI.&IIOIII II. IIQII•U GIVIII If VI"IC411 IIIVOI.VIO DIICIIIII 1111,. UGUI.&IIOIII ., Kllll Of ACQDIIIf Ill CMIN't• Of •OUI 111lHICLI Ill OOIVIIIIIJ Of OTM(a VIMIC\1(11 § ITOI'IIGN IUOIIIOGULI YIILD IIGN ::.::;: W-11 UCiNfl OTHia (,._fl