[Federal Register: February 12, 2004 (Volume 69, Number 29)]
[Rules and Regulations]
[Page 6919-6920]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr12fe04-6]
=======================================================================
-----------------------------------------------------------------------
DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
RIN 0720-AA74
TRICARE; Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS); Appeals and Hearings Procedures, Formal Review
AGENCY: Office of the Secretary, DoD.
ACTION: Final rule.
-----------------------------------------------------------------------
SUMMARY: This final rule makes administrative corrections to the 32 CFR
part 199, section 199.10, ``Appeal and Hearing Procedures.'' These
corrections include revising Sec. 199.10, adding paragraphs (c)(1)
through (c)(5), and making other minor editorial changes.
EFFECTIVE DATE: May 1, 1983.
FOR FURTHER INFORMATION CONTACT: Gail L. Jones, Medical Benefits and
Reimbursement Systems, TRICARE Management Activity (TMA), telephone
(303) 676-3401.
SUPPLEMENTARY INFORMATION:
I. Background
Paragraphs (c)(1) through (c)(5) were inadvertently omitted when
the July 1, 1991, edition of the 32 CFR was published. The discovery
that the formal review process was missing from Sec. 199.10 occurred at
the time that TRICARE was tasked to promulgated an appeal process for
TRICARE Claimcheck denials.
The appeals procedures found in this final rule reflect the appeals
process as it has continuously existed and been administered by the
Department of Defense since its original effective date of May 1, 1983.
This final rule is being published solely to reflect the inadvertent
omission by the United States Government Printing Office of these
procedures in 32 CFR part 199. This correction to Sec. 199.10 is made
in an effort to ensure that any party to an initial determination or
reconsideration decision who may want to request a formal review is
aware of these procedures.
II. Public Comments
We published this rule on March 13, 2003, as an interim final rule,
with a 60-day comment period, and received no public comments.
III. Changes in the Final Rule
Additional administrative changes were made to correct designated
paragraphs in (a)(8)(ii)(A) through (B). We have redesignated these
paragraphs to (a)(8)(ii)(A) through (C).
IV. Rulemaking Procedures
Executive Order 12866 requires certain regulatory assessments for
any ``significant regulatory action'' defined as one, which would
result in an annual effect on the economy of $100 million or more, or
have other substantial impacts.
The Regulatory Flexibility Act (RFA) requires that each Federal
agency prepare, and make available for public comment, a regulatory
flexibility analysis when the agency issues a regulation which would
have a significant impact on a substantial number of small entities.
This rule has been designated as a significant rule and has been
reviewed by the Office of Management and Budget as required under the
provisions of Executive Order 12866. The Department of Defense
certifies that this final rule would not have a significant impact on
small business entities.
This rule will not impose additional information collection
requirements on the public under the Paperwork Reduction Act of 1980
(44 U.S.C. 3501-3511).
This rule is being issued as a final rule.
List of Subjects in 32 CFR Part 199
Claims, Health insurance, Individuals with disabilities, Dental
Health, Military personnel.
[[Page 6920]]
0
Accordingly, 32 CFR part 199 is amended as follows:
PART 1999--[AMENDED]
0
1. The authority citation for part 199 continues to read as follows:
Authority: 5 U.S.C. 301; 10 U.S.C. chapter 55.
0
2. Section 199.10 is amended by redesignating both paragraphs
(a)(8)(ii)(A) and paragraph (a)(8)(ii)(B) as paragraphs (a)(8)(ii)(A)
through (a)(8)(ii)(C), by revising paragraph (b) introductory text, and
by republishing paragraph (c) to read as follows:
Sec. 199.10 Appeals and hearing procedures.
* * * * *
(b) Reconsideration. Any party to the initial determination made by
the CHAMPUS contractor, or a CHAMPUS peer review organization may
request reconsideration.
* * * * *
(c) Formal review. Except as explained in this paragraph, any party
to an initial determination made by OCHAMPUS, or a reconsideration
determination made by the CHAMPUS contractor, may request a formal
review by OCHAMPUS if the party is dissatisfied with the initial or
reconsideration determination unless the initial or reconsideration
determination is final under paragraph (b)(5) of this section; involves
the sanctioning of a provider by the exclusion, suspension or
termination of authorized provider status; involves a written decision
issued pursuant to Sec. 199.9(h)(1)(iv)(A) regarding the temporary
suspension of claims processing; or involves a reconsideration
determination by a CHAMPUS peer review organization. A hearing, but not
a formal review level or appeal, may be available to a party to an
initial determination involving the sanctioning of a provider or to a
party to a written decision involving a temporary suspension of claims
processing. A beneficiary (or an authorized representative of a
beneficiary), but not a provider (except as provided in Sec. 199.15),
may request a hearing, but not a formal review, of a reconsideration
determination made by a CHAMPUS peer review organization.
(1) Requesting a formal review. (i) Written request required. The
request must be in writing, shall state the specific matter in dispute,
shall include copies of the written determination (notice of
reconsideration determination of OCHAMPUS initial determination) being
appealed, and shall include any additional information or documents not
submitted previously.
(ii) Where to file. The request shall be submitted to the Chief,
Office of Appeals and Hearings, TRICARE Management Activity, 16401 East
Centredtech Parkway, Aurora, Colorado 80011-9066.
(iii) Allowed time to file. The request shall be mailed within 60
days after the date of the notice of the reconsideration determination
or OCHAMPUS initial determination being appealed.
(iv) Official filing date. A request for a formal review shall be
deemed filed on the date it is mailed and postmarked. If the request
does not have a postmark, it shall be deemed filed on the date received
by OCHAMPUS.
(2) The formal review process. The purpose of the formal review is
to determine whether the initial determination or reconsideration
determination was made in accordance with law, regulation, policies,
and guidelines in effect at the time the care was provided or requested
or at the time of the initial determination, reconsideration, or formal
review decision involving a provider request for approval as an
authorized CHAMPUS provider. The formal review is performed by the
Chief, Office of Appeals and Hearings, OCHAMPUS, or a designee, and is
a thorough review of the case. The formal review determination shall be
based on the information, upon which the initial determination and/or
reconsideration determination was based, and any additional information
the appealing party may submit or OCHAMPUS may obtain.
(3) Timeliness of formal review determination. The Chief, Office of
Appeals and Hearings, OCHAMPUS, or a designee normally shall issue the
formal review determination no later than 90 days from the date of
receipt of the request for formal review by OCHAMPUS.
(4) Notice of formal review determination. The Chief, Office of
Appeals and Hearings, OCHAMPUS, or a designee shall issue a written
notice of the formal review determination to the appealing party at his
or her last known address. The notice of the formal review
determination must contain the following elements:
(i) A statement of the issue or issues under appeal.
(ii) The provisions of law, regulation, policies, and guidelines
that apply to the issue or issues under appeal.
(iii) A discussion of the original and additional information that
is relevant to the issue or issues under appeal.
(iv) Whether the formal review upholds the prior determination or
determinations or reverses the prior determination or determinations in
whole or in part and the rationale for the action.
(v) A statement of the right to request a hearing in any case when
the formal review determination is less than fully favorable, the issue
is appealable, and the amount in dispute is $300 or more.
(5) Effect of formal review determination. The formal review
determination is final if one or more of the following exist:
(i) The issue is not appealable. (See paragraph (a)(6) of this
section.)
(ii) The amount in dispute is less that $300. (See paragraph (a)(7)
of this section.)
(iii) Appeal rights have been offered but a request for hearing is
not received by OCHAMPUS within 60 days of the date of the notice of
the formal review determination.
* * * * *
Dated: February 5, 2004.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 04-3014 Filed 2-11-04; 8:45 am]
BILLING CODE 5001-06-M