[Code of Federal Regulations]
[Title 32, Volume 2]
[Revised as of July 1, 2008]
From the U.S. Government Printing Office via GPO Access
[CITE: 32CFR199.9]

[Page 215-231]
 
                       TITLE 32--NATIONAL DEFENSE
 
        CHAPTER I--OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED)
 
PART 199_CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED SERVICES 
 
Sec. 199.9  Administrative remedies for fraud, abuse, and conflict of 

interest.

    (a) General. (1) This section sets forth provisions for invoking 
administrative remedies under CHAMPUS in situations involving fraud, 
abuse, or conflict of interest. The remedies impact institutional 
providers, professional providers, and beneficiaries (including parents, 
guardians, or other representatives of beneficiaries), and cover 
situations involving criminal fraud, civil fraud, administrative 
determinations of conflicts of interest or dual compensation, and 
administrative determinations of fraud or abuse. The administrative 
actions, remedies, and procedures may differ based upon whether the 
initial findings were made by a court of law, another agency, or the 
Director, OCHAMPUS (or designee).
    (2) This section also sets forth provisions for invoking 
administrative remedies in situations requiring administrative action to 
enforce provisions of law, regulation, and policy in the administration 
of CHAMPUS and to ensure quality of care for CHAMPUS beneficiaries. 
Examples of such situations may include a case in which it is discovered 
that a provider fails to meet requirements under this part to be an 
authorized CHAMPUS provider; a case in which the provider ceases to be 
qualified as a CHAMPUS provider because of suspension or revocation of 
the provider's license by a local licensing authority; or a case in 
which a provider meets the minimum requirements under this part but, 
nonetheless, it is determined that it is in the best interest of the 
CHAMPUS or CHAMPUS beneficiaries that the provider should not be an 
authorized CHAMPUS provider.
    (3) The administrative remedies set forth in this section are in 
addition to, and not in lieu of, any other remedies

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or sanctions authorized by law or regulation. For example, 
administrative action under this section may be taken in a particular 
case even if the same case will be or has been processed under the 
administrative procedures established by the Department of Defense to 
implement the Program Fraud Civil Remedies Act.
    (4) Providers seeking payment from the Federal Government through 
programs such as CHAMPUS have a duty to familiarize themselves with, and 
comply with, the program requirements.
    (5) CHAMPUS contractors and peer review organizations have a 
responsibility to apply provisions of this regulation in the discharge 
of their duties, and to report all known situations involving fraud, 
abuse, or conflict of interest. Failure to report known situations 
involving fraud, abuse, or conflict of interest will result in the 
withholding of administrative payments or other contractual remedies as 
determined by the Director, OCHAMPUS, or a designee.
    (b) Abuse. The term ``abuse'' generally describes incidents and 
practices which may directly or indirectly cause financial loss to the 
Government under CHAMPUS or to CHAMPUS beneficiaries. For the definition 
of abuse, see Sec. 199.2 of this part. The type of abuse to which 
CHAMPUS is most vulnerable is the CHAMPUS claim involving the 
overutilization of medical and health care services. To avoid abuse 
situations, providers have certain obligations to provide services and 
supplies under CHAMPUS which are: Furnished at the appropriate level and 
only when and to the extent medically necessary as determined under the 
provisions of this part; of a quality that meets professionally 
recognized standards of health care; and, supported by adequate medical 
documentation as may reasonably be required under this part by the 
Director, OCHAMPUS, or a designee, to evidence the medical necessity and 
quality of services furnished, as well as the appropriateness of the 
level of care. A provider's failure to comply with these obligations can 
result in sanctions being imposed by the Director, OCHAMPUS, or a 
designee, under this section. Even when administrative remedies are not 
initiated under this section, abuse situations under CHAMPUS are a 
sufficient basis for denying all or any part of CHAMPUS cost-sharing of 
individual claims. The types of abuse or possible abuse situations under 
CHAMPUS include, but are not limited, to the following:
    (1) A pattern of waiver of beneficiary (patient) cost-share or 
deductible.
    Note: In a case of a legitimate bad debt write-off of patient cost-
share or deductible, the provider's record should include documentation 
as to what efforts were made to collect the debt, when the debt was 
written off, why the debt was written off, and the amount of the debt 
written off.
    (2) Improper billing practices. Examples include, charging CHAMPUS 
beneficiaries rates for services and supplies that are in excess of 
those charges routinely charged by the provider to the general public, 
commercial health insurance carriers, or other federal health benefit 
entitlement programs for the same or similar services. (This includes 
dual fee schedules--one for CHAMPUS beneficiaries and one for other 
patients or third-party payers. This also includes billing other third-
party payers the same as CHAMPUS is billed but accepting less than the 
billed amount as reimbursement. However, a formal discount arrangement 
such as through a preferred provider organization, may not necessarily 
constitute an improper billing practice.)
    (3) A pattern of claims for services which are not medically 
necessary or, if medically necessary, not to the extent rendered. For 
example, a battery of diagnostic tests are given when, based on the 
diagnosis, fewer tests were needed.
    (4) Care of inferior quality. For example, consistently furnishing 
medical or mental health services that do not meet accepted standards of 
care.
    (5) Failure to maintain adequate medical or financial records.
    (6) Refusal to furnish or allow the Government (for example, 
OCHAMPUS) or Government contractors access to records related to CHAMPUS 
claims.
    (7) Billing substantially in excess of customary or reasonable 
charges unless it is determined by OCHAMPUS that the excess charges are 
justified by

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unusual circumstances or medical complications requiring additional 
time, effort, or expense in localities when it is accepted medical 
practice to make an extra charge in such cases.
    (8) Unauthorized use of the term ``Civilian Health and Medical 
Program of the Uniformed Services (CHAMPUS)'' in private business. While 
the use of the term ``CHAMPUS'' is not prohibited by federal statute, 
misrepresentation or deception by use of the term ``CHAMPUS'' to imply 
an official connection with the Government or to defraud CHAMPUS 
beneficiaries may be a violation of federal statute. Regardless of 
whether the actual use of the term ``CHAMPUS'' may be actionable under 
federal statute, the unauthorized or deceptive use of the term 
``CHAMPUS'' in private business will be considered abuse for purposes of 
this Section.
    (c) Fraud. For the definition of fraud, see Sec. 199.2 of this 
part. Examples of situations which, for the purpose of this part, are 
presumed to be fraud include, but are not limited to:
    (1) Submitting CHAMPUS claims (including billings by providers when 
the claim is submitted by the beneficiary) for services, supplies, or 
equipment not furnished to, or used by, CHAMPUS beneficiaries. For 
example, billing or claiming services when the provider was on call 
(other than an authorized standby charge) and did not provide any 
specific medical care to the beneficiary; providing services to an 
ineligible person and billing or submitting a claim for the services in 
the name of an eligible CHAMPUS beneficiary; billing or submitting a 
CHAMPUS claim for an office visit for a missed appointment; or billing 
or submitting a CHAMPUS claim for individual psychotherapy when a 
medical visit was the only service provided.
    (2) Billing or submitting a CHAMPUS claim for costs for noncovered 
or nonchargeable services, supplies, or equipment disguised as covered 
items. Some examples are: (i) Billings or CHAMPUS claims for services 
which would be covered except for the frequency or duration of the 
services, such as billing or submitting a claim for two one-hour 
psychotherapy sessions furnished on separate days when the actual 
service furnished was a two-hour therapy session on a single day, (ii) 
spreading the billing or claims for services over a time period that 
reduces the apparent frequency to a level that may be cost-shared by 
CHAMPUS, (iii) charging to CHAMPUS, directly or indirectly, costs not 
incurred or not reasonably allowable to the services billed or claimed 
under CHAMPUS, for example, costs attributable to nonprogram activities, 
other enterprises, or the personal expenses of principals, or (iv) 
billing or submitting claim on a fee-for-service basis when in fact a 
personal service to a specific patient was not performed and the service 
rendered is part of the overall management of, for example, the 
laboratory or x-ray department.
    (3) Breach of a provider participation agreement which results in 
the beneficiary (including parent, guardian, or other representative) 
being billed for amounts which exceed the CHAMPUS-determined allowable 
charge or cost.
    (4) Billings or CHAMPUS claims for supplies or equipment which are 
clearly unsuitable for the patient's needs or are so lacking in quality 
or sufficiency for the purpose as to be virtually worthless.
    (5) Billings or CHAMPUS claims which involve flagrant and persistent 
overutilization of services without proper regard for results, the 
patient's ailments, condition, medical needs, or the physician's orders.
    (6) Misrepresentations of dates, frequency, duration, or description 
of services rendered, or of the identity of the recipient of the 
services or the individual who rendered the services.
    (7) Submitting falsified or altered CHAMPUS claims or medical or 
mental health patient records which misrepresent the type, frequency, or 
duration of services or supplies or misrepresent the name(s) of the 
individual(s) who provided the services or supplies.
    (8) Duplicate billings or CHAMPUS claims. This includes billing or 
submitting CHAMPUS claims more than once for the same services, billing 
or submitting claims both to CHAMPUS and the beneficiary for the same 
services, or billing or submitting claims both to CHAMPUS and other 
third-parties

[[Page 218]]

(such as other health insurance or government agencies) for the same 
services, without making full disclosure of material facts or immediate, 
voluntary repayment or notification to CHAMPUS upon receipt of payments 
which combined exceed the CHAMPUS-determined allowable charge of the 
services involved.
    (9) Misrepresentation by a provider of his or her credentials or 
concealing information or business practices which bear on the 
provider's qualifications for authorized CHAMPUS provider status. For 
example, a provider representing that he or she has a qualifying 
doctorate in clinical psychology when the degree is not from a 
regionally accredited university.
    (10) Reciprocal billing. Billing or claiming services which were 
furnished by another provider or furnished by the billing provider in a 
capacity other than as billed or claimed. For example, practices such as 
the following: (i) One provider performing services for another provider 
and the latter bills as though he had actually performed the services 
(e.g., a weekend fill-in); (ii) providing service as an institutional 
employee and billing as a professional provider for the services; (iii) 
billing for professional services when the services were provided by 
another individual who was an institutional employee; (iv) billing for 
professional services at a higher provider profile than would be paid 
for the person actually furnishing the services, (for example, bills 
reflecting that an M.D. or Ph.D. performed the services when services 
were actually furnished by a licensed social worker, psychiatric nurse, 
or marriage and family counselor); or (v) an authorized provider billing 
for services which were actually furnished by an unauthorized or 
sanctioned provider.
    (11) Submitting CHAMPUS claims at a rate higher than a rate 
established between CHAMPUS and the provider, if such a rate has been 
established. For example, billing or claiming a rate in excess of the 
provider's most favored rate limitation specified in a residential 
treatment center agreement.
    (12) Arrangements by providers with employees, independent 
contractors, suppliers, or others which appear to be designed primarily 
to overcharge the CHAMPUS through various means (such as commissions, 
fee-splitting, and kickbacks) used to divert or conceal improper or 
unnecessary costs or profits.
    (13) Agreements or arrangements between the supplier and recipient 
(recipient could be either a provider or beneficiary, including the 
parent, guardian, or other representative of the beneficiary) that 
result in billings or claims which include unnecessary costs or charges 
to CHAMPUS.
    (d) Conflict of Interest. (1) Conflict of interest includes any 
situation where an active duty member of the Uniformed Services 
(including a reserve member while on active duty, active duty for 
training, or inactive duty training) or civilian employee of the United 
States Government, through an official federal position has the apparent 
or actual opportunity to exert, directly or indirectly, any influence on 
the referral of CHAMPUS beneficiaries to himself/herself or others with 
some potential for personal gain or the appearance of impropriety. 
Although individuals under contract to the Uniformed Services are not 
considered ``employees,'' such individuals are subject to conflict of 
interest provisions by express terms of their contracts and, for 
purposes of this part, may be considered to be involved in conflict of 
interest situations as a result of their contract positions. In any 
situation involving potential conflict of interest of a Uniformed 
Service employee, the Director, OCHAMPUS, or a designee, may refer the 
case to the Uniformed Service concerned for appropriate review and 
action. If such a referral is made, a report of the results of findings 
and action taken shall be made to the Director, OCHAMPUS, by the 
Uniformed Service having jurisdiction within 90 days of receiving the 
referral.
    (2) CHAMPUS cost-sharing shall be denied on any claim where a 
conflict of interest situation is found to exist. This denial of cost-
sharing applies whether the claim is submitted by the individual who 
provided the care, the institutional provider in which the care was 
furnished, or the beneficiary.
    (e) Dual Compensation. (1) Federal law (5 U.S.C. 5536) prohibits 
active duty

[[Page 219]]

members of the Uniformed Services or employees (including part-time or 
intermittent) appointed in the civil service of the United States 
Government from receiving additional compensation from the Government 
above their normal pay and allowances. This prohibition applies to 
CHAMPUS payments for care furnished to CHAMPUS beneficiaries by active 
duty members of the Uniformed Services or civilian employees of the 
Government.
    (2) CHAMPUS cost-sharing of a claim shall be denied where the 
services or supplies were provided by an active duty member of the 
Uniformed Services or a civilian employee of the Government. This denial 
of CHAMPUS payment applies whether the claim for reimbursement is filed 
by the individual who provided the care, the institutional provider in 
which the care was furnished, or by the beneficiary.
    Note: Physicians of the National Health Service Corps (NHSC) may be 
assigned to areas where there is a shortage of medical providers. 
Although these physicians would be prohibited from accepting CHAMPUS 
payments as individuals if they are employees of the United States 
Government, the private organizations to which they may be assigned may 
be eligible for payment, as determined by the Director, OCHAMPUS, or a 
designee.
    (3) The prohibition against dual compensation does not apply to 
individuals under contract to the Uniformed Services or the Government.
    (f) Administrative Remedies. Administrative remedies available under 
CHAMPUS in this section are set forth below.
    (1) Provider exclusion or suspension. The Director, OCHAMPUS, or a 
designee, shall have the authority to exclude or suspend an otherwise 
authorized CHAMPUS provider from the program based on any criminal 
conviction or civil judgment involving fraud by the provider; fraud or 
abuse under CHAMPUS by the provider; exclusion or suspension of the 
provider by another agency of the Federal Government, a state, or local 
licensing authority; participation in a conflict of interest situation 
by the provider; or, when it is in the best interests of the program or 
CHAMPUS beneficiaries to exclude or suspend a provider under CHAMPUS. In 
all cases, the exclusion or suspension of a provider shall be effective 
15 calendar days from the date on the written initial determination 
issued under paragraph (h)(2) of this section.
    (i) Criminal conviction or civil judgment involving fraud by a 
provider--(A) Criminal conviction involving CHAMPUS fraud. A provider 
convicted by a Federal, state, foreign, or other court of competent 
jurisdiction of a crime involving CHAMPUS fraud, whether the crime is a 
felony or misdemeanor, shall be excluded or suspended from CHAMPUS for a 
period of time as determined by the Director, OCHAMPUS, or a designee. 
The CHAMPUS exclusion or suspension applies whether or not the provider, 
as a result of the conviction, receives probation or the sentence is 
suspended or deferred, and whether or not the conviction or sentence is 
under appeal.
    Note: Under the above paragraph (f)(1)(i)(A) of this section, an 
entity may be excluded or suspended from CHAMPUS whenever the entity is 
found to have a person, convicted of a crime involving CHAMPUS fraud, 
who has a direct or indirect ownership or control interest (see Sec. 
199.2) of 5 percent or more in the entity, or is an officer, director, 
agent or managing employee of the entity. The entity will have an 
opportunity to provide evidence to show that the ownership or control 
relationship has ceased. While an entity will not be excluded or 
suspended from CHAMPUS for employing a provider who has been sanctioned 
under this Section, the entity will be denied CHAMPUS payment for any 
services furnished by the sanctioned employee. As an authorized CHAMPUS 
provider, the entity is responsible for ensuring that all CHAMPUS claims 
involve services furnished to CHAMPUS beneficiaries by employees who 
meet all requirements under CHAMPUS for provider status.
    (B) Criminal conviction involving fraud of other Federal programs. 
Any provider convicted by a Federal, state, or other court of competent 
jurisdiction of a crime involving another Federal health care or benefit 
program (such as plans administered under titles XVIII and XIX of the 
Social Security Act, Federal Workmen's Compensation, and the Federal 
Employees Program (FEP) for employee health insurance), whether the 
crime is a felony or misdemeanor, shall be excluded from CHAMPUS for a 
period of time as determined by the Director, OCHAMPUS, or a designee. 
The

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CHAMPUS exclusion or suspension applies whether or not the provider, as 
a result of the conviction, receives probation or the sentence is 
suspended or deferred, and whether or not the conviction or sentence is 
under appeal.
    (C) Criminal conviction involving fraud of non-Federal programs. Any 
provider convicted by a Federal, state, foreign, or other court of 
competent jurisdiction of a crime involving any non-Federal health 
benefit program or private insurance involving health benefits may be 
excluded or suspended from CHAMPUS for a period of time as determined by 
the Director, OCHAMPUS, or a designee.
    (D) Civil fraud involving CHAMPUS. If a judgment involving civil 
fraud has been entered (whether or not it is appealed) against a 
provider in a civil action involving CHAMPUS benefits (whether or not 
other Federal programs are involved), the provider shall be excluded or 
suspended from CHAMPUS for a period determined by the Director, 
OCHAMPUS, or a designee.
    (E) Civil fraud involving other programs. If a judgment involving 
civil fraud has been entered against a provider (whether or not it has 
been appealed) in a civil action involving other public or private 
health care programs or health insurance, the provider may be excluded 
or suspended for a period of time determined by the Director, OCHAMPUS, 
or a designee.
    (ii) Administrative determination of fraud or abuse under CHAMPUS. 
If the Director, OCHAMPUS, or a designee, determines that a provider has 
committed fraud or abuse as defined in this part, the provider shall be 
excluded or suspended from CHAMPUS for a period of time determined by 
the Director, OCHAMPUS, or designee.
    (iii) Administrative determination that the provider has been 
excluded or suspended by another agency of the Federal Government, a 
state, or local licensing authority. Any provider who is excluded or 
suspended by any other Federal health care program (for example, 
Medicare), shall be excluded or suspended under CHAMPUS. A provider who 
has his/her credentials revoked through a Veterans Administration or 
Military Department credentials review process and who is excluded, 
suspended, terminated, retired, or separated, shall also be excluded or 
suspended under CHAMPUS. The period of time of exclusion or suspension 
shall be determined by the Director, OCHAMPUS, or a designee, pursuant 
to paragraph (g) of this section.
    (iv) Administrative determination that the provider has participated 
in a conflict of interest situation. The Director, OCHAMPUS, or a 
designee, may exclude or suspend any provider who has knowingly been 
involved in a conflict of interest situation under CHAMPUS. The period 
of time of exclusion or suspension shall be determined by the Director, 
OCHAMPUS, or a designee, pursuant to paragraph (g) of this section. For 
purposes of this administrative determination, it will be presumed that 
a CHAMPUS provider knowingly participated in a conflict of interest 
situation if the provider employs, in the treatment of a CHAMPUS 
beneficiary (resulting in a CHAMPUS claim), any medical personnel who 
are active duty members of the Uniformed Services or civilian employees 
of the Government. The burden of proof to rebut this presumption rests 
with the CHAMPUS provider. Two exceptions will be recognized to the 
presumption that a conflict of interest exists. First, indirect CHAMPUS 
payments may be made to private organizations to which physicians of the 
National Health Service Corps (NHSC) are assigned. Second, any off-duty 
Government medical personnel employed in an emergency room of an acute 
care hospital will be presumed not to have had the opportunity to exert, 
directly or indirectly, any influence on the referral of CHAMPUS 
beneficiaries; therefore, CHAMPUS payments may be made to the employing 
hospital provided the medical care was not furnished directly by the 
off-duty Government medical personnel in violation of dual compensation 
provisions.
    (v) Administrative determination that it is in the best interests of 
the CHAMPUS or CHAMPUS beneficiaries to exclude or suspend a provider--
(A) Unethical or improper practices or unprofessional conduct. (1) In 
most instances, unethical or improper practices or unprofessional 
conduct by a provider will be program

[[Page 221]]

abuse and subject the provider to exclusion or suspension for abuse. 
However, in some cases such practices and conduct may provide an 
independent basis for exclusion or suspension of the provider by the 
Director, OCHAMPUS, or a designee.
    (2) Such exclusions or suspensions may be based on findings or 
recommendations of state licensure boards, boards of quality assurance, 
other regulatory agencies, state medical societies, peer review 
organizations, or other professional associations.
    (B) In any other case in which the Director, OCHAMPUS (or designee), 
determines that exclusion or suspension of a provider is in the best 
interests of CHAMPUS or CHAMPUS beneficiaries. The Director, OCHAMPUS, 
or a designee, may exclude or suspend any provider if it is determined 
that the authorization of that particular provider under CHAMPUS poses 
an unreasonable potential for fraud, abuse, or professional misconduct. 
Any documented misconduct by the provider reflecting on the business or 
professional competence or integrity of the provider may be considered. 
Situations in which the Director, OCHAMPUS, or a designee, may take 
administrative action under this Section to protect CHAMPUS or CHAMPUS 
beneficiaries include, but are not limited to, a case in which it is 
determined that a provider poses an unreasonable potential cost to the 
Government to monitor the provider for fraud or abuse and to avoid the 
issuance of erroneous payments; or that the provider poses an 
unreasonable potential harm to the financial or health status of CHAMPUS 
beneficiaries; or that the provider poses any other unreasonable threat 
to the interests of CHAMPUS or CHAMPUS beneficiaries. One example of 
such circumstances involves a provider who, for his/her entire practice 
or for most of his/her practice, provides or bills for treatment that is 
not a CHAMPUS benefit, resulting in CHAMPUS frequently and repeatedly 
denying claims as non-covered services. This may occur when a 
professional provider furnishes sex therapy (a therapy which may be 
recognized by the provider's licensing authority but which is excluded 
from CHAMPUS coverage) and repeatedly submits CHAMPUS claims for the 
services.
    (2) Provider termination. The Director, OCHAMPUS, or a designee, 
shall terminate the provider status of any provider determined not to 
meet the qualifications established by this part to be an authorized 
CHAMPUS provider.
    (i) Effective date of termination. Except as provided in paragraph 
(g)(2)(ii) of this section, the termination shall be retroactive to the 
date on which the provider did not meet the requirements of this part.
    (A) The retroactive effective date of termination shall not be 
limited due to the passage of time, erroneous payment of claims, or any 
other events which may be cited as a basis for CHAMPUS recognition of 
the provider notwithstanding the fact that the provider does not meet 
program qualifications. Unless specific provision is made in this part 
to ``grandfather'' or authorize a provider who does not otherwise meet 
the qualifications established by this part, all unqualified providers 
shall be terminated.
    (B) Any claims cost-shared or paid under CHAMPUS for services or 
supplies furnished by the provider on or after the effective date of 
termination, even when the effective date is retroactive, shall be 
deemed an erroneous payment unless specific exception is provided in 
this part. All erroneous payments are subject to collection under Sec. 
199.11 of this part.
    (C) If an institution is terminated as an authorized CHAMPUS 
provider, the institution shall immediately give written notice of the 
termination to any CHAMPUS beneficiary (or their parent, guardian, or 
other representative) admitted to, or receiving care at, the institution 
on or after the effective date of the termination. In addition, when an 
institution is terminated with an effective date of termination after 
the date of the initial determination terminating the provider, any 
beneficiary admitted to the institution prior to the effective date of 
termination (or their parent, guardian, or other representative) shall 
be notified

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by the Director, OCHAMPUS, or a designee, by certified mail of the 
termination, and that CHAMPUS cost-sharing of the beneficiary's care in 
the institution will cease as of the effective date of the termination. 
However, any beneficiary admitted to the institution prior to any grace 
period extended to the institution under paragraph (f)(2)(ii)(A) of this 
section shall be advised that, if the beneficiary's care otherwise 
qualifies for CHAMPUS coverage, CHAMPUS cost-sharing of the care in the 
institution will continue in order to provide a reasonable period of 
transition of care; however the transitional period of CHAMPUS cost-
sharing shall not exceed the last day of the month following the month 
in which the institution's status as a CHAMPUS provider is terminated. 
(This authorized CHAMPUS cost-sharing of the inpatient care received 
during the transition period is an exception to the general rule that 
CHAMPUS payment for care furnished after the effective date of 
termination of the provider's status shall be deemed to be an erroneous 
payment.) If a major violation under paragraph (f)(2)(ii)(B) of this 
section is involved, in order to ensure immediate action is taken to 
transfer beneficiaries to an approved provider, CHAMPUS cost-sharing 
shall not be authorized after the effective date of termination of the 
provider's status.
    (ii) Institutions not in compliance with CHAMPUS standards. If it is 
determined that an institution is not in compliance with one or more of 
the standards applicable to its specific category of institution under 
this part, the Director, OCHAMPUS, or a designee, shall take immediate 
steps to bring about compliance or terminate the status of the provider 
as an authorized CHAMPUS provider.
    (A) Minor violations. An institution determined to be in violation 
of one or more of the standards shall be advised by certified mail of 
the nature of the discrepancy or discrepancies and will be given a grace 
period of 30 days to effect appropriate corrections. The grace period 
may be extended at the discretion of the Director, OCHAMPUS, or a 
designee, but in no event shall the extension exceed 90 days.
    (1) CHAMPUS will not cost-share a claim for any beneficiary admitted 
during the grace period.
    (2) Any beneficiary admitted to the institution prior to the grace 
period (or the beneficiary's parent, guardian, or other representative) 
will be notified by the Director, OCHAMPUS, or a designee, in writing, 
of the minor violations and the grace period granted the institution to 
correct the violations. The beneficiary will also be advised that, if 
the beneficiary's care otherwise meets all requirements for CHAMPUS 
coverage, CHAMPUS cost-sharing will continue during the grace period.
    (3) If the institution submits written notice before the end of the 
grace period that corrective action has been taken and if the Director, 
OCHAMPUS, or a designee, determines that the corrective action has 
eliminated the minor violations, the provider will be advised that the 
institution is restored to full status as an authorized CHAMPUS provider 
as of 12:01 a.m. on the day written notice of correction was received by 
the Director, OCHAMPUS, or a designee, or the day on which acceptable 
corrective action was completed in the judgment of the Director, 
OCHAMPUS, or a designee. Any beneficiary admitted to the institution 
prior to the grace period will be notified by the Director, OCHAMPUS, or 
a designee, of the corrective action and that the provider continues to 
be an authorized CHAMPUS provider. CHAMPUS cost-sharing for any 
beneficiary admitted to the institution during the grace period shall be 
allowed only for care received after 12:01 a.m. on the day written 
notice of correction was received by the Director, OCHAMPUS, or a 
designee, or the day on which acceptable corrective action was completed 
in the judgment of the Director, OCHAMPUS, or a designee.
    (4) If the institution has failed to give notification in writing 
before the end of the grace period that corrective action has been 
completed or, in the judgment of the Director, OCHAMPUS, or a designee, 
the institution has not completed acceptable corrective action during 
the grace period, the Director, OCHAMPUS, or a designee, may initiate 
action to terminate the provider as an authorized CHAMPUS provider.

[[Page 223]]

    (B) Major violations. If the Director, OCHAMPUS, or a designee, 
determines that an institution is in violation of standards detrimental 
to life, safety, or health, or substantially in violation of approved 
treatment programs, immediate action shall be taken to terminate the 
institution as an authorized CHAMPUS provider. The institution shall be 
notified by telegram, certified mail, or express mail of the termination 
under this subparagraph, effective on receipt of the notice. The notice 
shall include a brief statement of the nature of violations resulting in 
the termination and advise the institution that an initial determination 
formalizing the administrative action of termination will be issued 
pursuant to paragraph (h)(3)(ii) of this section within 15 days.
    (3) Beneficiary sanctions. (i) With entitlement to CHAMPUS benefits 
based on public law, an eligible beneficiary will not be suspended or 
excluded from CHAMPUS. However, the Director, OCHAMPUS, or a designee, 
may take action deemed appropriate and reasonable to protect the 
Government from those beneficiaries (including sponsors, parents, 
guardians, or representatives of beneficiaries) who have submitted false 
claims.
    (ii) Pursuant to Sec. 199.11 of this part, the Director, OCHAMPUS, 
or a designee, may recover erroneous payments on claims involving fraud 
or false or misleading statements. Remedies for recovery of the 
erroneous payments include the use of offset against future CHAMPUS 
payments.
    (iii) Under policies adopted by the Director, OCHAMPUS, or a 
designee, individuals who, based on reliable information, have 
previously submitted fraudulent or false CHAMPUS claims, may be required 
to comply with any procedures (e.g., partial or total pre-payment audit 
or review, restriction to a designated primary care provider, etc.) 
which the Director, OCHAMPUS, or a designee, deems appropriate to ensure 
that their future medical care and CHAMPUS claims (including the medical 
care and CHAMPUS claims submitted by or for members of their family) are 
valid.
    (g) Period of exclusion, suspension, or termination--(1) Exclusions 
or suspensions. Except as otherwise required by paragraph (g)(1)(i) of 
this section, the Director, OCHAMPUS, or a designee, shall determine the 
period of exclusion or suspension for a provider using the factors set 
forth in paragraph (g)(1)(ii) of this section.
    (i) Exclusion or suspension of a provider based on the provider's 
exclusion or suspension by another agency of the Federal Government, a 
state, or a local licensing authority. If the administrative action 
under CHAMPUS is based solely on the provider's exclusion or suspension 
by another agency, state, or local licensing authority, the period of 
exclusion or suspension under CHAMPUS shall be for the same length of 
time of exclusion or suspension imposed by the other agency, state, or 
local licensing authority. The provider may request reinstatement as an 
authorized CHAMPUS provider if reinstatement is achieved under the other 
program prior to the end of the period of exclusion or suspension. If 
the administrative action under CHAMPUS is not based solely on the 
provider's exclusion or suspension by another agency, state, or local 
licensing authority, the minimum period of exclusion or suspension shall 
be for the same period of exclusion or suspension imposed by the other 
agency, state, or local licensing authority.
    (ii) Factors to be considered in determining the period of exclusion 
or suspension of providers under CHAMPUS. In determining the period of 
exclusion or suspension of a provider, the Director, OCHAMPUS, or a 
designee, may consider any or all of the following:
    (A) When the case concerns all or any part of the same issues which 
have been the subject of criminal conviction or civil judgment involving 
fraud by a provider:
    (1) The period(s) of sentence, probation, and other sanction imposed 
by court order against the provider may be presumed reasonable and 
adopted as the administrative period of exclusion or suspension under 
CHAMPUS, unless aggravating or mitigating factors exist.
    (2) If any aggravating factors exist, then cause exists for the 
Director, OCHAMPUS, or a designee, to consider the factors set forth in 
paragraph

[[Page 224]]

(g)(1)(ii)(B) of this section, in imposing a period of administrative 
exclusion or suspension in excess of the period(s) of sentence, 
probation, and/or other sanctions imposed by court order. Examples of 
aggravating factors include, but are not limited to:
    (i) An administrative determination by the Director, OCHAMPUS, or a 
designee, that the basis for administrative exclusion or suspension 
includes an act(s) of fraud or abuse under CHAMPUS in addition to, or 
unrelated to, an act(s) of fraud included in the court conviction or 
civil judgment.
    (ii) The fraudulent act(s) involved in the criminal conviction or 
civil judgment, or similar acts, were committed over a significant 
period of time; that is, one year or more.
    (iii) The act(s) of fraud or abuse had an adverse physical, mental, 
or financial impact on one or more CHAMPUS beneficiaries.
    (iv) The loss or potential loss to CHAMPUS is over $5,000. The 
entire amount of loss or potential loss to CHAMPUS due to acts of fraud 
and abuse will be considered, in addition to the amount of loss involved 
in the court conviction or civil judgment, regardless of whether full or 
partial restitution has been made to CHAMPUS.
    (v) The provider has a prior court record, criminal or civil, or 
administrative record or finding of fraud or abuse.
    (3) If any mitigating factors exist, then cause may exist for the 
Director, OCHAMPUS, or a designee, to reduce a period of administrative 
exclusion or suspension from any period(s) imposed by court conviction 
or civil judgment. Only the existence of either of the following two 
factors may be considered in mitigation:
    (i) The criminal conviction or civil judgment only involved three or 
fewer misdemeanor offenses, and the total of the estimated losses 
incurred (including any loss from act(s) not involved in the conviction 
or judgment) is less than $1,000, regardless of whether full or partial 
restitution has been made.
    (ii) The criminal or civil court proceedings establish that the 
provider had a mental, emotional or physical condition, prior to or 
contemporaneous with the commission of the act(s), that reduced the 
provider's criminal or civil culpability.
    (B) The Director, OCHAMPUS, or a designee, may consider the 
following factors in determining a reasonable period of exclusion or 
suspension of a provider under CHAMPUS:
    (1) The nature of the claims and the circumstances under which they 
were presented;
    (2) The degree of culpability;
    (3) History of prior offenses (including whether claims were 
submitted while the provider was either excluded or suspended pursuant 
to prior administrative action);
    (4) Number of claims involved;
    (5) Dollar amount of claims involved;
    (6) Whether, if a crime was involved, it was a felony or 
misdemeanor;
    (7) If patients were injured financially, mentally, or physically; 
the number of patients; and the seriousness of the injury(ies);
    (8) The previous record of the provider under CHAMPUS;
    (9) Whether restitution has been made or arrangements for repayment 
accepted by the Government;
    (10) Whether the provider has resolved the conflict of interest 
situations or implemented procedures acceptable to the Director, 
OCHAMPUS, or a designee, which will prevent conflict of interest in the 
future; and,
    (11) Such other factors as may be deemed appropriate.
    (2) Terminations. When a provider's status as an authorized CHAMPUS 
provider is ended, other than through exclusion or suspension, the 
termination is based on a finding that the provider does not meet the 
qualifications to be an authorized provider, as set forth in this part. 
Therefore, the period of termination in all cases will be indefinite and 
will end only after the provider has successfully met the established 
qualifications for authorized provider status under CHAMPUS and has been 
reinstated under CHAMPUS. Except as otherwise provided in this 
subparagraph, the following guidelines control the termination of 
authorized CHAMPUS provider status for a provider whose license to 
practice (or, in the case of an institutional provider, to operate) has

[[Page 225]]

been temporarily or permanently suspended or revoked by the jurisdiction 
issuing the license.
    (i) Termination of the provider under CHAMPUS shall continue even if 
the provider obtains a license to practice in a second jurisdiction 
during the period of suspension or revocation of the provider's license 
by the original licensing jurisdiction. A provider who has licenses to 
practice in two or more jurisdictions and has one or more license(s) 
suspended or revoked will also be terminated as a CHAMPUS provider.
    (A) Professional providers shall remain terminated from the CHAMPUS 
until the jurisdiction(s) suspending or revoking the provider's 
license(s) to practice restores it or removes the impediment to 
restoration.
    (B) Institutional providers shall remain terminated under CHAMPUS 
until their license is restored. In the event the facility is sold, 
transferred, or reorganized as a new legal entity, and a license issued 
under a new name or to a different legal entity, the new entity must 
submit an application to be an authorized CHAMPUS provider.
    (ii) If the CHAMPUS provider status is terminated due to the loss of 
the provider's license, the effective date shall be retroactive to the 
date the provider lost the license; however, in the case of a 
professional provider who has licenses in two or more jurisdictions and 
submitted claims from a jurisdiction from which he/she had a valid 
license, the effective date of the termination will be 15 calendar days 
from the date of the written initial determination of termination for 
purposes of claims from the jurisdiction in which the provider still has 
a valid license.
    (h) Procedures for initiating and implementing the administrative 
remedies--(1) Temporary suspension of claims processing. (i) In general, 
temporary suspension of claims processing may be invoked to protect the 
interests of the Government for a period reasonably necessary to 
complete investigation or appropriate criminal, civil, and 
administrative proceedings. The temporary suspension only delays the 
ultimate payment of otherwise appropriate claims. When claims processing 
involving a participating provider is temporarily suspended, the 
participation agreement remains in full force and the provider cannot 
repudiate the agreement because of the delay in the final disposition of 
the claim(s). Once it has been determined appropriate to end the 
temporary suspension of claims processing, CHAMPUS claims which were the 
subject of the suspension and which are otherwise determined to be in 
compliance with the requirements of law and regulation, will be 
processed to completion and payment unless such action is deemed 
inappropriate as a result of criminal, civil, or administrative remedies 
ultimately invoked in the case.
    (ii) When adequate evidence exists to determine that a provider or 
beneficiary is submitting fraudulent or false claims or claims involving 
practices that may be fraud or abuse as defined by this part, the 
Director, OCHAMPUS, or a designee, may suspend CHAMPUS claims processing 
(in whole or in part) for claims submitted by the beneficiary or any 
CHAMPUS claims involving care furnished by the provider. The temporary 
suspension of claims processing for care furnished by a provider may be 
invoked against all such claims, whether or not the claims are submitted 
by the beneficiary or by the provider as a participating CHAMPUS 
provider. In cases involving a provider, notice of the suspension of 
claims processing may also be given to the beneficiary community either 
directly or indirectly through notice to appropriate military 
facilities, health benefit advisors, and the information or news media.
    (A) Adequate evidence is any information sufficient to support the 
reasonable belief that a particular act or omission has occurred.
    (B) Indictment or any other initiation of criminal charges, filing 
of a complaint for civil fraud, issuance of an administrative complaint 
under the Program Fraud Civil Remedies Act, or issuance of an initial 
determination under this part for submitting fraudulent or false claims 
or claims involving practices that may be fraud or abuse as defined by 
this part, shall constitute adequate evidence for invoking temporary 
suspension of claims processing.

[[Page 226]]

    (iii) The Director, OCHAMPUS, or a designee, may suspend CHAMPUS 
claims processing without first notifying the provider or beneficiary of 
the intent to suspend payments. Following a decision to invoke a 
temporary suspension, however, the Director, OCHAMPUS, or a designee, 
shall issue written notice advising the provider or beneficiary that:
    (A) A temporary suspension of claims processing has been ordered and 
a statement of the basis of the decision to suspend payment. Unless the 
suspension is based on any of the actions set forth in paragraph 
(h)(1)(ii)(B) of this section, the notice shall describe the suspected 
acts or omissions in terms sufficient to place the provider or 
beneficiary on notice without disclosing the Government's evidence.
    (B) Within 30 days (or, upon written request received by OCHAMPUS 
during the 30 days and for good cause shown, within 60 days) from the 
date of the notice, the provider or beneficiary may:
    (1) Submit to the Director, OCHAMPUS, or a designee, in writing, 
information (including documentary evidence) and argument in opposition 
to the suspension, provided the additional specific information raises a 
genuine dispute over the material facts, or
    (2) Submit a written request to present in person evidence or 
argument to the Director, OCHAMPUS, or a designee. All such 
presentations shall be made at the Office of Civilian Health and Medical 
Program of the Uniformed Services (OCHAMPUS) in Aurora, Colorado, at the 
provider's or beneficiary's own expense.
    (C) Additional proceedings to determine disputed material facts may 
be conducted unless:
    (1) The suspension is based on any of the actions set forth in 
paragraph (h)(1)(ii)(B) of this section, or,
    (2) A determination is made, on the basis of the advice of the 
responsible Government official (e.g., an official of the Department of 
Justice, the designated Reviewing Official under the Program Fraud Civil 
Remedies Act, etc.), that the substantial interests of the Government in 
pending or contemplated legal or administrative proceedings based on the 
same facts as the suspension would be prejudiced.
    (iv) If the beneficiary or provider submits, either in writing or in 
person, additional information or argument in opposition to the 
suspension, the Director, OCHAMPUS, or a designee, shall issue a 
suspending official's decision which modifies, terminates, or leaves in 
force the suspension of claims processing. However, a decision to 
terminate or modify the suspension shall be without prejudice to the 
subsequent imposition of suspension of claims processing, imposition of 
sanctions under this Sec. 199.9, the recovery of erroneous payments 
under Sec. 199.11 of this part, or any other administrative or legal 
action authorized by law or regulation. The suspending official's 
decision shall be in writing as follows:
    (A) A written decision based on all the information in the 
administrative record, including any submission by the beneficiary or 
provider, shall be final in a case:
    (1) Based on any of the actions set forth in paragraph (h)(1)(ii)(B) 
of this section,
    (2) In which the beneficiary's or provider's submission does not 
raise a genuine dispute over material facts, or
    (3) In which additional proceedings to determine disputed material 
facts have been denied on the basis of advice of a responsible 
Government official that the substantial interests of the Government in 
pending or contemplated legal or administrative proceedings would be 
prejudiced.
    (B) In a case in which additional proceedings are necessary as to 
disputed material facts, the suspending official's decision shall advise 
the beneficiary or provider that the case has been referred for handling 
as a hearing under Sec. 199.10 of this part.
    (v) A suspension of claims processing may be modified or terminated 
for reasons such as:
    (A) Newly discovered evidence;
    (B) Elimination of any of the causes for which the suspension was 
invoked; or
    (C) Other reasons the Director, OCHAMPUS, or a designee, deems 
appropriate.
    (vi) A suspension of claims processing shall be for a temporary 
period pending

[[Page 227]]

the completion of investigation and any ensuing legal or administrative 
proceedings, unless sooner terminated by the Director, OCHAMPUS, or a 
designee, or as provided in this subparagraph.
    (A) If legal or administrative proceedings are not initiated within 
12 months after the date of the suspension notice, the suspension shall 
be terminated unless the Government official responsible for initiation 
of the legal or administrative action requests its extension, in which 
case it may be extended for an additional 6 months. In no event may a 
suspension extend beyond 18 months, unless legal or administrative 
proceedings have been initiated during that period.
    (B) The Director, OCHAMPUS, or a designee, shall notify the 
Government official responsible for initiation of the legal or 
administrative action of the proposed termination of the suspension, at 
least 30 days before the 12-month period expires, to give the official 
an opportunity to request an extension.
    (2) Notice of proposed administrative sanction. (i) A provider shall 
be notified in writing of the proposed action to exclude, suspend, or 
terminate the provider's status as an authorized CHAMPUS provider.
    (A) The notice shall state which sanction will be taken and the 
effective date of that sanction as determined in accordance with the 
provisions of this part.
    (B) The notice shall inform the provider of the situation(s), 
circumstance(s), or action(s) which form the basis for the proposed 
sanction and reference the paragraph of this part under which the 
administrative action is being taken.
    (C) The notice will be sent to the provider's last known business or 
office address (or home address if there is no known business address.)
    (D) The notice shall offer the provider an opportunity to respond 
within 30 days (or, upon written request received by OCHAMPUS during the 
30 days and for good cause shown, within 60 days) from the date on the 
notice with either:
    (1) Documentary evidence and written argument contesting the 
proposed action; or,
    (2) A written request to present in person evidence or argument to 
the Director, OCHAMPUS, or a designee. All such presentations shall be 
made at the Office of the Civilian Health and Medical Program of the 
Uniformed Services (OCHAMPUS) in Aurora, Colorado, at the provider's own 
expense.
    (3) Initial determination. (i) If, after the provider has exhausted, 
or failed to comply with, the procedures specified in paragraph (h)(2) 
of this section, the Director, OCHAMPUS, or a designee, decides to 
invoke an administrative remedy of exclusion, suspension, or termination 
of a provider under CHAMPUS, written notice of the decision will be sent 
to the provider by certified mail. Except in those cases where the 
sanction has a retroactive effective date, the written notice shall be 
dated no later than 15 days before the decision becomes effective. For 
terminations under paragraph (f)(2)(ii)(B) of this section, the initial 
determination may be issued without first implementing or exhausting the 
procedures specified in paragraph (h)(2) of this section.
    (ii) The initial determination shall include:
    (A) A statement of the sanction being invoked;
    (B) A statement of the effective date of the sanction;
    (C) A statement of the facts, circumstances, or actions which form 
the basis for the sanction and a discussion of any information submitted 
by the provider relevant to the sanction;
    (D) A statement of the factors considered in determining the period 
of sanction;
    (E) The earliest date on which a request for reinstatement under 
CHAMPUS will be accepted;
    (F) The requirements and procedures for reinstatement; and,
    (G) Notice of the available hearing upon request of the sanctioned 
provider.
    (4) Reinstatement procedures--(i) Restitution. (A) There is no 
entitlement under CHAMPUS for payment (cost-sharing) of any claim that 
involves either criminal or civil fraud as defined

[[Page 228]]

by law, or fraud or abuse or conflict of interest as defined by this 
part. In addition, except as specifically provided in this part, there 
is no entitlement under CHAMPUS for payment (cost-sharing) of any claim 
for services or supplies furnished by a provider who does not meet the 
requirements to be an authorized CHAMPUS provider. In any of the 
situations described above, CHAMPUS payment shall be denied whether the 
claim is submitted by the provider as a participating claim or by the 
beneficiary for reimbursement. If an erroneous payment has been issued 
in any such case, collection of the payment will be processed under 
Sec. 199.11 of this part.
    (B) If the Government has made erroneous payments to a provider 
because of claims involving fraud, abuse, or conflicts of interest, 
restitution of the erroneous payments shall be made before a request for 
reinstatement as a CHAMPUS authorized provider will be considered. 
Without restitution or resolution of the debt under Sec. 199.11 of this 
part, a provider shall not be reinstated as an authorized CHAMPUS 
provider. This is not an appealable issue under Sec. 199.10 of this 
part.
    (C) For purposes of authorization as a CHAMPUS provider, a provider 
who is excluded or suspended under this Sec. 199.9 and who submits 
participating claims for services furnished on or after the effective 
date of the exclusion or suspension is considered to have forfeited or 
waived any right or entitlement to bill the beneficiary for the care 
involved in the claims. Similarly, because a provider is expected to 
know the CHAMPUS requirements for qualification as an authorized 
provider, any participating provider who fails to meet the qualification 
requirements for CHAMPUS is considered to have forfeited or waived any 
right or entitlement to bill the beneficiary for the care involved in 
the CHAMPUS claims. If, in either situation, the provider bills the 
beneficiary, restitution to the beneficiary may be required by the 
Director, OCHAMPUS, or a designee, as a condition for consideration of 
reinstatement as a CHAMPUS authorized provider.
    (ii) Terminated providers. A terminated provider who subsequently 
achieves the minimum qualifications to be an authorized CHAMPUS provider 
or who has had his/her license reinstated or the impediment to 
reinstatement removed by the appropriate licensing jurisdiction may 
submit a written request for reinstatement under CHAMPUS to the 
Director, OCHAMPUS, or a designee. If restitution or proper 
reinstatement of license is not at issue, the Director, OCHAMPUS, or a 
designee, will process the request for reinstatement under the 
procedures established for initial requests for authorized CHAMPUS 
provider status.
    (iii) Providers (other than entities) excluded or suspended under 
CHAMPUS. (A) A provider excluded or suspended from CHAMPUS (other than 
an entity excluded under Sec. 199.9(f)(1)(i)) may seek reinstatement by 
submitting a written request to the Director, OCHAMPUS, or a designee, 
any time after the date specified in the notice of exclusion or 
suspension or any earlier date specified in an appeal decision issued in 
the provider's appeal under Sec. 199.10 of this part. The request for 
reinstatement shall include:
    (1) Documentation sufficient to establish the provider's 
qualifications under this part to be a CHAMPUS authorized provider;
    (2) A statement from the provider setting forth the reasons why the 
provider should be reinstated, accompanied by written statements from 
professional associates, peer review bodies, and/or probation officers 
(if appropriate), attesting to their belief that the violations that led 
to exclusion or suspension will not be repeated.
    (B) A provider entity excluded from CHAMPUS under Sec. 
199.9(f)(1)(i) may seek reinstatement by submitting a written request to 
the Director, OCHAMPUS, or a designee, with documentation sufficient to 
establish the provider's qualifications under this part to be a CHAMPUS 
authorized provider and either:
    (1) Documentation showing the CHAMPUS reinstatement of the excluded 
individual provider whose conviction led to the CHAMPUS exclusion or 
suspension of the provider entity; or
    (2) Documentation acceptable to the Director, OCHAMPUS, or a 
designee,

[[Page 229]]

that shows that the individual whose conviction led to the entity's 
exclusion:
    (i) Has reduced his or her ownership or control interest in the 
entity below 5 percent; or
    (ii) Is no longer an officer, director, agent or managing employee 
of the entity; or
    (iii) Continues to maintain a 5 percent or more ownership or control 
interest in such entity, and that the entity due to circumstances beyond 
its control, is unable to obtain a divestiture.

    Note: Under paragraph (h)(4)(iii)(B)(2) of this section, the request 
for reinstatement may be submitted any time prior to the date specified 
in the notice of exclusion or suspension or an earlier date specified in 
the appeal decision issued under Sec. 199.10 of this part.

    (iv) Action on request for reinstatement. In order to reinstate a 
provider as a CHAMPUS authorized provider, the Director, OCHAMPUS, or a 
designee, must determine that:
    (A) The provider meets all requirements under this part to be an 
authorized CHAMPUS provider;
    (B) No additional criminal, civil, or administrative action has been 
taken or is being considered which could subject the provider to 
exclusion, suspension, or termination under this section;
    (C) In the case of a provider entity, verification has been made of 
the divestiture or termination of the owner, controlling party, officer, 
director, agent or managing employee whose conviction led to the 
entity's exclusion, or that the provider entity should be reinstated 
because the entity, due to circumstances beyond its control, cannot 
obtain a divestiture of the 5 percent or more ownership or controlling 
interest by the convicted party.
    (v) Notice of action on request for reinstatement--(A) Notice of 
approval of request. If the Director, OCHAMPUS, or a designee, approves 
the request for reinstatement, he or she will:
    (1) Give written notice to the sanctioned party specifying the date 
when the authorized provider status under CHAMPUS may resume; and
    (2) Give notice to those agencies and groups that were originally 
notified, in accordance with Sec. 199.9(k), of the imposition of the 
sanction. General notice may also be given to beneficiaries and other 
parties as deemed appropriate by the Director, OCHAMPUS, or a designee.
    (B) Notice of denial of request. If the Director, OCHAMPUS, or a 
designee, does not approve the request for reinstatement, written notice 
will be given to the provider. If established procedures for processing 
initial requests for authorized provider status are used to review the 
request for reinstatement, the established procedures may be used to 
provide the notice that the provider does not meet requirements of this 
part for such status. If the provider continues to be excluded, 
suspended, or terminated under the provisions of this section, the 
procedures set forth in this paragraph (h) may be followed in denying 
the provider's request for reinstatement.
    (5) Reversed or vacated convictions or civil judgments involving 
CHAMPUS fraud. (i) If a CHAMPUS provider is excluded or suspended solely 
on the basis of a criminal conviction or civil judgment involving a 
CHAMPUS fraud and the conviction or judgment is reversed or vacated on 
appeal, CHAMPUS will void the exclusion of a provider. Such action will 
not preclude the initiation of additional independent administrative 
action under this section or any other administrative remedy based on 
the same facts or events which were the subject of the criminal 
conviction or civil judgment.
    (ii) If an exclusion is voided under paragraph (h)(5)(i) of this 
section, CHAMPUS will make payment, either to the provider or the 
beneficiary (if the claim was not a participating claim) for otherwise 
authorized services under CHAMPUS that are furnished or performed during 
the period of exclusion.
    (iii) CHAMPUS will also void the exclusion of any entity that was 
excluded under Sec. 199.9(f)(1)(i) based solely on an individual's 
conviction that has been reversed or vacated on appeal.
    (iv) When CHAMPUS voids the exclusion of a provider or an entity, 
notice will be given to the agencies and others that were originally 
notified, in accordance with Sec. 199.9(k).

[[Page 230]]

    (i) Evidence required for determinations to invoke administrative 
remedies--(1) General. Any relevant evidence may be used by the 
Director, OCHAMPUS, or a designee, if it is the type of evidence on 
which reasonable persons are accustomed to rely in the conduct of 
serious affairs, regardless of the existence of any common law or 
statutory rule that might make improper the admission of such evidence 
over objection in civil or criminal courts.
    (2) Types of evidence. The types of evidence which the Director, 
OCHAMPUS, or a designee, may rely on in reaching a determination to 
invoke administrative remedies under this section include but are not 
limited to the following:
    (i) Results of audits conducted by or on behalf of the Government. 
Such audits can include the results of 100 percent review of claims and 
related records or a statistically valid sample audit of the claims or 
records. A statistical sampling shall constitute prima facie evidence of 
the number and amount of claims and the instances of fraud, abuse, or 
conflict of interest.
    (ii) Reports, including sanction reports, from various sources 
including a peer review organization (PRO) for the area served by the 
provider; state or local licensing or certification authorities; peer or 
medical review consultants of the Government, including consultants for 
Government contractors; state or local professional societies; or other 
sources deemed appropriate by the Director, OCHAMPUS, or a designee.
    (iii) Orders or documents issued by Federal, state, foreign, or 
other courts of competent jurisdiction which issue findings and/or 
criminal convictions or civil judgments involving the provider, and 
administrative rulings, findings, or determinations by any agency of the 
Federal Government, a state, or local licensing or certification 
authority regarding the provider's status with that agency or authority.
    (j) Suspending Administrative Action. (1) All or any administrative 
action may be suspended by the Director, OCHAMPUS, or a designee, 
pending action in the case by the Department of Defense--Inspector 
General, Defense Criminal Investigative Service, or the Department of 
Justice (including the responsible United States Attorney). However, 
action by the Department of Defense--Inspector General or the Department 
of Justice, including investigation, criminal prosecution, or civil 
litigation, does not preclude administrative action by OCHAMPUS.
    (2) The normal OCHAMPUS procedure is to suspend action on the 
administrative process pending an investigation by the Department of 
Defense--Inspector General or final disposition by the Department of 
Justice.
    (3) Though OCHAMPUS administrative action is taken independently of 
any action by the Department of Defense-Inspector General or by the 
Department of Justice, once a case is forwarded to the Department of 
Defense-Inspector General or the Department of Justice for legal action 
(criminal or civil), administrative action may be held in abeyance.
    (4) In some instances there may be dual jurisdiction between 
agencies; as in, for example, the joint regulations issued by the 
Department of Justice and the Government Accounting Office regarding 
debt collection.
    (k) Notice to Other Agencies. (1) When CHAMPUS excludes, suspends, 
or terminates a provider, the Director, OCHAMPUS, or a designee, will 
notify other appropriate agencies (for example, the Department of Health 
and Human Services and the state licensing agency that issued the 
provider's license to practice) that the individual has been excluded, 
suspended, or terminated as an authorized provider under CHAMPUS. An 
exclusion, suspension, or termination action is considered a public 
record. Such notice can include the notices and determinations sent to 
the suspended provider and other public documents such as testimony 
given at a hearing or exhibits or depositions given in a lawsuit or 
hearing. Notice may also be given to Uniformed Services Military 
Treatment Facilities, Health Benefit Advisors, beneficiaries and 
sponsors, the news media, and institutional providers if inpatient care 
was involved.
    (2) If CHAMPUS has temporarily suspended claims processing, notice 
of such action normally will be given to the affected provider and 
Uniformed

[[Page 231]]

Services Medical Treatment Facilities, Health Benefits Advisors, 
beneficiaries, and sponsors. Notice may also be given to any information 
or news media and any other individual, professional provider, or 
institutional provider, as deemed appropriate. However, since a 
``temporary suspension of claims processing'' is by definition not a 
final or formal agency action, the basis for the action generally will 
not be disclosed. It is noted that the basis for the action can be a 
result of questions arising from routine audits to investigation of 
possible criminal violations.
    (l) Compromise, Settlement, and Resolution Authority. (1) In lieu of 
invoking any remedy provided by this Section, the Director, OCHAMPUS, or 
a designee, may elect to enter into an agreement with the provider 
intended to correct the situation within an established time period and 
subject to any remedies deemed appropriate by the Director, OCHAMPUS, or 
a designee.
    (2) When it is in the best interest of CHAMPUS, the Director, 
OCHAMPUS, has the discretionary authority to waive an action or enter 
into compromise or settlement of administrative actions taken under this 
Sec. 199.9.
    (m) Government-wide effect of exclusion or suspension from CHAMPUS. 
As provided by section 2455 of the Federal Acquisition Streamlining Act 
of 1994, Pub. L. 103-355, October 13 1994, and Executive Order 12549, 
``Debarment and Suspension from Federal Financial and Nonfinancial 
Assistance Programs,'' February 18, 1986, any health care provider 
excluded or suspended from CHAMPUS under this section shall, as a 
general rule, also be debarred, suspended, or otherwise excluded from 
all other programs and activities involving Federal financial 
assistance. Among the other programs for which this debarment, 
suspension, or exclusion shall operate are the Medicare and Medicaid 
programs. This debarment, suspension, or termination requirement is 
subject to limited exceptions in the regulations governing the 
respective Federal programs affected. (Note: Other regulations related 
to this government-wide exclusion or suspension authority are 32 CFR 
Part 25 and 45 CFR Part 76.)

[54 FR 25246, June 14, 1989, as amended at 63 FR 48445, Sept. 10, 1998]