[Title 32 CFR 728.4]
[Code of Federal Regulations (annual edition) - July 1, 2002 Edition]
[Title 32 - NATIONAL DEFENSE]
[Subtitle A - Department of Defense (Continued)]
[Chapter Vi - DEPARTMENT OF THE NAVY]
[Subchapter C - PERSONNEL]
[Part 728 - MEDICAL AND DENTAL CARE FOR ELIGIBLE PERSONS AT NAVY MEDICAL DEPARTMENT FACILITIES]
[Subpart A - General]
[Sec. 728.4 - Policies.]
[From the U.S. Government Printing Office]
32NATIONAL DEFENSE52002-07-012002-07-01falsePolicies.728.4Sec. 728.4NATIONAL DEFENSEDepartment of Defense (Continued)DEPARTMENT OF THE NAVYPERSONNELMEDICAL AND DENTAL CARE FOR ELIGIBLE PERSONS AT NAVY MEDICAL DEPARTMENT FACILITIESGeneral
Sec. 728.4 Policies.
(a) Admissions to closed psychiatric wards. Admit patients to closed
psychiatric wards only when they have a psychiatric or emotional
disorder which renders them dangerous to themselves or others, or when a
period of careful closed psychiatric observation is necessary to
determine whether such a condition exists. When a patient is admitted to
a closed psychiatric ward, the reason for admission must be clearly
stated in the patient's clinical record by the physician admitting the
patient to the ward. These same policies apply equally in those
instances when it becomes necessary to place a patient under constant
surveillance while in an open ward.
(b) Absence from the sick list. See Sec. 728.4 (d), (x), and (y).
(c) Charges and collection. Charges for services rendered vary and
are set by the Office of the Assistant Secretary of Defense
(Comptroller) and published in a yearly NAVMEDCOMNOTE 6320, (Cost
elements of medical, dental, subsistence rates, and hospitalization
bills). Billing and collection actions also vary according to
entitlement or eligibility and are governed by the provisions of NAVMED
P-5020, Resource Management Handbook. See subpart J on the initiation of
collection action on pay patients.
(d) Convalescent leave. Convalescent leave, a period of authorized
absence of active duty members under medical care when such persons are
not yet fit for duty, may be granted by a member's commanding officer
(CO) or the hospital's CO per the following:
(1) Unless otherwise indicated, grant such leave only when
recommended by COMNAVMEDCOM through action taken upon a report by a
medical board, or the recommended findings of a physical evaluation
board or higher authority.
(2) Member's commanding officer (upon advice of attending
physician); commanding officers of Navy, Army, or Air Force medical
facilities; commanders of regional medical commands for persons
hospitalized in designated USTFs or in civilian facilities within their
respective areas of authority; and managers of Veterans Administration
hospitals within the 50 United States or in puerto Rico may grant
convalescent leave to active duty naval patients, with or without
reference to a medical board, physical evaluation board, or higher
authority provided the:
(i) Convalescent leave is being granted subsequent to a period of
hospitalization.
(ii) Member is not awaiting disciplinary action or separation from
the service for medical or administrative reasons.
(iii) Medical officer in charge:
(A) Considers the convalescent leave beneficial to the patient's
health.
(B) Certifies that the patient is not fit for duty, will not need
hospital treatment during the contemplated convalescent leave period,
and that such leave will not delay final disposition of the patient.
(3) When considered necessary by the attending physician and
approved on an individual basis by the commander of the respective
geographic regional medical command, convalescent leave in excess of 30
days may be granted. The authority to grant convalescent leave in excess
of 30 days may not be redelegated to hospital commanding officers.
Member's permanent command must be notified of such extensions (see
MILPERSMAN 3020360).
(4) Exercise care in granting convalescent leave to limit the
duration of such leave to that which is essential in relation to
diagnosis, prognosis, estimated duration of treatment, and patient's
probable final disposition.
(5) Upon return from convalescent leave;
(i) Forward one copy of original orders of officers, bearing all
endorsements, to the Commander, Naval Military Personnel Command
(COMNAVMILPERSCOM) (NMPC-4) or the Commandant of the Marine Corps (CMC),
as appropriate.
(ii) Make an entry on the administrative remarks page (page 13 for
Navy personnel) of the service records of enlisted personnel indicating
that convalescent leave was granted and the dates of departure and
return.
(6) lf considered beneficial to the patient's health, commanding
officers of hospitals may grant convalescent leave
[[Page 290]]
as a delay in reporting back to the parent command.
(e) Cosmetic surgery. (1) Defined as that surgery which is done to
revise or change the texture, configuration, or relationship of
contiguous structures of any feature of the human body which would be
considered by the average prudent observer to be within the broad range
of ``normal'' and acceptable variation for age or ethnic origin, and in
addition, is performed for a condition which is judged by competent
medical opinion to be without potential for jeopardy to physical or
mental health of an individual.
(2) Commanding officers will monitor, control, and assure compliance
with the following cosmetic surgery policy:
(i) Certain cosmetic procedures are a necessary part of training and
retention of skills to meet the requirements of certification and
recertification.
(ii) Insofar as they meet minimum requirements and serve to improve
the skills and techniques needed for reconstructive surgery, the
following cosmetic procedures may be performed as low priority surgery
on active duty members only when time and space are available.
(A) Cosmetic facial rhytidectomies (face lifts) will be a part of
all training programs required by certifying boards.
(B) Cosmetic augmentation mammaplasties will be done only by
properly credentialed surgeons and residents within surgical training
programs to meet requirements of certifying boards.
(f) Cross-utilization of uniformed services facilities. To provide
effective cross-utilization of medical and dental facilities of the
uniformed services, eligible persons, regardless of service affiliation,
will be given equal opportunity for health benefits. Catchment areas
have been established by the Department of Defense for each USMTF (see
Sec. 728.2(d)). Eligible beneficiaries residing within such a catchment
area are expected to use that inpatient facility for care. Make
provisions to assure that:
(1) Eligible beneficiaries residing in a catchment area served by a
USMTF not of the sponsor's own service may obtain care at that facility
or at a facility of the sponsor's service located in another catchment
area.
(2) If the facility to which an eligible beneficiary applies cannot
furnish needed care, the other facility or facilities in overlapping
catchment areas are contacted to determine whether care can be provided
thereat.
(g) Disengagement. Discontinuance of medical management by a naval
MTF for only a specific episode of care.
(1) General. Disengagement is accomplished only after alternative
sources of care (i.e., transfer to another USMTF, a USTF, or other
Federal source via the aeromedical evacuation system, if appropriate)
and attendant costs, if applicable, have been fully explained to patient
or responsible family member. Counselors may arrange for counseling by
other appropriate sources when the patient is or may be eligible for VA,
Medicare, MEDICAID, etc. benefits. With the individual's permission,
counselors may also contact State programs, local health organizations,
or health foundations to determine if care is available for the
condition upon which disengagement is based. After the disengagement
decision is made, the patient to be disengaged or the responsible family
member should be advised to return to the naval MTF for any care
required subsequent to receiving the care that necessitated
disengagement.
(2) CHAMPUS-eligible individuals. (i) Issue a Nonavailability
Statement (DD 1251) per Sec. 728.33, when appropriate, to patients
released to civilian sources for total care (disengaged) under CHAMPUS.
CHAMPUS-eligible patients disengaged for total care, who do not
otherwise require a DD 1251 (released for outpatient care or those
released whose residence is outside the inpatient catchment area of all
USMTFs and USTFs) will be given the original of a properly completed DD
2161, Referral For Civilian Medical Care, which clearly indicates that
the patient is released for total care under CHAMPUS. CHAMPUS-eligible
beneficiaries will be disengaged for services under CHAMPUS when:
(A) Required services are beyond your capability and these services
cannot be appropriately provided through
[[Page 291]]
one of the alternatives listed in Sec. 728.4(z), or
(B) You cannot effectively provide required services or manage the
overall course of care even if augmented by services procured from other
Government or civilian sources using naval MTF operation and maintenance
funds as authorized in subpart Sec. 728.4(z).
(ii) When a decision is made to disengage a CHAMPUS-eligible
individual, commanding officers (CO) or officers-in-charge (OIC) are
responsible for assuring that counseling and documentation of counseling
are appropriately accomplished. Complete a NAVMED 6320/30. Disengagement
for Civilian Medical Care, to document that all appropriate
disengagement procedures have been accomplished.
(iii) After obtaining the signature of the patient or responsible
family member, the counselor will file a copy of the DD 2161 and the
original of the NAVMED 6320/30 in the patient's Health Record.
(3) Patients other than active duty or CHAMPUS-eligible individuals-
-(i) Categories of patients. The following are categories of individuals
who also may be disengaged:
(A) Medicare-eligible individuals.
(B) MEDICAID-eligible individuals.
(C) Civilians (U.S. and foreign) admitted or treated as civilian
humanitarians.
(D) Secretarial designees.
(E) All other individuals, with or without private insurance, who
are not eligible for care at the expense of the Government.
(ii) Disengagement decision. Disengage such individuals when:
(A) Required services are beyond the capability of the MTF, and
services necessary for continued treatment in the MTF cannot be
appropriately provided by another USMTF, a USTF, or another Federal
source. (Explore alternative sources, for individuals eligible for care
from these sources, before making the disengagement decision.)
(B) The MTF cannot, within the facility's capability, effectively
provide required care or manage the overall course of treatment even if
augmented by services procured from other Government sources or through
procurement from civilian sources using supplemental care funding.
(iii) Counseling. The initial step in the disengagement process is
appropriate counseling and documentation. In an emergency, or when the
individual cannot be appropriately counseled prior to leaving the MTF,
establish procedures to ensure counseling and documentation are
accomplished during the next working day. Such ``follow-up'' counseling
may be in person or via a witnessed telephone conversation. In either
instance, the counselor will document counseling on a NAVMED 6320/30,
Disengagement for Civilian Medical Care. The disengagement decision
making authority must assure the accomplishment of counseling by
personally initiating this service or by referring the patient or
responsible family member to the HBA for counseling. As a minimum,
counseling will consist of:
(A) Explaining that the patient is being disengaged from treatment
at the facility and the reason therefor. Assure that the individual
understands the meaning of ``disengagement'' by explaining that the MTF
is unable to provide for the patient's present needs and must therefore
relinquish medical management of the patient to a health care provider
of the individual's choice.
(B) Assuring the individual that the disengagement action is taken
to provide for the patient's immediate medical needs. Also assure that
the individual understands that the disengagement is not indicative of
whether care is or will be available in the MTF for other aspects of
past, current, or future medical conditions.
(C) Explaining Medicare, MEDICAID, or other known programs as they
relate to the particular circumstance of the patient, including cost-
sharing, deductibles, allowable charges, participating and authorized
providers, physicians accepting assignment, claim filing procedures,
etc. Explain that once disengagement is accomplished, the Navy, is not
responsible for any costs for care received from a health care provider
of the patient's or responsible family member's choice.
(iv) Documentation. Commanding officers are responsible for ensuring
that proper documentation procedures are
[[Page 292]]
started and that providers and counselors under their commands are
apprised of their individual responsibilities for counseling and
documenting each disengagement. Failure to properly counsel and document
counseling may result in the naval MTF having to absorb the cost of the
entire episode of care. Document counseling on a NAVMED 6320/30.
Disengagement for Civilian Medical Care. Completion of all items on the
form assures documentation and written acknowledgement of appropriate
disengagement and counseling. If the patient or responsible family
member refuses to acknowledge receipt of counseling by signing the form,
state this fact on the bottom of the form and have it witnessed by an
officer. Give the patient or responsible family member a copy and
immediately file the original in the patient's Health Record.
(4) Active duty members. When an active duty member seeks care at a
USMTF, that USMTF retains some responsibility (e.g., notification,
medical cognizance, supplemental care, etc.) for that member even when
the member must be transferred to another facility for care. Therefore,
relinquishment of total management of an active duty member
(disengagement) cannot be accomplished.
(h) Domiciliary/custodial care. The type of care designed
essentially to assist an individual in meeting the normal activities of
daily living, i.e., services which constitute personal care such as help
in walking and getting in or out of bed, help in bathing, dressing,
feeding, preparation of special diets, and supervision over medications
which can usually be self-administered and which does not entail or
require the continuing attention of trained medical or paramedical
personnel. The essential characteristics to be considered are the level
of care and medical supervision that the patient requires, rather than
such factors as diagnosis, type of condition, or the degree of
functional limitation. Such care will not be provided in naval MTFs
except when required for active duty members of the uniformed services.
(i) Emergency care. Treat patients authorized only emergency care
and those admitted as civilian emergencies only during the period of the
emergency. Initiate action to effect appropriate disposition of such
patients as soon as the emergency period ends.
(j) Evaluation after admission. Evaluate each patient as soon as
possible after admission and continue reevaluation until disposition is
made. Anticipate each patient's probable type and date of disposition.
Necessary processing by the various medical and administrative entities
will take place concurrently with treatment of the patient. Make the
medical disposition decision as early as possible for U.S. military
patients inasmuch as immediate transfer to a specialized VA center or to
a VA spinal cord injury center may be in their best interest (see
NAVMEDCOMINST 6320.1.2). Make disposition decisions for military
personnel of NATO nations in conformance with Sec. 728.42(d).
(k) Extent of care. Subject to the restrictions and priorities in
Sec. 728.3, eligible persons will be provided medical and dental care to
the extent authorized, required, and available. When an individual is
accepted for care, all care and adjuncts thereto, such as nonstandard
supplies, as determined by the CO to be necessary, will be provided from
resources available to the CO unless specifically prohibited elsewhere
in this part. When a patient has been accepted and required care is
beyond the capability of the accepting MTF, the CO thereof will arrange
for the required care by one of the means shown below. The method of
choice will be based upon professional considerations and travel
economy.
(1) Transfer the patient per Sec. 728.4(bb).
(2) Procure from civilian sources the necessary material or
professional personal services required for the patient's proper care
and treatment.
(3) Care authorized in Sec. 728.4(k)(2) will normally be
accomplished in the naval MTF. However, when such action is not
feasible, supplementation may be obtained outside the facility. Patients
may be sent to other Federal or civilian facilities for specific
treatment or services under Sec. 728.4(k)(3) provided they remain under
medical management of the CO of the sending facility during the entire
period of care.
[[Page 293]]
(l) Family planning services. Provide family planning services
following the provisions of SECNAVINST 6300.2A.
(m) Grouping of patients. Group hospitalized patients according to
their requirements for housing, medical, or dental care. Provide gender
identified quarters, facilities, and professional supervision on that
basis when appropriate. Individuals who must be retained under limited
medical supervision (medical hold) solely for administrative reasons or
for medical conditions which can be treated on a clinic basis will be
provided quarters and messing facilities, where practicable, separately
from those hospitalized. Provide medical care for such patients on a
periodic clinic appointment basis (see Sec. 728.4(p) for handling
enlisted convalescent patients). Make maximum use of administrative
versus medical personnel in the supervision of such patients.
(n) Health benefits advising--(1) General. A Health Benefits
Advising program must be started at all shore commands having one or
more medical officers. While health benefits advisors are not required
aboard every ship with a medical officer, the medical department
representative can usually provide services to personnel requiring help.
The number of health benefits advisors (HBAs) of a command will be
commensurate with counseling and assistance requirements. The program
provides health benefits information and counseling to beneficiaries of
the Uniformed Services Health Benefits Program (USHBP) and to others who
may or may not qualify for care in USMTFs. Office location of HBAs,
their names, and telephone numbers will be widely publicized locally. If
additional help is required, contact MEDCOM-333 on AUTOVON 294-1127 or
commercial (202) 653-1127. In addition to the duties described in
Sec. 728.4(n)(2), HBAs will:
(i) Maintain a depository of up-to-date officially supplied health
benefits information for availability to all beneficiaries.
(ii) Provide information and guidance to beneficiaries and generally
support the medical and dental staff by providing help to eligible
beneficiaries seeking or obtaining services from USMTFs, civilian
facilities, VA facilities, Medicare, MEDICAID, and other health
programs.
(iii) Assure that when a referral or disengagement is required,
patients or responsible family members are:
(A) Fully informed that such action is taken to provide for their
immediate medical or dental requirements and that the disengagement or
referral has no bearing on whether care may be available in the naval
MTF for other aspects of current or other future medical conditions.
(B) Provided the services and counseling outlined in
Sec. 728.4(n)(2) or Sec. 728.3(g)(3)(ii), as appropriate, prior to their
departure from the facility when such beneficiaries are referred or
disengaged because care required is beyond the naval MTF's capability.
In an emergency, or when the patient or sponsor cannot be seen by the
HBA prior to leaving, provide these benefits as soon thereafter as
possible.
(2) Counseling and assisting CHAMPUS-eligible individuals. HBAs, as
a minimum, will:
(i) Explain alternatives available to the patient.
(ii) If appropriate, explain CHAMPUS as it relates to the particular
circumstance, including the cost-sharing provisions applicable to the
patient, allowable charges, provider participation, and claim filing
procedures. Fully inform the patient or responsible family member that
when a patient is disengaged for care under CHAMPUS or when cooperative
care is to be considered for payment under the provisions of
Sec. 728.4(z) (5) and (6), the naval MTF is not responsible for monetary
amounts above the CHAMPUS-determined allowable charge or for charges
CHAMPUS does not allow.
(iii) Explain why the naval MTF is paying for the supplemental care,
if appropriate (see Sec. 728.4(z) (3) and (4)), and how the bill will be
handled. Then:
(A) Complete a DD 2161, Referral For Civilian Medical Care, marking
the appropriate source of payment with the concurrence of the naval MTF
commanding officer or CO's designee.
(B) If referred for a specified procedure with a consultation report
to be returned to the naval MTF retaining medical management, annotate
the DD 2161 in the consultation report section
[[Page 294]]
to state this requirement. Advise patient or responsible family member
to arrange for a completed copy of the DD 2161 to be returned to the
naval MTF for payment, if appropriate, and inclusion in patient's
medical record.
(iv) Brief patient or responsible family member on the use of the DD
2161 in USMTF payment procedures and CHAMPUS claims processing, as
appropriate. Provide sufficient copies of DD 2161 and explain that
CHAMPUS contractors will return claims submitted without a required DD
2161. Obtain signature of patient or responsible family member on the
form.
(v) Arrange for counseling from appropriate sources when the patient
is eligible for VA, Medicare, or MEDICAID benefits.
(vi) Serve as liaison between civilian providers and naval MTF on
administrative matters related to the referral and disengagement
process.
(vii) Serve as liaison between naval MTF and cooperative care
coordinators on matters relating to care provided or recommended by
naval MTF providers, as appropriate.
(viii) Explain why the patient is being disengaged and, per
Sec. 728.4(g)(2), provide a DD 1251, Nonavailability Statement, or DD
2161, Referral For Civilian Medical Care, as appropriate.
(o) Immunizations. Administer immunizations per BUMED INST 6230.1H.
(p) Medical holding companies. Medical holding companies (MHC) have
been established at certain activities to facilitate handling of
enlisted convalescent patients whose medical conditions are such that,
although they cannot be returned to full duty, they can perform light
duty ashore commensurate with their condition while completing their
medical care on an outpatient basis. Where feasible, process such
patients for transfer.
(q) Notifications. The interests of the Navy, Marine Corps, and DOD
have been adversely affected by past procedures which emphasized making
notifications only when an active duty member's condition was classed as
either seriously ill or injured or classed as very seriously ill or
injured. However, even temporary disabilities which preclude
communication with the next of kin have generated understandable concern
and criticism, especially when emergency hospitalization has resulted.
Accordingly, naval MTFs will effect procedures to make notifications
required in Sec. 728.4(q) (2), (3), and (4) upon admission or diagnosis
of individuals specified. The provisions of Sec. 728.4(q) supplement
articles 1810520 and 4210100 of the Naval Military Personnel Manual and
chapter 1 of Marine Corps Order P3040.4B, Marine Corps Casualty
Procedures Manual; they do not supersede them.
(1) Privacy Act. The right to privacy of individuals for whom
hospitalization reports and other notifications are made will be
safeguarded as required by the Privacy Act, implemented in the
Department of the Navy by SECNAVINST 5211.5C, U.S. Navy Regulations, the
Manual of the Judge Advocate General, the Marine Corps Casualty
Procedures Manual, and the Manual of the Medical Department.
(2) Active duty flag or general officers and retired Marine Corps
general officers. Upon admission of subject officers, make telephonic
contact with MEDCOM-33 on AUTOVON 294-1179 or commercial (202) 653-1179
(after duty hours, contact the command duty officer on AUTOVON 294-1327
or commercial (202) 653-1327) to provide the following information:
(i) Initial. Include in the initial report:
(A) Officer's name, grade, social security number, and designator.
(B) Duty assignment in ship or station, or other status.
(C) Date of admission.
(D) Present condition, stating if serious or very serious.
(E) Diagnosis, prognosis, and estimated period of hospitalization.
To prevent possible invasion of privacy, report the diagnosis only in
International Classification of Diseases--9th Edition (ICD-9-CM) code
designator.
(ii) Progress reports. Call frequency and content will be at the
discretion of the commanding officer. However, promptly report changes
in condition or status.
(iii) Termination report. Make a termination of hospitalization
report to provide appropriate details for informational purposes.
[[Page 295]]
(iv) Additional commands to apprise. The geographic naval medical
region serving the hospital and, if different, the one serving the
officer's command will also be apprised of such admissions.
(3) Active duty members--(i) Notification of member's command. The
commanding officer of naval medical treatment facilities has
responsibility for notifying each member's commanding officer under the
conditions listed below. Make COMNAVMILPERS COM or CMC, as appropriate,
information addressees on their respective personnel:
(A) Direct admissions. Upon direct admission of an active duty
member, with or without orders regardless of expected length of stay.
The patient administration department (administrative watch officer
after hours) is responsible for preparation, per Sec. 728.4(q)(4), and
release of these messages. If the patient is attached to a local command
(CO's determination), initial notification may be made telephonically.
Record the name, grade or rate, and position of the person receiving the
call at the member's command on the back of the NAVMED 6300/5, Inpatient
Admission/Disposition Record and include the name and telephone number
of the MTF's point of contact as given to the patient's command.
(B) Change in medical condition. Upon becoming aware of any medical
condition, including pregnancy, which will now or in the foreseeable
future result in the loss of a member's full duty services in excess of
72 hours. Transmit this information in a message, prepared per
Sec. 728.4(q)(4), marked ``Commanding Officer's Eyes Only.''
(ii) Notification of next of kin (NOK)--(A) Admitted members. As
part of the admission procedure, encourage all patients to communicate
expeditiously and regularly with their NOK. When an active duty member's
incapacity makes timely personal communication impractical, i.e.,
fractures, burns, eye pathology, psychiatric or emotional disorders,
etc., MTF personnel will initiate the notification process. Do not start
the process if the patient specifically declines such notification or it
is clear that the NOK already has knowledge of the admission (commands
should develop a local form for such patients to sign attesting their
desire or refusal to have their NOK notified). Once notification has
been made, the facility will make progress reports, at least weekly,
until the patient is again able to communicate with the NOK.
(1) Navy personnel. Upon admission of Navy personnel, effect the
following notification procedures.
(i) In the contiguous 48 states. Patient administration department
personnel will notify the NOK in person, by telephone, telegraph, or by
other expeditious means. Included are notifications of the NOK upon
arrival of all Navy patients received in the medical air-evacuation
system.
(ii) Outside the contiguous 48 states. If the next of kin has
accompanied the patient on the tour of duty and is in the immediate
area, hospital personnel will notify the next of kin in person, by
telephone, telegraph, or by other expeditious means. If the next of kin
is located in the 48 contiguous United States, use telegraphic means to
notify COMNAVMILPERSCOM who will provide notification to the NOK.
(2) Marine Corps personnel. When Marine Corps personnel are
admitted, effect the following notification procedures.
(i) In the contiguous 48 states. The commander of the unit or
activity to which the casualty member is assigned is responsible for
initiating notification procedures to the NOK of seriously or very
seriously ill or injured Marine Corps personnel. Patient administration
department personnel will assure that liaison is established with the
appropriate command or activity when such personnel are admitted.
Patient administration personnel will notify the Marine's command by
telephone and request that cognizance be assumed for in-person initial
notification of the NOK of Marine Corps patients admitted with an
incapacity that makes personal and timely communication impractical and
for those arriving via the medical air-evacuation system. If a member's
command is unknown or cannot be contacted, inform CMC (MHP-10) on
AUTOVON 224-1787 or commercial (202) 694-1787.
(ii) Outside the contiguous 48 states. Make casualty notification
for Marine
[[Page 296]]
Corps personnel hospitalized in naval MTFs outside the contiguous 48
States to the individual's command. If the command is unknown or not
located in close proximity to the MTF, notify CMC (MHP-10). When initial
notification to the individual's command is made via message, make CMC
(MHP-10) an information addressee.
(iii) In and outside the United States. In life-threatening
situations, the Commandant of the Marine Corps desires and encourages
medical officers to communicate with the next of kin. In other
circumstances, request that the Marine Corps member communicate with the
NOK if able. If unable, the medical officer should communicate with the
NOK after personal notification has been effected.
(B) Terminally ill patients. As soon as a diagnosis is made and
confirmed (on inpatients or outpatients) that a Navy member is
terminally ill, MILPERSMAN 4210100 requires notification of the primary
and secondary next of kin. Accomplish notification the same as for Navy
members admitted as seriously or very seriously ill or injured, i.e., by
priority message to the Commander, Naval Military Personnel Command and
to the Casualty Assistance Calls/Funeral Honors Support Program
Coordinator, as appropriate, who has cognizance over the geographical
area in which the primary and secondary NOK resides (see OPNAVINST
1770.1). Submit followup reports when appropriate. See MILPERSMAN
4210100 for further amplification and for information addressees.
(1) In the contiguous 48 states. Notification responsibility is
assigned to the USMTF making the diagnosis and to the member's duty
station if diagnosed in a civilian facility.
(2) Outside the contiguous 48 states. Notification responsibility is
assigned to the naval medical facility making the diagnosis. When
diagnosed in nonnaval facilities or aboard deployed naval vessels,
notification responsibility belongs to the Commander, Naval Military
Personnel Command.
(C) Other uniformed services patients. Establish liaison with other
uniformed services to assure proper notification upon admission or
diagnosis of active duty members of other services.
(D) Nonactive duty patients. At the discretion of individual
commanding officers, the provisions of Sec. 728.4(q)(3)(ii) on providing
notification to the NOK may be extended to admissions or diagnosis of
nonactive duty patients; e.g., admission of dependents of members on
duty overseas.
(4) Messages--(i) Content. Phrase contents of messages (and
telephonic notifications) in lay terms and provide sufficient details
concerning the patient's condition, prognosis, and diagnosis. Messages
will also contain the name and telephone number of the facility's point
of contact. When appropriate for addressal, psychiatric and other
sensitive diagnoses will be related with discretion. When indicated,
also include specific comment as to whether the presence of the next of
kin is medically warranted. Note: In making notification to the NOK of
patients diagnosed as having Acquired Immune Deficiency Syndrome (AIDS)
or Human Immunodeficiency Virus (HIV), use one of the symptoms of the
disease as the diagnosis (e.g., pneumonia) rather than ``HIV'',
``AIDS'', or the diagnostic code for AIDS.
(ii) Information addressees. Make the commander of the geographic
naval medical region servicing the member's command and the one
servicing the hospital, if different, information addressees on all
messages. For Marine Corps personnel, also include CMC (MHP-10) and the
appropriate Marine Corps district headquarters as information
addressees, COMNAVMEDCOM WASHINGTON DC requires information copies of
messages only when a patient has been placed on the seriously ill or
injured or very seriously ill or injured list or diagnosed as terminally
ill.
(r) Outpatient care. Whenever possible, perform diagnostic
procedures and provide preoperative and post operative care, surgical
care, convalescence, and followup observations and treatment on an
outpatient basis.
(s) Performance of duties while in an inpatient status. U.S.
military patients may be assigned duties in and around naval MTFs when
such duties will be,
[[Page 297]]
in the judgement of the attending physician, of a therapeutic value.
Physical condition, past training, and other acquired skills must all be
considered before assigning any patient a given task. Do not assign
patients duties which are not within their capabilities or which require
more than a very brief period of orientation.
(t) Prolonged definitive medical care. Prolonged definitive medical
care in naval MTFs will not be provided for U.S. military patients who
are unlikely to return to duty. The time at which a patient should be
processed for disability separation must be determined on an individual
basis, taking into consideration the interests of the patient as well as
those of the Government. A long-term patient roster will be maintained
and updated at least once monthly to enable commanding officers and
other appropriate staff members to monitor the progress of all patients
with 30 or more continuous days of hospitalization. Include on the
roster basic patient identification data (name, grade or rate, register
number, ward or absent status, clinic service, and whether assigned to a
medical holding company), projected disposition (date, type, and
profile), diagnosis, and cumulative hospital days (present facility and
total).
(u) Remediable physical defects of active duty members--(1) General.
When a medical evaluation reveals that a Navy or Marine Corps patient on
active duty has developed a remediable defect while on active duty, the
patient will be offered the opportunity of operative repair or other
appropriate remediable treatment, if medically indicated.
(2) Refusal of treatment. Per MANMED art. 18-15, when a member
refuses to submit to recommended therapeutic measures for a remediable
defect or condition which has interfered with the member's performance
of duty and following prescribed therapy, the member is expected to be
fit for full duty, the following procedures will apply:
(i) Transfer the member to a naval MTF for further evaluation and
appearance before a medical board. After counseling per MANMED art. 18-
15, any member of the naval service who refuses to submit to recommended
medical, surgical, dental, or diagnostic measures, other than routine
treatment for minor or temporary disabilities, will be asked to sign a
completed NAVMED 6100/4, Medical Board Certificate Relative to
Counseling on Refusal of Surgery and/or Treatment, attesting to the
counseling.
(ii) The board will study all pertinent information, inquire into
the merits of the individual's refusal to submit to treatment, and
report the facts with appropriate recommendations.
(iii) As a general rule, refusal of minor surgery should be
considered unreasonable in the absence of substantial contraindications.
Refusal of major surgical operations may be reasonable or unreasonable,
according to the circumstances, The age of the patient, previous
unsuccessful operations, existing physical or mental contraindications,
and any special risks should all be taken into consideration.
(iv) Where surgical procedures are involved, the board's report will
contain answers to the following questions:
(A) Is surgical treatment required to relieve the incapacity and
restore the individual to a duty status, and may it be expected to do
so?
(B) Is the proposed surgery an established procedure that qualified
and experienced surgeons ordinarily would recommend and undertake?
(C) Considering the risks ordinarily associated with surgical
treatment, the patient's age and general physical condition, and the
member's reason for refusing treatment, is the refusal reasonable or
unreasonable? (Fear of surgery or religious scruples may be considered,
along with all the other evidence, for whatever weight may appear
appropriate.)
(v) If a member needing surgery is mentally competent, do not
perform surgery over the member's protestation.
(vi) In medical, dental, or diagnostic situations, the board should
show the need and risk of the recommended procedure(s).
(vii) If a medical board decides that a diagnostic, medical, dental,
or surgical procedure is indicated, these findings must be made known to
the patient. The board's report will show that the patient was afforded
an opportunity to submit a written statement explaining
[[Page 298]]
the grounds for refusal. Forward any statement with the board's report.
Advise the patient that even if the disability originally arose in line
of duty, its continuance may be attributable to the member's
unreasonable refusal to cooperate in its correction; and that the
continuance of the disability might, therefore, result in the member's
separation without benefits.
(viii) Also advise the patient that:
(A) Title 10 U.S.C. 1207 precludes disposition under chapter 61 of
10 U.S.C. if such a member's disability is due to intentional
misconduct, willful neglect, or if it was incurred during a period of
unauthorized absence. A member's refusal to complete a recommended
therapy regimen or diagnostic procedure may be interpreted as willful
neglect.
(B) Benefits from the Veterans Administration will be dependent upon
a finding that the disability was incurred in line of duty and is not
due to the member's willful misconduct.
(ix) The Social Security Act contains special provisions relating to
benefits for ``disabled'' persons and certain provisions relating to
persons disabled ``in line of duty'' during service in the Armed Forces.
In many instances persons deemed to have ``remediable'' disorders have
been held not ``disabled'' within the meaning of that term as used in
the statute, and Federal courts have upheld that interpretation. One who
is deemed unreasonably to have refused to undergo available surgical
procedures may be deemed both ``not disabled'' and to have incurred the
condition ``not in the line of duty.''
(x) Forward the board's report directly to the Central Physical
Evaluation Board with a copy to MEDCOM-25 except in those instances when
the convening authority desires referral of the medical board report for
Departmental review.
(xi) Per MANMED art. 18-15, a member who refuses medical, dental, or
surgical treatment for a condition that existed prior to entry into the
service (EPTE defect), not aggravated by a period of active service but
which interferes with the performance of duties, should be processed for
reason of physical disability, convenience to the Government, or
enlisted in error rather than under the refusal of treatment provisions.
Procedures are delineated in BUMEDINST 1910.2G and SECNAVINST 1910.4A.
(3) Other uniformed services patients. When a patient of another
service is found to have a remediable physical defect developed in the
military service, refer the matter to the nearest headquarters of the
service concerned.
(v) Responsibilities of the commanding officer. In connection with
the provisions of this part, commanding officers of naval MTFs will:
(1) Determine which persons within the various categories authorized
care in a facility will receive treatment in, be admitted to, and be
discharged from that specific facility.
(2) Supervise care and treatment, including the employment of
recognized professional procedures.
(3) Provide each patient with the best possible care in keeping with
accepted professional standards and the assigned primary mission of the
facility.
(4) Provide for counseling patients and naval MTF providers when
care required is beyond the naval MTF's capability. This includes:
(i) Establishing training programs to acquaint naval MTF providers
and HBAs with the uniformed services' referral for supplemental/
cooperative care or services policy outlined in Sec. 728.4(z).
(ii) Implementing control measures to ensure that:
(A) Providers requesting care under the provisions Sec. 728.4(z) are
qualified to maintain physician case management when required.
(B) Care requested under the supplemental/cooperative care criteria
is medically necessary, legitimate, and otherwise permissible under the
terms of that part of the USHBP under which it will be considered for
payment.
(C) Providers explain to patients the reason for a referral and the
type of referral being made.
(D) Attending physicians properly refer beneficiaries to the HBA for
counseling and services per Sec. 728.4(n).
(E) Uniform criteria are applied in determining cooperative care
situations without consideration of rate, grade, or uniformed service
affiliation.
[[Page 299]]
(F) All DD 2161's are properly completed and approved by the
commanding officer or designee.
(G) A copy of the completed DD 2161 is returned to the naval MTF for
inclusion in the medical record of the patient.
(w) Sick call. A regularly scheduled assembly of sick and injured
military personnel established to provide routine medical care.
Subsequent to examination, personnel medically unfit for duty will be
admitted to an MTF or placed sick in quarters; personnel not admitted or
placed sick in quarters will be given such treatment as is deemed
necessary. When excused from duty for medical reasons which do not
require hospitalization, military personnel may be authorized to remain
in quarters, not to exceed 72 hours.
(x) Sicklist--authorized absence from. Commanding officers of naval
MTFs may authorize absences of up to 72 hours for dependents and retired
personnel without formal discharge from the sicklist. When absences are
authorized in excess of 24 hours, subsistence charges or dependent's
rate, as applicable, for that period will not be collected and the
number of reportable occupied bed days will be appropriately reduced.
Prior to authorizing such absences, the attending physician will advise
patients of their physical limitations and of any necessary safety
precautions, and will annotate the clinical record that patients have
been so advised. For treatment under the Medical Care Recovery Act, make
reporting consistent with Sec. 728.4(aa).
(y) Subsisting out. A category in which officer and enlisted
patients on the sicklist of a naval MTF may be placed when their daily
presence is not required for treatment nor examination, but who are not
yet ready for return to duty. As a general rule, patients placed in this
category should reside in the area of the facility and should be
examined by the attending physician at least weekly. Enlisted personnel
in a subsisting out status should be granted commuted rations.
(1) Granting of subsisting out privileges is one of many disposition
alternatives; however, recommend that other avenues (medical holding
company, convalescent leave, limited duty, etc.) be considered before
granting this privilege.
(2) Naval MTF patients in a subsisting out status should not be
confused with those enlisted personnel in a rehabilitation program who
are granted liberty and are drawing commuted rations, but are required
to be present at the treating facility during normal working hours.
These personnel are not subsisting out and must have a bed assigned at
the naval MTF.
(3) Naval MTF patients who are required to report for examinations
or treatment more often than every 48 hours should not be placed in a
subsisting out status.
(z) Supplemental/cooperative care or services--(1) General. When
such services as defined in Sec. 728.2(cc) are rendered to other than
CHAMPUS-eligible individuals, the cost thereof is chargeable to
operation and maintenance funds available for operation of the facility
requesting care or services. Cooperative care applies to CHAMPUS-
eligible patients receiving inpatient or outpatient care in a USMTF who
require care or services beyond the capability of that USMTF. The
following general principles apply to such CHAMPUS-eligible patients:
(i) Cooperation of uniformed services physicians. USMTF physicians
are required to cooperate in providing CHAMPUS contractors and OCHAMPUS
additional medical information. SECNAVINST 5211.5C delineates policies,
conditions, and procedures that govern safeguarding, using, accessing,
and disseminating personal information kept in a system of records.
Providing information to CHAMPUS contractors and OCHAMPUS will be
governed thereby.
(ii) Physician case management. Where required by NAVMEDCOMINST
6320.18 (CHAMPUS Regulation; implementation of), uniformed services
physicians are required to provide case management (oversight) as would
an attending or supervising civilian physician.
(iii) CHAMPUS-authorized providers. CHAMPUS contractors are
responsible for determining whether a civilian provider is CHAMPUS-
authorized and for providing such information, upon request, to USMTFs.
[[Page 300]]
(iv) Phychiatric or psychotherapeutic services. If psychiatric care
is being rendered by a psychiatric or clinical social worker, a
psychiatric nurse, or a marriage and family counselor, and the uniformed
services facility has made a determination that it does not have the
professional staff competent to provide required physician case
management, the patient may be (partially) disengaged for the
psychiatric or psychotherapeutic service, yet have the remainder of
required medical care provided by the naval MTF.
(v) Forms and documentation. A DD 2161, Referral For Civilian
Medical Care, will be provided to each patient who is to receive
supplemental or cooperative care or services. When supplemental care is
required under the provisions of Sec. 728.4(z) (3) and (4), the
provisions of Sec. 728.4(z)(3)(iii) apply. When cooperative care or
services are required under the provisions of Sec. 728.4(z) (5) and (6),
the provisions of Sec. 728.4(z)(5)(iv) apply.
(vi) Clarification of unusual circumstances. Commanding officers of
naval MTFs will submit requests for clarification of unusual
circumstances to OCHAMPUS or CHAMPUS contractors via the Commander,
Naval Medical Command (MEDCOM-33) for consideration.
(2) Care beyond a naval MTF's capability. When, either during
initial evaluation or during the course of treatment of CHAMPUS-eligible
beneficiaries, required services are beyond the capability of the naval
MTF, the commanding officer will arrange for the services from an
alternate source in the following order, subject to restrictions
specified. The provisions of Sec. 728.4(z)(2)(i) through (iii) must be
followed before either supplemental care, authorized in
Sec. 728.4(z)(4), is considered for payment from Navy Operations and
Maintenance funds, or cooperative care, authorized in Sec. 728.4(z)(6),
is to be considered for payment under the terms of CHAMPUS.
(i) Obtain from another USMTF or other Federal MTF the authorized
care necessary for continued treatment of the patient within the naval
MTF, when such action is medically feasible and economically
advantageous to the Government.
(ii) When the patient is a retired member or dependent, transfer per
Sec. 728.4(bb)(3) (i), (ii), (iii), or (iv), in that order. When the
patient is a dependent of a member of a NATO nation, transfer per
Sec. 728.4(bb)(4) (i), (ii), or (iii), in that order.
(iii) With the patient's permission, the naval MTF may contact State
programs, local health agencies, or health foundations to determine if
benefits are available.
(iv) Obtain such supplemental care or services as delineated in
Sec. 728.4(z)(4) from a civilian source using local operation and
maintenance funds, or
(v) Obtain such cooperative care or services as delineated in
Sec. 728.4(z)(6) from a civilian source under the terms of CHAMPUS.
(3) Operation and maintenance funds. When local operation and
maintenance funds are to be used to obtain supplemental care or
services, the following guidelines are applicable:
(i) Care or services must be legitimate, medically necessary, and
ordered by a qualified USMTF provider.
(ii) The naval MTF must make the necessary arrangements for
obtaining required care or services from a specific source of care.
(iii) Upon approval of the naval MTF commanding officer or designee,
provide the patient or sponsor with a properly completed DD 2161,
Referral For Civilian Medical Care. The DD 2161 will be marked by the
health benefits advisor or other designated individual to show the naval
MTF as the source of payment. Forward a copy to the MTF's contracting or
supply officer who is the point of contact for coordinating obligations
with the comptroller and thus is responsible for assuring proper
processing for payment.
(iv) Authorize care on an inpatient or outpatient basis for the
minimum period necessary for the civilian provider to perform the
specific test, procedure, treatment, or consultation requested. Patients
receiving inpatient services in civilian medical facilities will not be
counted as an occupied bed in the naval MTF, but will be continued on
the naval MTF's inpatient census. Continue to charge pay patients the
USMTF inpatient rate appropriate for their patient category.
[[Page 301]]
(v) Naval MTF physicians will maintain professional contact with
civilian providers.
(4) Care and services authorized. Use local operation and
maintenance funds to defray the cost of the following when CHAMPUS-
eligible patients are referred to civilian sources for the following
types of care or services;
(i) All specialty consultations for the purpose of establishing or
confirming diagnoses or recommending a course of treatment.
(ii) All diagnostic tests, diagnostic examinations, and diagnostic
procedures (including genetic tests and CAT scans), ordered by qualified
USMTF providers.
(iii) Prescription drugs and medical supplies.
(iv) Civilian ambulance service ordered by USMTF personnel.
(5) CHAMPUS funds. When payment is to be considered under the terms
of CHAMPUS for cooperative care, even though the beneficiary remains
under naval MTF control, the following guidelines are applicable:
(i) Process charges for care under the terms of CHAMPUS.
(A) If the charge for a covered service or supply is above the
CHAMPUS-determined reasonable charge, the direct care system will not
assume any liability on behalf of the patient where a civilian provider
is concerned, although a USMTF physician recommended or prescribed the
service or supply.
(B) Payment consideration for all care or services meeting
cooperative care criteria will be under the terms of CHAMPUS and payment
for such care or services will not be made from naval MTF funds.
Conversely, any care or services meeting naval MTF supplemental care or
services payment criteria will not be considered under the terms of
CHAMPUS.
(ii) Care must be legitimate and otherwise permissible under the
terms of CHAMPUS and must be ordered by a qualified USMTF provider.
(iii) Provide assistance to beneficiaries referred or disengaged
under CHAMPUS. Although USMTF personnel are not authorized to refer
beneficiaries to a specific civilian provider for care under CHAMPUS,
health benefits advisors are authorized to contact the cooperative care
coordinator of the appropriate CHAMPUS contractor for aid in determining
authorized providers with the capability of rendering required services.
Such information may be given to beneficiaries. Also encourage
beneficiaries to obtain required services only from providers willing to
participate in CHAMPUS. Subject to the availability of space,
facilities, and capabilities of the staff, USMTFs may provide
consultative and such other ancillary aid as required by the civilian
provider selected by the beneficiary.
(iv) Provide a properly completed DD 2161, Referral For Civilian
Medical Care, to patients who are referred (versus disengaged) to
civilian sources under the terms of CHAMPUS for cooperative care. (A
Nonavailability Statement (DD 1251) may also be required. Provide this
form when required under Sec. 728.33.) The DD 2161 will be marked by the
health benefits advisor, or other designated individual, to show CHAMPUS
as the source of payment consideration. All such DD 2161's must be
approved by the commanding officer or designee. Give the patient
sufficient copies to ensure a copy of the DD 2161 accompanies each
CHAMPUS claim. Advise patients that CHAMPUS contractors will return
claims received without the DD 2161. Also advise patients to arrange for
return of a completed copy of the DD 2161 to the naval MTF for inclusion
in their medical record.
(v) Such patients receiving inpatient or outpatient care or services
will pay the patient's share of the costs as specified under the terms
of CHAMPUS for their beneficiary category. Patients receiving inpatient
services will not be continued on the naval MTF's census and will not be
charged the USMTF inpatient rate.
(vi) Certain ancillary services authorized under CHAMPUS require
physician case management during the course of treatment. USMTF
physicians will manage the provision of ancillary services by civilian
providers when such services are obtained under the terms of CHAMPUS.
Examples include physical therapy, private duty (special) nursing,
rental or lease/purchase of durable medical equipment,
[[Page 302]]
and services under the CHAMPUS Program for the Handicapped. USMTF
providers exercising physician case management responsibility for
ancillary services under CHAMPUS are subject to the same benefit
limitations and certification of need requirements applicable to
civilian providers under the terms of CHAMPUS for the same types of
care. USMTF physicians exercising physician case management
responsibility will maintain professional contact with civilian
providers of care.
(6) Care and services authorized. Refer CHAMPUS-eligible patients to
civilian sources for the following under the terms of CHAMPUS:
(i) Authorized nondiagnostic medical services such as physical
therapy, speech therapy, radiation therapy, and private duty (special)
nursing.
(ii) Preauthorized (by OCHAMPUS) adjunctive dental care, including
orthodontia related to surgical correction of cleft palate.
(iii) Durable medical equipment. (CHAMPUS payment will be considered
only if the equipment is not available on a loan basis from the naval
MTF.)
(iv) Prosthetic devices (limited benefit), orthopedic braces and
appliances.
(v) Optical devices (limited benefit).
(vi) Civilian ambulance service to a USMTF when service is ordered
by other than direct care personnel.
(vii) All CHAMPUS Program for the Handicapped care.
(viii) Psychotherapeutic or psychiatric care.
(ix) Except for those types of care or services delineated in
Sec. 728.4(z)(4), all other CHAMPUS authorized medical services not
available in the naval MTF (for example, neonatal intensive care).
(aa) Third party liability case. Per chapter 24, section 2403, JAG
Manual, use the following guidelines to complete and submit a NAVJAG
5890/12, Hospital and Medical Care, 3rd Party Liability Case, when a
third party may be liable for the injury or disease being treated:
(1) Preparation. All naval MTFs will use the front of NAVJAG 5890/12
to report the value of medical care furnished to any patient when (i) a
third party may be legally liable for causing the injury or disease, or
(ii) when a Government claim is possible under workmen's compensation,
no-fault insurance (see responsibilities for apprising the insurance
carrier in Sec. 728.4(aa)(5)), uninsured motorist insurance, or under
medical payments insurance (e.g., in all automobile accident cases).
Block 4 of this form requires an appended statement of the patient or an
accident report, if available. Prior to requesting such a statement from
a patient, the person preparing the front side of NAVJAG 5890/12 will
show the patient the Privacy Act statement printed at the bottom of the
form and have the patient sign his or her name beneath the statement.
(2) Submission--(i) Naval patients. For naval patients, submit the
completed front side of the NAVJAG 5890/12 to the appropriate action JAG
designee listed in section 2401 of the JAG Manual at the following
times:
(A) Initial. Make an initial submission as soon as practicable after
a patient is admitted for any period of inpatient care, or if it appears
that more than 7 outpatient treatments will be furnished. This
submission should not be delayed pending the accumulation of all
potential charges from the treating facility. This submission need not
be based upon an extensive investigation of the cause of the injury or
disease, but it should include all known facts. Statements by the
patient, police reports, and similar information (if available), should
be appended to the form.
(B) Interim. Make an interim submission every 4 months after the
initial submission until the patient is transferred or released from the
facility, or changed from an inpatient status to an outpatient status.
(C) Final. Make a final submission upon completion of treatment or
upon transfer of the patient to another facility. The facility to which
the patient is transferred should be noted on the form. Report control
symbol NAVJAG 5890-1 is assigned to this report.
(ii) Nonnaval patients. When care is provided to personnel of
another Federal agency or department, that agency or department
generally will assert any claim in behalf of the United States. In such
instances, submit the NAVJAG 5890/12's (initial, interim, and
[[Page 303]]
final) directly to the appropriate of the following:
(A) U.S. Army. Commanding general of the Army or comparable area
commander in which the incident occurred.
(B) U.S. Air Force. Staff judge advocate of the Air Force
installation nearest the location where the initial medical care was
provided.
(C) U.S. Coast Guard. Commandant (G-K-2). U.S. Coast Guard,
Washington, DC 20593-0001.
(D) Department of Labor. The appropriate Office of Workers'
Compensation Programs (OWCP).
(E) Veterans Administration. Director of the Veterans Administration
hospital responsible for medical care of the patient being provided
treatment.
(F) Department of Health and Human Services (DHHS). Regional
attorney's office in the area were the incident occurred.
(3) Supplementary documents. An SF 502 should accompany the final
submission in all cases involving inpatient care. Additionally, when
Government care exceeds $1,000, inpatient facilities should complete and
submit the back side of NAVJAG 5890/12 to the action JAG designee. On
this side of the form, the determination of ``patient status'' may be
used on local hospital usage.
(4) Health record entries. Retain copies of all NAVJAG 5890/12's in
the Health Record of the patient. Immediately notify action JAG
designees when a patient receives additional treatment subsequent to the
issuance of a final NAVJAG 5890/12 if the subsequent treatment is
related to the condition which gave rise to the claim.
(5) No-fault insurance. When no-fault insurance is or may be
involved, the naval legal service office at which the JAG designee is
located is responsible for apprising the insurance carrier that the
Federal payment for the benefits of this part is secondary to any no-
fault insurance coverage available to the injured individual.
(6) Additional guidance. Chapter 24 of the JAG Manual and BUMEDINST
5890.1A contain supplemental information.
(bb) Transfer of patients--(1) General. Treat all patients at the
lowest echelon equipped and staffed to provide necessary care; however,
when transfer to another MTF is considered necessary, use Government
transportation when available. Accomplish medical regulating per the
provisions of OPNAVINST 4630.25B and BUMEDINST 6320.1D.
(2) U.S. military patients. Do not retain U.S. military patients in
acute care MTFs longer than the minimum time necessary to attain the
mental or physical state required for return to duty or separation from
the service. When required care is not available at the facility
providing area inpatient care, transfer patients to the most readily
accessible USMTF or designated USTF possessing the required capability.
Transportation of the patient and a medical attendant or attendants, if
required, is authorized at Government expense. Since the VA is staffed
and equipped to provide care in the most expeditious manner, follow the
administrative procedures outlined in NAVMEDCOMINST 6320.12 when:
(i) A patient has received the maximum benefit of hospitalization in
a naval MTF but requires a protracted period of nursing home type care.
The VA can provide this type care or arrange for it from a civilian
source for individuals so entitled.
(ii) Determined that there is or may be spinal cord injury
necessitating immediate medical and psychological attention.
(iii) A patient has sustained an apparently severe head injury or
has been blinded necessitating immediate intervention beyond the
capabilities of naval MTFs.
(iv) A determination has been made by the Secretary concerned that a
member on active duty has an alcohol or drug dependency or drug abuse
disability.
(3) Retired members and dependents. When a retired member of a
dependent requires care beyond the capabilities of a facility and a
transfer is necessary, the commanding officer of that facility may:
(i) Arrange for transfer to another USMTF or designated USTF located
in an overlapping inpatient catchment area of the transferring facility
if either has the required capability.
(ii) If the patient or sponsor agrees, arrange for transfer to the
nearest
[[Page 304]]
USMTF or designated USTF with required capability, regardless of its
location.
(iii) Arrange for transfer of retired members to the Veterans
Administration MTF nearest the patient's residence.
(iv) Provide aid in releasing the patient to a civilian provider of
the patient's choice under the terms of Medicare, if the patient is
entitled. Beneficiaries entitled to Medicare, Part A, because they are
65 years of age or older or because of a disability or chronic renal
disease, lose CHAMPUS eligibility but remain eligible for care in USMTFs
and designated USTFs.
(v) If the patient is authorized benefits under CHAMPUS, disengage
from medical management and issue a Non-availability Statement (DD 1251)
per the provisions of Sec. 728.33, for care under CHAMPUS. This step
should only be taken after due consideration is made of the
supplemental/cooperative care policy addressed in Sec. 728.4(z).
(4) Dependents of members of NATO nations. When a dependent, as
defined in Sec. 728.41, of a member of a NATO nation requires care
beyond the capabilities of a facility and a transfer is necessary, the
commanding officer of that facility may:
(i) Arrange for transfer to another USMTF or designated USTF with
required capability if either is located in an overlapping inpatient
catchment area of the transferring facility.
(ii) If the patient or sponsor agrees, arrange for transfer to the
nearest USMTF or designated USTF with required capability, regardless of
its location.
(iii) Effect disposition per Sec. 728.42(d).
(5) Others--(i) Medical care. Section 34 of title 24, United States
Code, provides that hospitalization and outpatient services may be
provided outside the continental limits of the United States and in
Alaska to officers and employees of any department or agency of the
Federal Government, to employees of a contractor with the United States
or the contractor's subcontractor, to dependents of such persons, and in
emergencies to such other persons as the Secretary of the Navy may
prescribe: Provided, such services are not otherwise available in
reasonably accessible and appropriate non-Federal facilities.
Hospitalization of such persons in a naval MTF is further limited by 24
U.S.C. 35 to the treatment of acute medical and surgical conditions,
exclusive of nervous, mental, or contagious diseases, or those requiring
domiciliary care.
(ii) Dental care. Section 35 of title 24 provides for space
available routine dental care, other than dental prosthesis and
orthodontia, for the categories of individuals enumerated in
Sec. 728.4(bb)(5)(i): Provided, that such services are not otherwise
available in reasonably accessible and appropriate non-Federal
facilities.
(iii) Transfer. Accomplish transfer and subsequent treatment of
individuals in Sec. 728.4(bb)(5)(i) per the provisions of law enumerated
in Sec. 728.4(bb)(5) (i) and (ii).
(cc) Verification of patient eligibility--(1) DEERS. (i) The Defense
Enrollment Eligibility Reporting System (DEERS) was implemented by
OPNAVINST 1750.2. Where DEERS has been started at naval medical and
dental treatment facilities, commanding officers will appoint, in
writing, a DEERS project officer to perform at the base level. The
project officer's responsibilities and functions include coordinating,
executing, and maintaining base-level DEERS policies and procedures;
providing liaison with line activities, base-level personnel project
officers, and base-level public affairs project officers; meeting and
helping the contractor field representative on site visits to each
facility under the project officer's cognizance; and compiling and
submitting reports required within the command and by higher authority.
(ii) Commanding officers of afloat and deployable units are
encouraged to appoint a unit DEERS medical project officer as a liaison
with the hospital project officer providing services to local medical
and dental treatment facilities. Distribute notice of such appointments
to all concerned facilities.
(iii) When a DEERS project officer has been appointed by a naval MTF
or DTF, submit a message (report control symbol MED 6320-42) to
COMNAVMEDCOM, with information
[[Page 305]]
copies to appropriate chain of command activities, no later than 10
October annually, and situationally when changes occur. As a minimum,
the report will provide:
(A) Name of reporting facility. If the project officer is
responsible for more than one facility, list all such facilities.
(B) Mailing address including complete zip code (zip + 4) and unit
identification code (UIC). Include this information for all facilities
listed in Sec. 728.4(cc)(1)(iii)(A).
(C) Name, grade, and corps of the DEERS project officer designated.
(D) Position title within parent facility.
(E) AUTOVON and commercial telephone numbers.
(2) DEERS and the identification card. This subpart includes DEERS
procedures for eligibility verification checks to be used in conjunction
with the identification card system as a basis for verifying eligibility
for medical and dental care in USMTFs and uniformed services dental
treatment facilities (USDTFs). For other than emergency care, certain
patients are required to have a valid ID card in their possession and,
under the circumstances described in Sec. 728.4(cc)(3), are also
required to meet DEERS criteria before treatment or services are
rendered. Although DEERS and the ID card system are interrelated, there
will be instances where a beneficiary is in possession of an apparently
valid ID card and the DEERS verification check shows that eligibility
has terminated or vice versa. Eligibility verification via an ID card
does not override an indication of ineligibility in DEERS without some
other collateral documentation. Dependents (in possession of or without
ID cards) who undergo DEERS checking will be considered ineligible for
the reasons stated in Sec. 728.4(cc)(4)(v) (A) through (G). For problem
resolution, refer dependents of active duty members to the personnel
support detachment (PSD) servicing the sponsor's command; refer
retirees, their dependents, and survivors to the local PSD.
(3) Identification cards and procedures. All individuals, including
members of uniformed services in uniform, must provide valid
identification when requesting health benefits. Although the most widely
recognized and acceptable forms of identification are DD 1173, DD 2,
Form PHS-1866-1, and Form PHS-1866-3 (Ret), individuals presenting for
care without such identification may be rendered care upon presentation
of other identification as outlined in this part. Under the
circumstances indicated, the following procedures will be followed when
individuals present without the required ID card.
(i) Children under 10. Although a DD 1173 (Uniformed Services
Identification and Privilege Card) may be issued to children under 10
years of age, under normal circumstances they are not. Accordingly,
certification and identification of children under 10 years of age are
the responsibility of the member, retired member, accompanying parent,
legal guardian, or acting guardian. Either the DD 1173 issued the spouse
of a member or former member or the identification card of the member or
former member (DD 2, DD 2 (Ret), Form PHS-1866-1, or Form PHS-1866-3
(Ret)) is acceptable for the purpose of verifying eligibility of a child
under 10 years of age.
(ii) Indefinite expiration. The fact that the word ``indefinite''
may appear in the space for the expiration date on a member's card does
not lessen its acceptability for identification of a child. See
Sec. 728.4(cc)(3)(iii) for dependent's cards with an indefinite
expiration date.
(iii) Expiration date. To be valid, a dependent's DD 1173 must have
an expiration date. Do not honor a dependent's DD 1173 with an
expiration date of ``indefinite''. Furthermore, such a card should be
confiscated, per NAVMILPERSCOMINST 1750.1A, and forwarded to the local
PSD. The PSD may then forward it to the Commander, Naval Military
Personnel Command, (NMPC (641D)/Pers 7312), Department of the Navy,
Washington, DC 20370-5000 for investigation and final disposition.
Render necessary emergency treatment to such a person. The patient
administration department must determine such a patient's beneficiary
status within 30 calendar days and forward such determination to the
fiscal department. If indicated, billing
[[Page 306]]
action for treatment will then proceed following NAVMED P-5020.
(iv) Without cards or with expired cards. (A) When parents or
parents-in-law (including step-parents and step-parents-in-law) request
care in naval MTFs or DTFs without a DD 1173 in their possession or with
expired DD 1173's, render care if they or their sponsor sign a statement
that the individual requiring care has a valid ID card or that an
application has been submitted for a renewal DD 1173. In the latter
instance, include in the statement the allegation that: (1) The
beneficiary is dependent upon the service member for over one-half of
his or her support, and (2) that there has been no material change in
the beneficiary's circumstances since the previous determination of
dependency and issuance of the expired card. Place the statement in the
beneficiary's medical record. Inform the patient or sponsor that if
eligibility is not verified by presentation of a valid ID card to the
patient administration department within 30 calendar days, the facility
will initiate action to recoup the cost of care. If indicated, billing
action for the cost of treatment will then proceed following NAVMED P-
5020.
(B) When recent accessions, National Guard, reservists, or Reserve
units are called to active duty for a period greater than 30 days and
neither the members nor their dependents are at yet in receipt of their
identification cards, satisfactory collateral identification may be
accepted in lieu thereof, i.e., official documents such as orders, along
with a marriage license, or birth certificate which establish the
individual's status as a dependent of a member called to duty for a
period which is not specified as 30 days or less. For a child, the
collateral documentation must include satisfactory evidence that the
child is within the age limiting criteria outlined in Sec. 728.31(b)(4).
An eligible dependent's entitlement, under the provisions of this
subpart, starts on the first day of the sponsor's active service and
ends as of midnight on the last day of active service.
(4) DEERS checking. Unless otherwise indicated, all DEERS
verification procedures will be accomplished in conjunction with
possession of a valid ID card.
(i) Prospective DEERS processing--(A) Appointments. To minimize
difficulties for MTFs, DTFs, and patients, DEERS checks are necessary
for prospective patients with future appointments made through a central
or clinic appointment desk. Without advance DEERS checking, patients
could arrive at a facility with valid ID cards but may fail the DEERS
check, or may arrive without ID cards but be identified by the DEERS
check as eligible. Records, including full social security numbers, of
central and clinic appointment systems will be passed daily to the DEERS
representative for a prospective DEERS check. This enables appointment
clerks to notify individuals with appointments of any apparent problem
with the DEERS or ID card system and refer those with problems to
appropriate authorities prior to the appointment.
(B) Prescriptions. Minimum checking requirements of the program
require prospective DEERS checks on all individuals presenting
prescriptions of civilian providers (see Sec. 728.4(cc)(4)(iv)(D)).
(ii) Retrospective DEERS processing. Pass daily logs (for walk-in
patients, patients presenting in emergencies, or patients replacing last
minute appointment cancellations) to the DEERS representative for
retrospective batch processing if necessary for the facility to meet the
minimum checking requirements in Sec. 728.4(cc)(4)(iv). For DEERS
processing, the last four digits of a social security number are
insufficient. Accordingly, when retrospective processing is necessary,
the full social security number of each patient must be included on
daily logs.
(iii) Priorities. With the following initial priorities, conduct
DEERS eligibility checks using a CRT terminal, single-number dialer
telephone, or 800 number access provided for the specific purpose of
DEERS checking to:
(A) Determine whether a beneficiary is enrolled.
(B) Verify beneficiary eligibility. Eastablishment of eligibility is
under the cognizance of personnel support activities and detachments.
[[Page 307]]
(C) Identify any errors on the data base.
(iv) Minimum checking requirements. Process patients presenting at
USMTFs and DTFs in the 50 States for DEERS eligibility verification per
the following minimum checking requirements.
(A) Twenty five percent of all outpatient visits.
(B) One hundred percent of all admissions.
(C) One hundred percent of all dental visits at all DTFs for other
than active duty members, retired members, and dependent.
(1) Active duty members are exempt from DEERS eligibility
verification checking at DTFs.
(2) Retired members will receive a DEERS vertification check at the
initial visit to any DTF and annually thereafter at time of treatment at
the same facility. To qualify for care as a result of the annually
performed verification check, the individual performing the eligibility
check will make a notation to this effect on an SF 603, Health Record--
Dental. Include in the notation the date and result of the check.
(3) Dependents will have a DEERS eligibility verification check upon
initial presentation for evaluation or treatment. This check will be
valid for up to 30 days if, when the check is conducted, the period of
eligibility requested is 30 days. A 30-day eligibility check may be
accomplished online or via telephone by filling in or requesting the
operator to fill in a 30 day period in the requested treatment dates on
the DEERS eligibility inquiry screen. Each service or clinic is expected
to establish auditable procedures to trace the date of the last
eligibility verification on a particular dependent.
(D) One hundred percent of pharmacy outpatients presenting new
prescriptions written by a civilian provider. Prospective DEERS checks
are required for all patients presenting prescriptions of civilian
providers. A DEERS check is not required upon presentation of a request
for refill of a prescription of a civilian provider if the original
prescription was filled by a USMTF within the past 120 days.
(E) One hundred percent of all individuals requesting treatment
without a valid ID card if they represent themselves as individuals who
are eligible to be included in the DEERS data base.
(v) Ineligibility determinations. When a DEERS verification check is
performed and eligibility cannot be verified for any of the following
reasons, deny routine nonemergency care unless the beneficiary meets the
criteria for a DEERS eligibility override as noted in
Sec. 728.4(cc)(4)(viii).
(A) Sponsor not enrolled in DEERS.
(B) Dependent not enrolled in DEERS.
(C) ``End eligibility date'' has passed. Each individual in the
DEERS data base has a date assigned on which eligibility is scheduled to
end.
(D) Sponsor has separated from active duty and is no longer entitled
to benefits.
(E) Spouse has a final divorce decree from sponsor and is not
entitled to continued eligibility as a former spouse.
(F) Dependent child is married.
(G) Dependent becomes an active duty member of a uniformed service.
(Applies only to CHAMPUS benefits since the former dependent becomes
entitled to direct care benefits in his or her own right as an active
duty member and must enroll in DEERS.)
(vi) Emergency situations. When a physician determines that
emergency care is necessary, initiate treatment. If admitted after
emergency treatment has been provided, a retrospective DEERS check is
required. If an emergency admission or emergency outpatient treatment is
accomplished for an individual whose proof of eligibility is in
question, the patient administration department must determine the
individual's beneficiary status within 30 calendar days of treatment and
forward such determination to the fiscal department. Eligibility
verifications will normally consist of presentation of a valid ID card
along with either a positive DEERS check or a DEERS override as noted in
Sec. 728.4(cc)(4)(viii). If indicated, billing action for treatment will
then proceed per NAVMED P-5020.
(vii) Eligibility verification for nonemergency care. When a
prospective patient presents without a valid ID card and:
[[Page 308]]
(A) DEERS does not verify eligibility, deny nonemergency care. Care
denial will only be accomplished by supervisory personnel designated by
the commanding officer.
(B) The individual is on the DEERS data base, do not provide
nonemergency care until a NAVMED 6320/9, Dependent's Eligibility for
Medical Care, is signed by the member, patient, patient's parent, or
patient's legal or acting guardian. This form attests the fact that
eligibility has been established per appropriate directives and includes
the reason a valid ID card is not in the prospective patient's
possession. Apprise the aforementioned responsible individual of the
provisions on the form NAVMED 6320/9 now requiring presentation of a
valid ID card within 30 calendar days. Deny treatment or admission in
physician determined nonemergency situations of persons refusing to sign
the certification on the NAVMED 6320/9. For persons rendered treatment,
patient administration department personnel must determine their
eligibility status within 30 calendar days and forward such
determination to the fiscal department. If indicated, billing action for
treatment will then proceed following NAVMED P-5020.
(viii) DEERS overrides. Possession of an ID card alone does not
constitute sufficient proof of eligibility when the DEERS check does not
verify eligibility. What constitutes sufficient proof will be determined
by the reason the patient failed the DEERS check. For example, groups
most expected to fail DEERS eligibility checks are recent accession
members and their dependents, Guard or Reserve members recently
activated for training periods of greater than 30 days and their
dependents, and parents and parents-in-law with expired ID cards. Upon
presentation of a valid ID card, the following are reasons to
``override'' a DEERS check either showing the individual as ineligible
or when an individual does not appear in the DEERS data base.
(A) DD 1172. Patient presents an original of a copy of a DD 1172,
Application for Uniformed Services Identification and Privilege Card,
which is also used to enroll beneficiaries in DEERS. If the original is
used, the personnel support detachment (PSD) furnishing the original
will list the telephone number of the verifying officer to aid in
verification. Any copy presented must have an original signature in
section III; printed name of verifying officer, his or her grade, title,
and telephone number; and the date the copy was issued. For treatment
purposes, this override expires 120 days from the date issued.
(B) Recently issued identification cards--(1) DD 1173. Patient
presents a recently issued DD 1173, Uniformed Services Identification
and Privilege Card. Examples are spouses recently married to sponsor,
newly eligible stepchildren, family members of sponsors recently
entering on active duty for a period greater than 30 days, parents or
parents-in-law, and unremarried spouses recently determined eligible.
For treatment purposes, this override expires 120 days from the date
issued.
(2) Other ID cards. Patient presents any of the following ID cards
with a date of issue within the previous 120 days: DD 2, DD 2 (Ret),
Form PHS 1866-1, or Form PHs 1866-3 (Ret). When these ID cards are used
for the purpose of verifying eligibility for a child, collateral
documentation is necessary to ensure the child is actually the alleged
sponsor's dependent and in determining whether the child is within the
age limiting criteria outlined in Sec. 728.31(b)(4).
(C) Active duty orders. Patient or sponsor presents recently issued
orders to active duty for a period greater than 30 days. Copies of such
orders may be accepted up to 120 days of their issue date.
(D) Newborn infants. Newborn infants for a period of 1 year after
birth provided the sponsor presents a valid ID card.
(E) Recently expired ID cards. If the DEERS data base shows an
individual as ineligible due to an ID card that has expired within the
previous 120 days (shown on the screen as ``Elig with valid ID card''),
care may be rendered when the patient has a new ID card issued within
the previous 120 days.
(F) Sponsor's duty station has an FPO or APO number or sponsor is
stationed outside the 50 United States. Do not deny
[[Page 309]]
care to bona fide dependents of sponsors assigned to a duty station
outside the 50 United States or assigned to a duty station with an FPO
or APO address as long as the sponsor appears on the DEERS data base.
Before initiating nonemergency care, request collateral documentation
showing relationship to sponsor when the relationship is or may be in
doubt.
(G) Survivors. Dependents of deceased sponsors when the deceased
sponsor failed to enroll in or have his or her dependents enrolled in
DEERS. This situation will be evidenced when an eligibility check on the
surviving widow or widower (or other dependent) finds that the sponsor
does not appear (screen shows ``Sponsor SSN Not Found'') or the
survivor's name appears as the sponsor but the survivor is not listed
separately as a dependent. In any of these situations, if the survivor
has a valid ID card, treat the individual on the first visit and refer
him or her to the local personnel support detachment for correction of
the DEERS data base. For second and subsequent visits prior to
appearance on the DEERS data base, require survivors to present a DD
1172 issued per Sec. 728.4(cc)(4)(viii)(A).
(H) Patients not eligible for DEERS enrollment. (1) Secretarial
designees are not eligible for enrollment in DEERS. Their eligibility
determination is verified by the letter, on one of the service
Secretaries' letterhead, of authorization issued.
(2) When it becomes necessary to make a determination of eligibility
on other individuals not eligible for entry on the DEERS data base,
patient administration department personnel will obtain a determination
from the purported sponsoring agency, if appropriate. When necessary to
treat or admit a person who cannot otherwise present proof of
eligibility for care at the expense of the Government, do not deny care
based only on the fact that the individual is not on the DEERS data
base. In such instances, follow the procedures in NAVMED P-5020 to
minimize, to the fullest extent possible, the write-off of uncollectible
accounts.