[Title 32 CFR 732.19]
[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 732 - NONNAVAL MEDICAL AND DENTAL CARE]
[Subpart B - Medical and Dental Care From Nonnaval Sources]
[Sec. 732.19 - Claims.]
[From the U.S. Government Printing Office]


32NATIONAL DEFENSE52002-07-012002-07-01false732.19Sec. 732.19NATIONAL DEFENSEDepartment of Defense (Continued)DEPARTMENT OF THE NAVYPERSONNELNONNAVAL MEDICAL AND DENTAL CAREMedical and Dental Care From Nonnaval Sources
Sec. 732.19  Claims.

    (a) Member's responsibility. Members receiving care are responsible 
for preparation and submission of claims to the cognizant adjudication 
authority identified in Sec. 732.20. A complete claim includes:
    (1) NAVMED 6320/10, Statement of Civilian Medical/Dental Care. In 
addition to its use as an authorization document, the original and three 
copies of a

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NAVMED 6320/10 are required to adjudicate claims in each instance of 
sickness, injury, or maternity care when treatment is received from a 
non-Federal source under the provisions of this part. The form should be 
prepared by a naval medical or dental officer, when practicable, by the 
senior officer present where a naval medical or dental officer is not on 
duty, or by the member receiving care when on detached duty where a 
senior officer is not present.
    (i) For nonemergency care with prior approval, submit the NAVMED 
6320/10 containing the prior approval, after completing blocks 8 through 
18.
    (ii) For emergency care (or nonemergency care without prior 
approval), submit a NAVMED 6320/10 after completing blocks 1 through 18. 
Assure that the diagnosis is listed in block 10. If prior approval was 
not obtained, state in block 11 circumstances necessitating use of non-
Federal facilities.
    (iii) Signature by the member in block 17 implies agreement for 
release of information to the responsible adjudication authority 
receiving the claim for processing. Signature by the certifying officer 
in block 18 will be considered certification that documentation has been 
entered in the member's Health Record as directed in article 16-24 of 
MANMED.
    (2) Itemized bills. The original and three copies of itemized bills 
to show:
    (i) Dates on or between which services were rendered or supplies 
furnished.
    (ii) Nature of and charges for each item.
    (iii) Diagnosis.
    (iv) Acknowledgment of receipt of the services or supplies on the 
face of the bill or by separate certificate. The acknowledgment must 
include the statement. ``Services were received and were satisfactory.''
    (3) Claims for reimbursement. To effect reimbursement, also submit 
the original and three copies of paid receipts and an SF 1164. Claim for 
Reimbursement for Expenditures on Official Business, completed per 
paragraphs 046377-2 a and b of the Naval Comptroller Manual (NAVCOMPT 
MAN).
    (4) Notice of eligibility (NOE) and line of duty (LOD) 
determination. When a reservist claims benefits for care received 
totally after the completion of either an active duty or active duty for 
training period, the claim should also include:
    (i) An NOE issued per SECNAVINST 1770.3.
    (ii) An LOD determination from the member's commanding officer.
    (b) Adjudicating authority's responsibility. Reviewing and 
processing properly completed claims and forwarding approved claims to 
the appropriate disbursing office should be completed within 30 days of 
receipt. Advice may be requested from COMNAVMEDCOM (MEDCOM-333 (A/V 294-
1127)) for medical or MEDCOM-06 (A/V 294-1250)) for dental on unusual or 
questionable instances of care. Advise claimants of any delay 
experienced in processing claims.
    (1) Review. The receiving adjudication authority will carefully 
review each claim submitted for payment or reimbursement to verify 
whether:
    (i) Claimant was entitled to benefits (i.e., was on active duty, 
active duty for training, inactive duty training, was not an 
unauthorized absentee, etc.). As required by part 728 of this chapter, a 
Defense Enrollment Eligibility Reporting System (DEERS) eligibility 
check must be performed on claims to all claimants required to be 
enrolled in DEERS.
    (ii) Care rendered was due to a bona fide emergency. (Note: When 
questions arise as to the emergency nature of care, forward the claim 
and all supporting documentation to the appropriate clinical specialist 
at the nearest naval hospital for review.)
    (iii) Prior approval was granted if a bona fide emergency did not 
exist. (Note: If prior approval was not obtained and the condition 
treated is determined to have been nonemergent, the claim may be 
denied.) Consideration should always be given to cases that would have 
received prior approval but, due to lack of knowledge of the program, 
the member did not submit a request.
    (iv) Care rendered was authorized under the provisions of this part.

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    (v) Care rendered was appropriate for the specific condition 
treated. (NOTE: When questions arise regarding appropriateness of care, 
forward all documentation to a clinical specialist at the nearest naval 
hospital for review. If care is determined to have been inappropriate, 
the claim may be denied to the extent the member was negligent.)
    (vi) Claimed benefits did not result from a referral by a USMTF. If 
the member was an inpatient or an outpatient in a USMTF immediately 
prior to being referred to a civilian source of care, the civilian care 
is supplemental and may be the responsibility of the referring USMTF. 
See Sec. 732.11(p) for the definition of supplemental care.
    (2) Dispproval. If a determination is made to disapprove a claim, 
provide the member (and provider of care, when applicable) a prompt and 
courteous letter stating the reason for the disapproval and the 
appropriate avenues of appeal as outlined in Sec. 732.24.
    (3) Processing. Subpart C contains the chargeable accounting 
classifications and Standard Document Numbers (SDN) to be cited on the 
NAVCOMPT 2277, Voucher for Disbursement and/or Collection, on an SF 1164 
submitted per paragraph (a)(3) of this section, and on supporting 
documents of approved claims before submission to disbursing offices.
    (i) For payment to providers of care, a NAV COMPT 2277 will be 
prepared and certified approved for payment by the adjudicating 
authority. This form must accompany the NAVMED 6320/10 and supporting 
documentation per paragraph 046393-1 of the NAVCOMPTMAN.
    (ii) Where reimbursement is requested, the SF 1164 submitted per 
Sec. 732.19(a)(3) will be completed, per paragraph 046377 of the 
NAVCOMPTMAN, and certified approved for payment by the adjudicating 
authority. This form must accompany the NAVMED 6320/10 and supporting 
documentation.
    (c) Amount payable. Amounts payable are those considered reasonable 
after taking into consideration all facts. Normally, payment should be 
approved at rates generally prevailing within the geographic area where 
services or supplies were furnished. Although rates specially 
established by the Veterans Administration, CHAMPUS, or those used in 
Medicare are not controlling, they should be considered along with other 
facts.
    (1) Excessive charges. If any charge is excessive, the adjudication 
authority will advise the provider of care of the conclusion reached and 
afford the provider an opportunity to voluntarily reduce the amount of 
the claim. If this does not result in a proper reduction and the claim 
is that of a physician or dentist, refer the difference in opinions to 
the grievance committee of the provider's professional group for an 
opinion of the reasonableness of the charge. If satisfactory settlement 
of any claim cannot thus be made, forward all documentation to 
COMNAVMEDCOM (MEDCOM-333) for decision. Charges determined to be above 
the allowed amount or charges for unauthorized services are the 
responsibility of the service member.
    (2) Third party payment. Do not withhold payment while seeking funds 
from health benefit plans or from insurance policies for which premiums 
are paid privately by service members (see Sec. 732.22 for possible 
recovery of payments action).
    (3) No-fault insurance. In States with no-fault automobile insurance 
requirements, adjudication authorities will notify the insurance carrier 
identified in item 16 of the NAVMED 6320/10 that Federal payment of the 
benefits in this part is secondary to any no-fault insurance coverage 
available to the potentially covered member.
    (d) Duplicate payments. Adjudication authorities and disbursing 
activities should take precautions against duplicate payments per 
paragraph 046073 of the NAVCOMPTMAN.