[Federal Register Volume 59, Number 89 (Tuesday, May 10, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-11164]


[[Page Unknown]]

[Federal Register: May 10, 1994]


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OFFICE OF PERSONNEL MANAGEMENT
5 CFR Part 890

RIN 3206-AG03

 

Federal Employees Health Benefits Program: Debarment

AGENCY: Office of Personnel Management.

ACTION: Interim regulations with request for comments.

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SUMMARY: The Office of Personnel Management (OPM) is issuing interim 
regulations to incorporate into regulations the statutory requirement 
that carriers in the Federal Employees Health Benefits (FEHB) Program 
may not deny claims for services or supplies due to the debarment of 
the providers who supplied them if the claimants could not have known 
that the provider was debarred. The purpose of these regulations is to 
comply with the provision of law that requires OPM to prescribe 
regulations on this issue.

DATES: These interim regulations are effective June 9, 1994. Comments 
must be received on or before July 11, 1994.

ADDRESSES: Written comments may be sent to Lucretia F. Myers, Assistant 
Director for Insurance Programs, Retirement and Insurance Group, Office 
of Personnel Management, P.O. Box 57, Washington, DC 20044, or 
delivered to OPM, room 3415, 1900 E Street NW., Washington, DC.

FOR FURTHER INFORMATION CONTACT:
Margaret Sears (202) 606-0191.

SUPPLEMENTARY INFORMATION: On October 30, 1989, OPM published interim 
regulations in the Federal Register (54 FR 43939) implementing title I 
of Public Law 100-654, which allowed OPM to exclude from further 
participation in the FEHB Program any health care provider (1) 
convicted of fraud or various other cited examples of unethical 
professional conduct, or (2) determined by OPM to have committed 
various cited offenses against the FEHB Program.
    Public Law 100-654 contained a provision requiring OPM to prescribe 
regulations allowing payment of claims for service or supplies 
furnished by debarred providers if the claimant could not reasonably 
have known of the debarment. This issue was inadvertently not addressed 
by the regulations published October 30, 1989. Therefore, in compliance 
with the requirements of 5 U.S.C. 8902a(i) OPM is now issuing these 
interim regulations.
    Under these interim regulations, carriers cannot deny claims based 
on debarment if there was no reasonably way the claimant could have 
known that the provider was debarred. When an individual who has not 
previously been notified of a provider's debarment, submits a claim for 
services or supplies furnished by a debarred provider, the carrier must 
(1) honor the claim under the terms of its contract with OPM, and (2) 
inform the individual about the debarment of the provider and the 
minimum period of time remaining under the terms of the debarment.
    In practical terms, this generally means that the first claim(s) an 
enrollee submits for services or supplies received after a provider has 
been debarred, but before the enrollee has been informed of the 
debarment, is (are) paid to the same extent it (they) would have been 
paid had the provider not been debarred. The carrier must, at the same 
time, inform the enrollee concerning the debarment. The carrier will 
deny any subsequent claims for service or supplies furnished during the 
period the provider is debarred.

Waiver of Notice of Proposed Rulemaking

    Pursuant to section 553(b)(3)(B) of title 5 of the U.S. code, I 
find that good cause exists for waiving the general notice of 
rulemaking because this regulation primarily affects Federal employees 
and annuitants and merely incorporates statutory requirements into 
regulation.

Regulatory Flexibility Act

    I certify that these regulations will not have a significant 
economic impact on a substantial number of small entities because it 
primarily affects Federal employees and annuitants.

E.O. 12866, Regulatory Review

    This rule has been reviewed by OMB in accordance with E.O. 12866.

List of Subjects in 5 CFR Part 890

    Administrative practice and procedure, Government employees, Health 
facilities, Health insurance, Health professions, Hostages, Reporting 
and recordkeeping requirements, Retirement.

U.S. Office of Personnel Management.
Lorraine A. Green,
Deputy Director.

    Accordingly, OPM is amending 5 CFR Part 890 as follows:

PART 890--FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM

    1. The authority citation for part 890 continues to read as 
follows:

    Authority: 5 U.S.C. 8913; sec. 890.803 also issued under 50 
U.S.C. 403p, 22 U.S.C. 4069c and 4069c-1; subpart L also issued 
under sec. 599C of Pub. L. 101-513, 104 Stat. 2064.

    2. In subpart J, a new Sec. 890.1006 is added to read as follows:


Sec. 890.1006  Payment of claims for service or supplies furnished by 
debarred providers.

    Health plans may not deny claims for services or supplies based on 
debarment of the provider under this subpart if the claimant did not 
know or could not reasonably be expected to have known of the 
debarment. In any such instance, the carrier involved must take 
appropriate measures to ensure that the individual is informed of the 
debarment and the minimum period of time remaining under the terms of 
the debarment.

[FR Doc. 94-11164 Filed 5-9-94; 8:45 am]
BILLING CODE 6325-01-M