[Federal Register Volume 61, Number 213 (Friday, November 1, 1996)]
[Proposed Rules]
[Pages 56486-56491]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-27668]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AE64


Civilian Health and Medical Program of the Department of Veterans 
Affairs (CHAMPVA)

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: This document proposes to amend regulations concerning medical 
care for survivors and dependents of certain veterans, hereinafter 
referred to as the Civilian Health and Medical Program of the 
Department of Veterans Affairs (CHAMPVA). These proposed regulations 
would establish basic policies and procedures governing the

[[Page 56487]]

administration of the CHAMPVA program, including CHAMPVA claims 
processing procedures and a description of benefits and services.

DATES: Comments must be received on or before December 31, 1996.

ADDRESSES: Mail or hand deliver written comments to: Director, Office 
of Regulations Management (02D), Department of Veterans Affairs, 810 
Vermont Ave., NW, Room 1154, Washington, DC 20420. Comments should 
indicate that they are submitted in response to ``RIN 2900-AE64.'' All 
written comments will be available for public inspection at the above 
address in the Office of Regulations Management, Room 1158, between the 
hours of 8:00 a.m. and 4:30 p.m., Monday through Friday (except 
holidays).

FOR FURTHER INFORMATION CONTACT: Susan Schmetzer, Health Administration 
Center (formerly CHAMPVA Center), P.O. Box 65023, Denver, CO 80206-
5023, at (303) 331-7552. (This is not a toll-free number).

SUPPLEMENTARY INFORMATION: The provisions of 38 U.S.C. 1713 authorize 
VA to provide medical care to the dependents and survivors of certain 
veterans ``in the same or similar manner and subject to the same or 
similar limitations'' as medical care is furnished by the Department of 
Defense (DoD) to certain dependents and survivors of active duty and 
retired members of the Armed Forces under 10 United States Code, 
Chapter 55, Civilian Health and Medical Program of the Uniformed 
Services (CHAMPUS). This document proposes to amend VA regulations to 
include CHAMPVA claims processing procedures.
    It is also noted that during the past several years VA has made 
changes with respect to CHAMPVA claims processing services. Previously, 
VA had an agreement with DoD to contract with commercial claims 
processors (fiscal intermediaries) for the processing of VA claims. 
However, in an effort to both contain costs and to improve services to 
the beneficiaries, VA now conducts its own claims processing services 
and has consolidated the operations in Denver, Colorado.
    The Secretary hereby certifies that these regulatory amendments 
would not have a significant economic impact on a substantial number of 
small entities as they are defined in the Regulatory Flexibility Act, 5 
U.S.C. Sec. 601-612. These amendments would not cause significant 
economic impact on health care providers, suppliers, or entities since 
only a small portion of their business concerns CHAMPVA beneficiaries. 
The proposed rule would mostly impact individuals who are VA 
beneficiaries. Pursuant to 5 U.S.C. 605(b), these amendments are exempt 
from the initial and final regulatory flexibility analyses requirements 
of sections 603 and 604.

    The Catalog of Federal Domestic Assistance Program numbers are 
64.009, 64.010, 64.011.

Lists of Subjects in 38 CFR Part 17

    Alcoholism, Claims, Dental services, Drug abuse, Foreign relations, 
Government contracts, Grant programs-Health, Health care, Health 
facilities, Health professions, Medical devices, Medical research, 
Mental health programs, Nursing home care, Philippines, Veterans.

    Approved
Jesse Brown,
Secretary of Veterans Affairs.

    For the reasons set out in the preamble, 38 CFR part 17 is proposed 
to be amended as set forth below:

PART 17--MEDICAL

    1. The authority citation for part 17 continues to read as follows:

    Authority: 38 U.S.C. 501, 1721, unless otherwise noted.

    2. Section 17.84 is removed.
    3. A new center heading consisting of Secs. 17.270-17.278 is added 
to read as follows:

Civilian Health and Medical Program of the Department of Veterans 
Affairs (CHAMPVA)--Medical Care for Survivors and Dependents of Certain 
Veterans

Sec.
17.270  General Provisions
17.271  Eligibility
17.272  Benefit Limitations/Exclusions
17.273  Preauthorization
17.274  Cost Sharing
17.275  Claim Filing Deadline
17.276  Appeal/Review Process
17.277  Third Party Liability/Medical Care Cost Recovery
17.278  Confidentiality of Records


Sec. 17.270  General Provisions.

    (a) CHAMPVA is the Civilian Health and Medical Program of the 
Department of Veterans Affairs. Pursuant to 38 U.S.C. 1713, VA is 
authorized to provide medical care in the same or similar manner and 
subject to the same or similar limitations as medical care furnished to 
certain dependents and survivors of active duty and retired members of 
the Armed Forces. The CHAMPVA program is designed to accomplish this 
purpose. Under CHAMPVA, VA shares the cost of medically necessary 
services and supplies for eligible beneficiaries as set forth below.
    (b) For purposes of this section, the definitions of ``child,'' 
``service-connected condition/disability,'' ``spouse,'' and ``surviving 
spouse'' shall be those set forth further in 38 U.S.C. 101. The term 
``fiscal'' year refers to October 1, through September 30.

(Authority: 38 U.S.C. 1713)


Sec. 17.271  Eligibility.

    (a) The following persons are eligible for CHAMPVA benefits 
provided that they are not eligible for CHAMPUS or Medicare Part A 
(except as noted in 17.271).
    (1) The spouse or child of a veteran who has been adjudicated by VA 
as having a permanent and total service-connected disability;
    (2) The surviving spouse or child of a veteran who died as a result 
of an adjudicated service-connected condition(s); or who, at the time 
of death, was adjudicated permanently and totally disabled from a 
service-connected condition(s);
    (3) The surviving spouse or child of a person who died on active 
military service and in the line of duty and not due to such person's 
own misconduct; and
    (4) An eligible child who is pursuing a full-time course of 
instruction approved under 38 U.S.C. Chapter 36, and who incurs a 
disabling illness or injury while pursuing such course (between terms, 
semesters or quarters; or during a vacation or holiday period) which is 
not the result of his or her own willful misconduct and which results 
in the inability to continue or resume the chosen program of education 
shall remain eligible for medical care until:
    (i) the end of the six-month period beginning on the date the 
disability is removed; or
    (ii) the end of the two-year period beginning on the date of the 
onset of the disability; or
    (iii) the twenty-third birthday of the child, whichever occurs 
first.

(Authority: 38 U.S.C. 1713)

    (b) Persons who lose eligibility for CHAMPVA by becoming 
potentially eligible for Medicare Part A as a result of reaching age 65 
or who qualify for Medicare Part A benefits on the basis of a 
disability, including end stage renal disease, may re-establish CHAMPVA 
eligibility by submitting documentation from the Social Security 
Administration (SSA) certifying their non-entitlement to or exhaustion 
of Medicare Part A benefits. Persons under age 65 who are enrolled in 
both Medicare Part A and B

[[Page 56488]]

may become potentially eligible for CHAMPVA as a secondary payer to 
Medicare. In cases where CHAMPVA eligibility is restored upon 
exhaustion of Medicare benefits, CHAMPVA coverage will extend even 
during subsequent periods of Medicare eligibility. When both CHAMPVA 
and Medicare eligibility exist, CHAMPVA shall be the secondary payer.

(Authority: 38 U.S.C. 1713(d))


Sec. 17.272  Benefits Limitations/Exclusions.

    (a) Benefits cover allowable expenses for medical services and 
supplies that are medically necessary and appropriate for the treatment 
of a condition and that are not specifically excluded from program 
coverage. Covered benefits may have limitations. The fact that a 
physician may prescribe, order, recommend, or approve a service or 
supply does not, of itself, make it medically necessary or make the 
charge an allowable expense, even though it is not listed specifically 
as an exclusion. The following are specifically excluded from program 
coverage:
    (1) Services, procedures or supplies for which the beneficiary has 
no legal obligation to pay, or for which no charge would be made in the 
absence of coverage under a health benefits plan.
    (2) Services and supplies required as a result of an occupational 
disease or injury for which benefits are payable under workers' 
compensation or similar protection plan (whether or not such benefits 
have been applied for or paid) except when such benefits are exhausted 
and are otherwise not excluded from CHAMPVA coverage.
    (3) Services and supplies that are paid directly or indirectly by a 
local, state or Federal government agency (Medicaid excluded), 
including court-ordered treatment.
    (4) Services and supplies that are not medically or psychologically 
necessary for the diagnosis or treatment of a covered condition 
(including mental disorder) or injury.
    (5) Radiology, laboratory, and pathological services and machine 
diagnostic testing not related to a specific illness or injury or a 
definitive set of symptoms.
    (6) Services and supplies above the appropriate level required to 
provide necessary medical care.
    (7) Services and supplies related to an inpatient admission 
primarily to perform diagnostic tests, examinations, and procedures 
that could have been and are performed routinely on an outpatient 
basis.
    (8) Postpartum inpatient stay of a mother for purposes of staying 
with the newborn infant (primarily for the purpose of breast feeding 
the infant) when the infant (but not the mother) requires the extended 
stay; or continued inpatient stay of a newborn infant primarily for 
purposes of remaining with the mother when the mother (but not the 
newborn infant) requires extended postpartum inpatient stay.
    (9) Therapeutic absences from an inpatient facility or residential 
treatment center (RTC).
    (10) Custodial care.
    (11) Inpatient stays primarily for domiciliary care purposes.
    (12) Inpatient stays primarily for rest or rest cures.
    (13) Services and supplies provided as a part of, or under, a 
scientific or medical study, grant, or research program.
    (14) Services and supplies not provided in accordance with accepted 
professional medical standards or related to experimental or 
investigational procedures or treatment regimens.
    (15) Services or supplies prescribed or provided by a member of the 
beneficiary's immediate family, or a person living in the beneficiary's 
or sponsor's household.
    (16) Services and supplies that are (or are eligible to be) payable 
under another medical insurance or program, either private or 
governmental, such as coverage through employment or Medicare.
    (17) Service or supplies subject to preauthorization (see 
Sec. 17.273) which were obtained without the required preauthorization; 
and services and supplies which were not provided according to the 
terms of the preauthorization.
    (18) Inpatient stays primarily to control or detain a runaway 
child, whether or not admission is to an authorized institution.
    (19) Services and supplies in connection with cosmetic surgery.
    (20) Electrolysis.
    (21) Dental care with the following exceptions:
    (i) Dental care that is medically necessary in the treatment of an 
otherwise covered medical condition is an integral part of the 
treatment of such medical condition, and is essential to the control of 
the primary medical condition.
    (ii) Dental care required in preparation for, or as a result of, 
radiation therapy for oral or facial cancer.
    (iii) Gingival Hyperplasia.
    (iv) Loss of jaw substance due to direct trauma to the jaw or due 
to treatment of neoplasm.
    (v) Intraoral abscess when it extends beyond the dental alveolus.
    (vi) Extraoral abscess.
    (vii) Cellulitis and osteitis which is clearly exacerbating and 
directly affecting a medical condition currently under treatment.
    (viii) Repair of fracture, dislocation, and other injuries of the 
jaw, to include removal of teeth and tooth fragments only when such 
removal is incidental to the repair of the jaw.
    (ix) Treatment for stabilization of myofascial pain dysfunction 
syndrome, also referred to as temporomandibular joint (TMJ) syndrome. 
Authorization is limited to initial radiographs, up to four office 
visits, and the construction of an occlusal splint.
    (x) Total or complete ankyloglossia.
    (xi) Adjunctive dental and orthodontic support for cleft palate.
    (xii) Prosthetic replacement of jaw due to trauma or cancer.
    (22) Nonsurgical treatment of obesity or morbid obesity for dietary 
control or weight reduction (with the exception of gastric bypass, 
gastric stapling, or gastroplasty procedures in connection with morbid 
obesity when determined to be medically necessary).
    (23) Services and supplies related to transsexualism or other 
similar conditions such as gender dysphoria (including, but not limited 
to, intersex surgery and psychotherapy, except for ambiguous genitalia 
which was documented to be present at birth).
    (24) Sex therapy, sexual advice, sexual counseling, sex behavior 
modification, psychotherapy for mental disorders involving sexual 
deviations (e.g., transvestic fetish), or other similar services, and 
any supplies provided in connection with therapy for sexual 
dysfunctions or inadequacies.
    (25) Removal of corns or calluses or trimming of toenails and other 
routine podiatry services, except those required as a result of a 
diagnosed systemic medical disease affecting the lower limbs, such as 
severe diabetes.
    (26) Services and supplies, to include psychological testing, 
provided in connection with a specific developmental disorder. The 
following exception applies: Diagnostic and evaluative services 
required to arrive at a differential diagnosis for an otherwise 
eligible child unless the state is required to provide those services 
under Public Law 94-142, Education for All Handicapped Children Act of 
1975 as amended, See 20 U.S.C. Chapter 33.
    (27) Surgery to reverse voluntary surgical sterilization 
procedures.
    (28) Services and supplies related to artificial insemination 
(including semen donors and semen banks), in vitro fertilization, 
gamete intrafallopian

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transfer and all other noncoital reproductive technologies.
    (29) Nonprescription contraceptives.
    (30) Diagnostic tests to establish paternity of a child; or tests 
to determine sex of an unborn child.
    (31) Preventive care (such as routine, annual, or employment-
requested physical examinations; routine screening procedures; and 
immunizations). The following exceptions apply:
    (i) Well-baby care from birth to the age of two years, including 
newborn examination, phenylketonuria (PKU) testing and newborn 
circumcision.
    (ii) Rabies vaccine following an animal bite.
    (iii) Tetanus vaccine following an accidental injury.
    (iv) Rh immune globulin.
    (v) Pap smears.
    (vi) Mammography tests.
    (vii) Genetic testing and counseling determined to be medically 
necessary.
    (viii) Chromosome analysis in cases of habitual abortion or 
infertility.
    (ix) Gamma globulin.
    (32) Chiropractic and naturopathic services.
    (33) Counseling services that are not medically necessary in the 
treatment of a diagnosed medical condition (such as educational 
counseling; vocational counseling; and counseling for socioeconomic 
purposes, stress management, life style modification, etc.).
    (34) Acupuncture, whether used as a therapeutic agent or as an 
anesthetic.
    (35) Hair transplants, wigs, or hairpieces, except that benefits 
may be extended for one wig or hairpiece per beneficiary (lifetime 
maximum) when the attending physician certifies that alopecia has 
resulted from treatment of malignant disease and the beneficiary 
certifies that a wig or hairpiece has not been obtained previously 
through the U.S. Government (including the Department of Veterans 
Affairs). The wig or hairpiece benefit does not include coverage for 
the following:
    (i) Maintenance, wig or hairpiece supplies, or replacement of the 
wig or hairpiece.
    (ii) Hair transplant or any other surgical procedure involving the 
attachment of hair or a wig or hairpiece to the scalp.
    (iii) Any diagnostic or therapeutic method or supply intended to 
encourage hair growth.
    (36) Self-help, academic education or vocational training services 
and supplies.
    (37) Exercise equipment, spas, whirlpools, hot tubs, swimming 
pools, health club membership or other such charges or items.
    (38) General exercise programs, even if recommended by a physician.
    (39) Services of an audiologist or speech therapist, except when 
prescribed by a physician and rendered as a part of treatment addressed 
to the physical defect itself and not to any educational or 
occupational deficit.
    (40) Eye exercises or visual training (orthoptics).
    (41) Eye and hearing examinations except when rendered in 
connection with medical or surgical treatment of a covered illness or 
injury or in connection with well-baby care.
    (42) Eyeglasses, spectacles, contact lenses, or other optical 
devices with the following exceptions:
    (i) When necessary to perform the function of the human lens, lost 
as a result of intraocular surgery, ocular injury or congenital 
absence.
    (ii) Pinhole glasses prescribed for use after surgery for detached 
retina.
    (iii) Lenses prescribed as ``treatment'' instead or surgery for the 
following conditions:
    (A) Contact lenses used for treatment of infantile glaucoma.
    (B) Corneal or scleral lenses prescribed in connection with 
treatment of keratoconus.
    (C) Scleral lenses prescribed to retain moisture when normal 
tearing is not present or is inadequate.
    (D) Corneal or scleral lenses prescribed to reduce a corneal 
irregularity other than astigmatism.
    (iv) The specified benefits are limited to one set of lenses 
related to one qualifying eye condition as set forth in (iii)(A-D) of 
this Section. If there is a prescription change requiring a new set of 
lenses, but still related to the qualifying eye condition, benefits may 
be extended for a second set of lenses, subject to medical review.
    (43) Hearing aids or other auditory sensory enhancing devices.
    (44) Prostheses with the following exceptions:
    (i) Artificial limbs and eyes, or items inserted surgically in the 
body as an integral part of a surgical procedure.
    (ii) Dental prostheses specifically required in connection with 
otherwise covered orthodontia directly related to the surgical 
correction of a cleft palate anomaly.
    (45) Orthopedic shoes, arch supports, shoe inserts, and other 
supportive devices for the feet, including custom-made built-up shoes, 
or regular shoes later built up with the following exception: Shoes 
that are an integral part of an orthopedic brace and which cannot be 
used separately from the brace are covered.
    (46) Services or advice rendered by telephone or other telephonic 
device, including remote monitoring, except for transtelephonic 
monitoring of cardiac pacemakers.
    (47) Air conditioners, humidifiers, dehumidifiers, and purifiers.
    (48) Elevators or wheelchair lifts.
    (49) Alterations to living spaces or permanent features attached 
thereto, even when necessary to accommodate installation of covered 
durable medical equipment or to facilitate entrance or exit.
    (50) Items of clothing, even if required by virtue of an allergy 
(such as cotton fabric versus synthetic fabric and vegetable-dyed 
shoes).
    (51) Food, food substitutes, vitamins or other nutritional 
supplements, including those related to prenatal care for a home 
patient whose condition permits oral feeding.
    (52) Enuretic (bed-wetting) devices; enuretic conditioning 
programs.
    (53) Autopsy and post-mortem examinations.
    (54) All camping, even when organized for a specific therapeutic 
purpose (such as diabetic camp or a camp for emotionally disturbed 
children), or when offered as a part of an otherwise covered treatment 
plan.
    (55) Housekeeping, homemaker, or attendant services, including a 
sitter or companion.
    (56) Personal comfort or convenience items, such as beauty and 
barber services, radio, television, and telephone.
    (57) Smoking cessation services and supplies.
    (58) Megavitamin psychiatric therapy; orthomolecular psychiatric 
therapy.
    (59) All transportation except for specialized transportation with 
life sustaining equipment, when medically required for the treatment of 
a covered condition.
    (60) Inpatient mental health services in excess of 30 days in any 
fiscal year (or in an admission), in the case of a patient 19 years of 
age or older; 45 days in any fiscal year (or in an admission), in the 
case of a patient under 19 years of age; or 150 days of residential 
treatment care in any fiscal year (or in an admission), unless a waiver 
for extended coverage is granted in advance.
    (61) Outpatient mental health services in excess of 23 visits in a 
fiscal year, unless a waiver for extended coverage is granted in 
advance.
    (62) Institutional services for partial hospitalization in excess 
of 60 treatment days in any fiscal year (or in an admission), unless a 
waiver for extended coverage is granted in advance.

[[Page 56490]]

    (63) Detoxification in a hospital setting or rehabilitation 
facility in excess of seven days.
    (64) Outpatient substance abuse services in excess of 60 visits 
during a benefit period. A benefit period begins with the first date of 
covered service and ends 365 days later.
    (65) Family therapy for substance abuse in excess of 15 visits 
during a benefit period. A benefit period begins with the first date of 
covered service and ends 365 days later.
    (66) Services that are provided to a beneficiary who is referred to 
a provider of such services by a provider who has an economic interest 
in the facility to which the patient is referred, unless a waiver is 
granted.
    (67) Abortion, except when a physician certifies that the life of 
the mother would be endangered if the fetus were carried to term.
    (68) Abortion counseling.
    (69) Aversion therapy.
    (70) Rental or purchase of biofeedback equipment.
    (71) Biofeedback therapy for treatment of ordinary muscle tension 
states (including tension headaches) or for psychosomatic conditions.
    (72) Drug maintenance programs where one addictive drug is 
substituted for another, such as methadone substituted for heroin.
    (73) Immunotherapy for malignant diseases, except for treatment of 
Stage O and Stage A carcinoma of the bladder.
    (74) Services and supplies provided by other than a hospital, such 
as nonskilled nursing homes, intermediate care facilities, halfway 
houses, homes for the aged, or other institutions of similar purpose.
    (75) Services performed when the patient is not physically present.
    (76) Medical photography.
    (77) Special tutoring.
    (78) Surgery for psychological reasons.
    (79) Treatment of premenstrual syndrome (PMS).
    (80) Medications not requiring a prescription, except for insulin.
    (81) Thermography.
    (82) Removal of tattoos.
    (83) Penile implant/testicular prosthesis procedures and related 
supplies for psychological impotence.
    (84) Dermabrasion of the face.
    (85) Chemical peeling for facial wrinkles.
    (86) Panniculectomy, body sculpting procedures.
    (b) CHAMPVA-determined allowable amount.
    (1) The term allowable amount is the maximum CHAMPVA-determined 
level of payment to a hospital or other authorized institutional 
provider, a physician or other authorized individual professional 
provider, or other authorized provider for covered services. The 
CHAMPVA-allowable amount is determined prior to cost sharing and the 
application of deductibles and/or other health insurance.
    (2) A Medicare-participating hospital must accept the CHAMPVA-
determined allowable amount for inpatient services as payment-in-full. 
(Reference 42 CFR Parts 489 and 1003).
    (3) An authorized provider of covered medical services or supplies 
shall accept the CHAMPVA-determined allowable amount as payment-in-
full.
    (4) A provider who has collected and not made an appropriate 
refund, or attempts to collect from the beneficiary, any amount in 
excess of the CHAMPVA-determined allowable amount may be subject to 
exclusion from Federal benefit programs.

(Authority: 38 U.S.C. 1713)


Sec. 17.273  Preauthorization.

    (a) Preauthorization or advance approval is required for any of the 
following:
    (1) Non-emergent inpatient mental health and substance abuse care, 
including admission of emotionally disturbed children and adolescents 
to residential treatment centers.
    (2) All admissions to a partial hospitalization program (including 
alcohol rehabilitation).
    (3) Outpatient mental health visits in excess of 23 per calendar 
year and/or more than two (2) sessions per week.
    (4) Dental care.
    (5) Durable medical equipment with a purchase price in excess of 
$300.00.
    (6) Organ transplants.

(Authority: 38 U.S.C. 1713)


Sec. 17.274  Cost sharing.

    (a) With the exception of services obtained directly from VA 
medical facilities, CHAMPVA is a cost-sharing program in which the cost 
of covered services is shared with the beneficiary. In addition to the 
beneficiary cost share, an annual (calendar year) outpatient deductible 
requirement ($50 per beneficiary or $100 per family) must be satisfied 
prior to the payment of outpatient benefits. There is no deductible for 
inpatient services. CHAMPVA pays the CHAMPVA-determined allowable 
amount less the deductible, if applicable, and less the beneficiary 
cost share. To provide financial protection against the impact of a 
long-term illness or injury, an annual cost limit or ``catastrophic 
cap'' has been placed on the beneficiary cost-share amount for covered 
services and supplies. This annual cap on cost sharing is $7,500 per 
CHAMPVA-eligible family. Credits to the annual catastrophic cap are 
limited to the applied annual deductible(s) and the beneficiary cost-
share amount. Costs above the CHAMPVA-allowable amount, as well as 
costs associated with noncovered services, are not credited to the 
catastrophic cap computation.
    (b) If the CHAMPVA benefit payment is under $1.00, payment will not 
be issued. Catastrophic cap and deductible will, however, be credited.

(Authority: 38 U.S.C. 1713)


Sec. 17.275  Claim filing deadline.

    (a) Unless an exception is granted under paragraph (b) of this 
subsection, claims for medical services and supplies must be filed with 
the Center no later than:
    (1) One year after the date of service; or
    (2) In the case of inpatient care, one year after the date of 
discharge; or
    (3) In the case of retroactive approval for medical services/
supplies, 180 days following beneficiary notification of authorization; 
or
    (4) In the case of retroactive approval of CHAMPVA eligibility, 180 
days following notification to the beneficiary of authorization for 
services occurring on or after the date of first eligibility.
    (b) Requests for an exception to the claim filing deadline must be 
submitted, in writing, to the Center and include a complete explanation 
of the circumstances resulting in late filing along with all available 
supporting documentation. Each request for an exception to the claim 
filing deadline will be reviewed individually and considered on its own 
merit. The Center Director may grant exceptions to the requirements in 
paragraph (a) if he or she determines that there was good cause for 
missing the filing deadline. For example, when dual coverage exists, 
the CHAMPVA allowable amount cannot be determined until after the 
primary insurance carrier has adjudicated the claim. In such 
circumstances an exception may be granted provided that the delay on 
the part of the primary insurance carrier is not attributable to the 
beneficiary. Delays due to provider billing procedures do not 
constitute a valid basis for an exception.


Sec. 17.276  Appeal/review process.

    Notice of the initial determination regarding payment of CHAMPVA 
benefits will be provided to the beneficiary on a CHAMPVA

[[Page 56491]]

Explanation of Benefits (EOB) form. The EOB form is generated by the 
CHAMPVA automated payment processing system. If a beneficiary disagrees 
with the determination concerning covered services or calculation of 
benefits, he or she may request reconsideration. Such requests must be 
submitted to the Center in writing within one year of the date of the 
initial determination. The request must state why the beneficiary 
believes the decision is in error and must include any new and relevant 
information not previously considered. Any request for reconsideration 
that does not identify the reason for dispute will be returned to the 
claimant without further consideration. After reviewing the claim and 
any relevant supporting documentation, a CHAMPVA benefits advisor will 
issue a written determination to the beneficiary that affirms, reverses 
or modifies the previous decision. If the beneficiary is still 
dissatisfied, within 30 days of the date of the decision he or she may 
make a written request for review by the Center Director. The Director 
will review the claim and any relevant supporting documentation and 
issue a decision in writing that affirms, reverses or modifies the 
previous decision. The decision of the Director with respect to benefit 
coverage and computation of benefits is final.

(Authority: 38 U.S.C. 1713)

    Note: Denial of CHAMPVA benefits based on legal eligibility 
requirements may be appealed to the Board of Veterans Appeals in 
accordance with 38 C.F.R. Part 20. Medical determinations are not 
appealable to the Board. 20 C.F.R. Sec. 20.101.


Sec. 17.277  Third Part Liability/Medicare Cost Recovery.

    The Center will actively pursue third party liability/medical care 
cost recovery in accordance with 38 CFR 1.900, et seq.


Sec. 17.278  Confidentiality of records.

    Confidentiality of records will be maintained in accordance with 38 
CFR 1.500, et seq.
[FR Doc. 96-27668 Filed 10-31-96; 8:45 am]
BILLING CODE 8320-01-P