[Federal Register Volume 69, Number 29 (Thursday, February 12, 2004)]
[Rules and Regulations]
[Pages 6919-6920]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-3014]


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DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

RIN 0720-AA74


TRICARE; Civilian Health and Medical Program of the Uniformed 
Services (CHAMPUS); Appeals and Hearings Procedures, Formal Review

AGENCY: Office of the Secretary, DoD.

ACTION: Final rule.

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SUMMARY: This final rule makes administrative corrections to the 32 CFR 
part 199, section 199.10, ``Appeal and Hearing Procedures.'' These 
corrections include revising Sec. 199.10, adding paragraphs (c)(1) 
through (c)(5), and making other minor editorial changes.

EFFECTIVE DATE: May 1, 1983.

FOR FURTHER INFORMATION CONTACT: Gail L. Jones, Medical Benefits and 
Reimbursement Systems, TRICARE Management Activity (TMA), telephone 
(303) 676-3401.

SUPPLEMENTARY INFORMATION:

I. Background

    Paragraphs (c)(1) through (c)(5) were inadvertently omitted when 
the July 1, 1991, edition of the 32 CFR was published. The discovery 
that the formal review process was missing from Sec. 199.10 occurred at 
the time that TRICARE was tasked to promulgated an appeal process for 
TRICARE Claimcheck denials.
    The appeals procedures found in this final rule reflect the appeals 
process as it has continuously existed and been administered by the 
Department of Defense since its original effective date of May 1, 1983. 
This final rule is being published solely to reflect the inadvertent 
omission by the United States Government Printing Office of these 
procedures in 32 CFR part 199. This correction to Sec. 199.10 is made 
in an effort to ensure that any party to an initial determination or 
reconsideration decision who may want to request a formal review is 
aware of these procedures.

II. Public Comments

    We published this rule on March 13, 2003, as an interim final rule, 
with a 60-day comment period, and received no public comments.

III. Changes in the Final Rule

    Additional administrative changes were made to correct designated 
paragraphs in (a)(8)(ii)(A) through (B). We have redesignated these 
paragraphs to (a)(8)(ii)(A) through (C).

IV. Rulemaking Procedures

    Executive Order 12866 requires certain regulatory assessments for 
any ``significant regulatory action'' defined as one, which would 
result in an annual effect on the economy of $100 million or more, or 
have other substantial impacts.
    The Regulatory Flexibility Act (RFA) requires that each Federal 
agency prepare, and make available for public comment, a regulatory 
flexibility analysis when the agency issues a regulation which would 
have a significant impact on a substantial number of small entities.
    This rule has been designated as a significant rule and has been 
reviewed by the Office of Management and Budget as required under the 
provisions of Executive Order 12866. The Department of Defense 
certifies that this final rule would not have a significant impact on 
small business entities.
    This rule will not impose additional information collection 
requirements on the public under the Paperwork Reduction Act of 1980 
(44 U.S.C. 3501-3511).
    This rule is being issued as a final rule.

List of Subjects in 32 CFR Part 199

    Claims, Health insurance, Individuals with disabilities, Dental 
Health, Military personnel.


[[Page 6920]]



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Accordingly, 32 CFR part 199 is amended as follows:

PART 1999--[AMENDED]

0
1. The authority citation for part 199 continues to read as follows:

    Authority: 5 U.S.C. 301; 10 U.S.C. chapter 55.


0
2. Section 199.10 is amended by redesignating both paragraphs 
(a)(8)(ii)(A) and paragraph (a)(8)(ii)(B) as paragraphs (a)(8)(ii)(A) 
through (a)(8)(ii)(C), by revising paragraph (b) introductory text, and 
by republishing paragraph (c) to read as follows:


Sec. 199.10  Appeals and hearing procedures.

* * * * *
    (b) Reconsideration. Any party to the initial determination made by 
the CHAMPUS contractor, or a CHAMPUS peer review organization may 
request reconsideration.
* * * * *
    (c) Formal review. Except as explained in this paragraph, any party 
to an initial determination made by OCHAMPUS, or a reconsideration 
determination made by the CHAMPUS contractor, may request a formal 
review by OCHAMPUS if the party is dissatisfied with the initial or 
reconsideration determination unless the initial or reconsideration 
determination is final under paragraph (b)(5) of this section; involves 
the sanctioning of a provider by the exclusion, suspension or 
termination of authorized provider status; involves a written decision 
issued pursuant to Sec. 199.9(h)(1)(iv)(A) regarding the temporary 
suspension of claims processing; or involves a reconsideration 
determination by a CHAMPUS peer review organization. A hearing, but not 
a formal review level or appeal, may be available to a party to an 
initial determination involving the sanctioning of a provider or to a 
party to a written decision involving a temporary suspension of claims 
processing. A beneficiary (or an authorized representative of a 
beneficiary), but not a provider (except as provided in Sec. 199.15), 
may request a hearing, but not a formal review, of a reconsideration 
determination made by a CHAMPUS peer review organization.
    (1) Requesting a formal review. (i) Written request required. The 
request must be in writing, shall state the specific matter in dispute, 
shall include copies of the written determination (notice of 
reconsideration determination of OCHAMPUS initial determination) being 
appealed, and shall include any additional information or documents not 
submitted previously.
    (ii) Where to file. The request shall be submitted to the Chief, 
Office of Appeals and Hearings, TRICARE Management Activity, 16401 East 
Centredtech Parkway, Aurora, Colorado 80011-9066.
    (iii) Allowed time to file. The request shall be mailed within 60 
days after the date of the notice of the reconsideration determination 
or OCHAMPUS initial determination being appealed.
    (iv) Official filing date. A request for a formal review shall be 
deemed filed on the date it is mailed and postmarked. If the request 
does not have a postmark, it shall be deemed filed on the date received 
by OCHAMPUS.
    (2) The formal review process. The purpose of the formal review is 
to determine whether the initial determination or reconsideration 
determination was made in accordance with law, regulation, policies, 
and guidelines in effect at the time the care was provided or requested 
or at the time of the initial determination, reconsideration, or formal 
review decision involving a provider request for approval as an 
authorized CHAMPUS provider. The formal review is performed by the 
Chief, Office of Appeals and Hearings, OCHAMPUS, or a designee, and is 
a thorough review of the case. The formal review determination shall be 
based on the information, upon which the initial determination and/or 
reconsideration determination was based, and any additional information 
the appealing party may submit or OCHAMPUS may obtain.
    (3) Timeliness of formal review determination. The Chief, Office of 
Appeals and Hearings, OCHAMPUS, or a designee normally shall issue the 
formal review determination no later than 90 days from the date of 
receipt of the request for formal review by OCHAMPUS.
    (4) Notice of formal review determination. The Chief, Office of 
Appeals and Hearings, OCHAMPUS, or a designee shall issue a written 
notice of the formal review determination to the appealing party at his 
or her last known address. The notice of the formal review 
determination must contain the following elements:
    (i) A statement of the issue or issues under appeal.
    (ii) The provisions of law, regulation, policies, and guidelines 
that apply to the issue or issues under appeal.
    (iii) A discussion of the original and additional information that 
is relevant to the issue or issues under appeal.
    (iv) Whether the formal review upholds the prior determination or 
determinations or reverses the prior determination or determinations in 
whole or in part and the rationale for the action.
    (v) A statement of the right to request a hearing in any case when 
the formal review determination is less than fully favorable, the issue 
is appealable, and the amount in dispute is $300 or more.
    (5) Effect of formal review determination. The formal review 
determination is final if one or more of the following exist:
    (i) The issue is not appealable. (See paragraph (a)(6) of this 
section.)
    (ii) The amount in dispute is less that $300. (See paragraph (a)(7) 
of this section.)
    (iii) Appeal rights have been offered but a request for hearing is 
not received by OCHAMPUS within 60 days of the date of the notice of 
the formal review determination.
* * * * *

    Dated: February 5, 2004.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 04-3014 Filed 2-11-04; 8:45 am]
BILLING CODE 5001-06-M