TRICARE; Elimination of the Non-Availability Statement (NAS) Requirement for Non-Emergency Inpatient Mental Health Care, 12951-12953 [2013-03418]
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Federal Register / Vol. 78, No. 38 / Tuesday, February 26, 2013 / Rules and Regulations
§ 50.3
Definitions.
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*
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(n) Assent means a child’s affirmative
agreement to participate in a clinical
investigation. Mere failure to object
should not, absent affirmative
agreement, be construed as assent.
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*
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*
(r) Permission means the agreement of
parent(s) or guardian to the
participation of their child or ward in a
clinical investigation.
(s) Guardian means an individual
who is authorized under applicable
State or local law to consent on behalf
of a child to general medical care.
■ 3. Revise § 50.51 to read as follows:
§ 50.51 Clinical investigations not
involving greater than minimal risk.
Any clinical investigation within the
scope described in §§ 50.1 and 56.101 of
this chapter in which no greater than
minimal risk to children is presented
may involve children as subjects only if
the IRB finds that:
(a) No greater than minimal risk to
children is presented; and
(b) Adequate provisions are made for
soliciting the assent of the children and
the permission of their parents or
guardians as set forth in § 50.55.
■ 4. Revise the introductory text of
§ 50.52 to read as follows:
§ 50.52 Clinical investigations involving
greater than minimal risk but presenting the
prospect of direct benefit to individual
subjects.
Any clinical investigation within the
scope described in §§ 50.1 and 56.101 of
this chapter in which more than
minimal risk to children is presented by
an intervention or procedure that holds
out the prospect of direct benefit for the
individual subject, or by a monitoring
procedure that is likely to contribute to
the subject’s well-being, may involve
children as subjects only if the IRB finds
that:
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■ 5. Revise the introductory text of
§ 50.53 to read as follows:
wreier-aviles on DSK5TPTVN1PROD with RULES
§ 50.53 Clinical investigations involving
greater than minimal risk and no prospect
of direct benefit to individual subjects, but
likely to yield generalizable knowledge
about the subjects’ disorder or condition.
Any clinical investigation within the
scope described in §§ 50.1 and 56.101 of
this chapter in which more than
minimal risk to children is presented by
an intervention or procedure that does
not hold out the prospect of direct
benefit for the individual subject, or by
a monitoring procedure that is not likely
to contribute to the well-being of the
VerDate Mar<15>2010
14:06 Feb 25, 2013
Jkt 229001
subject, may involve children as
subjects only if the IRB finds that:
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■ 6. Revise paragraph (a) of § 50.54 to
read as follows:
§ 50.54 Clinical investigations not
otherwise approvable that present an
opportunity to understand, prevent, or
alleviate a serious problem affecting the
health or welfare of children.
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(a) The IRB finds that the clinical
investigation presents a reasonable
opportunity to further the
understanding, prevention, or
alleviation of a serious problem
affecting the health or welfare of
children; and
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■ 7. Revise paragraph (e) of § 50.55 to
read as follows:
12951
to determine compliance with part 50,
subpart D of this chapter, either at the
time of continuing review or, at the
discretion of the IRB, at an earlier date.
Dated: February 21, 2013.
Leslie Kux,
Assistant Commissioner for Policy.
[FR Doc. 2013–04387 Filed 2–25–13; 8:45 am]
BILLING CODE 4160–01–P
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§ 50.55 Requirements for permission by
parents or guardians and for assent by
children.
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(e) In addition to the determinations
required under other applicable sections
of this subpart D, the IRB must
determine, in accordance with and to
the extent that consent is required under
part 50, that the permission of each
child’s parents or guardian is granted.
(1) Where parental permission is to be
obtained, the IRB may find that the
permission of one parent is sufficient for
clinical investigations to be conducted
under § 50.51 or § 50.52.
(2) Where clinical investigations are
covered by § 50.53 or § 50.54 and
permission is to be obtained from
parents, both parents must give their
permission unless one parent is
deceased, unknown, incompetent, or
not reasonably available, or when only
one parent has legal responsibility for
the care and custody of the child.
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PART 56—INSTITUTIONAL REVIEW
BOARDS
8. The authority citation for 21 CFR
part 56 continues to read as follows:
■
Authority: 21 U.S.C. 321, 343, 346, 346a,
348, 350a, 350b, 351, 352, 353, 355, 360,
360c–360f, 360h–360j, 371, 379e, 381; 42
U.S.C. 216, 241, 262, 263b–263n.
9. Revise in § 56.109 the second
sentence of paragraph (h) to read as
follows:
■
§ 56.109
IRB review of research.
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(h) * * * When some or all of the
subjects in a study that was ongoing on
April 30, 2001, are children, an IRB
must conduct a review of the research
PO 00000
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Fmt 4700
Sfmt 4700
DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
[Docket ID: DOD–2011–HA–0059]
RIN 0720–AB52
TRICARE; Elimination of the NonAvailability Statement (NAS)
Requirement for Non-Emergency
Inpatient Mental Health Care
Office of the Secretary,
Department of Defense.
ACTION: Final rule.
AGENCY:
SUMMARY: This final rule eliminates the
requirement that states a NAS is needed
for non-emergency inpatient mental
health care in order for a TRICARE
Standard beneficiary’s claim to be paid.
Currently, NAS are required for nonemergency inpatient mental health care
for TRICARE Standard beneficiaries
who live within a military treatment
facility catchment area. At this time, the
number of NASs issued is negligible as
most mental health admissions are
emergency admissions. Requiring a NAS
for a relatively few non-emergency
inpatient mental health admissions is
disproportionate to the cost of
maintaining the systems necessary to
process and coordinate the NAS.
DATES: Effective March 28, 2013.
Mr.
Richard Hart, TRICARE Policy and
Operations, TRICARE Management
Activity, 5111 Leesburg Pike, Suite 810,
Falls Church, VA 22041, 703–681–0047.
SUPPLEMENTARY INFORMATION:
FOR FURTHER INFORMATION CONTACT:
Executive Summary
I. Purpose of This Regulatory Action
a. Currently, NAS are required for
non-emergency inpatient mental health
care for TRICARE Standard beneficiaries
who live within a military treatment
facility catchment area. Pursuant to
section 1080(c)(2) of title 10, United
States Code, the Secretary can waive the
requirement to obtain NASs following
an evaluation of the effectiveness of
such statements in optimizing the use of
E:\FR\FM\26FER1.SGM
26FER1
12952
Federal Register / Vol. 78, No. 38 / Tuesday, February 26, 2013 / Rules and Regulations
III. Costs and Benefits of This
Regulatory Action
There are no anticipated budgetary
health care cost increases. Requiring a
NAS for a relatively few non-emergency
inpatient mental health admissions is
disproportionate to the cost of
maintaining the systems necessary to
process and coordinate the NAS.
II. Summary of the Major Provisions of
This Regulatory Action
wreier-aviles on DSK5TPTVN1PROD with RULES
facilities of the uniformed services. At
this time, the number of NASs issued is
negligible as most mental health
admissions are emergency admissions.
Requiring a NAS for a relatively few
non-emergency inpatient mental health
admissions is disproportionate to the
cost of maintaining the systems
necessary to process and coordinate the
NAS. This final rule eliminates the
requirement for a NAS for nonemergency inpatient mental health care
in order for the TRICARE Standard
beneficiary’s claim to be paid.
b. Authority: 5 U.S.C. 301; 10 U.S.C.
chapter 55.
Executive Order 12866, ‘‘Regulatory
Planning and Review’’ and Executive
Order 13563, ‘‘Improving Regulation
and Regulatory Review’’
Executive Order 12866 requires that a
comprehensive regulatory impact
analysis be performed on any
economically significant regulatory
action, defined as one that would result
in an annual effect of $100 million or
more on the national economy or which
would have other substantial impacts.
This final rule is not economically
significant nor a significant regulatory
action as defined under these executives
orders.
This final rule eliminates the
requirement for a NAS for nonemergency inpatient mental health care
in order for the TRICARE Standard
beneficiary’s claim to be paid.
The elimination of the requirement
for a NAS for non-emergency inpatient
mental health care for TRICARE
Standard beneficiaries is separate and
distinct from the ongoing right of first
refusal for specialty services requested
by a civilian provider under TRICARE
Prime, if the services are available at the
MTF, or the ongoing statutory
requirement for preadmission
authorization before inpatient mental
health services may be provided. This
final rule does not eliminate the right of
first refusal or requirement for
preadmission authorization.
In reviewing the proposed rule, we
discovered that we had inadvertently
deleted not only the requirement to
obtain a NAS for non-emergency
inpatient mental health services for
TRICARE Standard beneficiaries living
within the 40-mile catchment area of a
military treatment facility, but also the
Department’s general implementation of
section 721 of Public Law 106–398, as
amended by section 735 of Public Law
107–107, regarding the Secretary’s
statutory authority to require a NAS. We
have remedied that oversight in this
final rule, thereby preserving the option
to impose the requirement to obtain
NASs in the future, consistent with
existing statutory authority, should
circumstances change and a
demonstration be made that, by
performing specific procedures at
affected military medical treatment
facilities, use of such facilities would be
optimized and significant costs avoided.
Section 199.4(a)(9) is thereby amended
to retain this general authority while
still eliminating the current requirement
to obtain a NAS for non-emergency
inpatient mental health services.
VerDate Mar<15>2010
14:06 Feb 25, 2013
Jkt 229001
Public Comments
The proposed rule was published in
the Federal Register on September 16,
2011 (76 FR 57690). No public
comments were received.
Regulatory Procedures
Sec. 202, Public Law 104–4, ‘‘Unfunded
Mandates Reform Act’’
This rule does not contain unfunded
mandates. It does not contain a Federal
mandate that may result in the
expenditure by State, local and tribal
governments, in aggregate, or by the
private sector, of $100 million or more
in any 1 year.
Public Law 96–354, ‘‘Regulatory
Flexibility Act’’ (5 U.S.C. 601)
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 final rule
will not have a significant impact on a
substantial number of small entities for
purposes of the RFA. Thus this final
rule is not subject to this requirement.
Paperwork Reduction Act of 1995 (44
U.S.C. 3501–3511)
This final rule will not impose
additional reporting or recordkeeping
requirements under the Paperwork
Reduction Act of 1995.
Executive Order 13132, ‘‘Federalism’’
We have examined the impacts of the
rule under Executive Order 13132 and
PO 00000
Frm 00020
Fmt 4700
Sfmt 4700
it does not have policies that have
federalism implications that would have
substantial direct effects on the States,
on the relationship between the
National Government and the States, or
on the distribution of power and
responsibilities among the various
levels of government, therefore,
consultation with State and local
officials is not required.
List of Subjects in 32 CFR Part 199
Claims, Dental health, Health care,
Health insurance, Individuals with
disabilities, Military personnel.
Accordingly, 32 CFR part 199 is
amended as follows:
PART 199—[AMENDED]
1. The authority citation for part 199
continues to read as follows:
■
Authority: 5 U.S.C. 301; 10 U.S.C. chapter
55.
2. Section 199.4 is amended by
revising paragraph (a)(9) to read as
follows:
■
§ 199.4
Basic program benefits.
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(a) * * *
(9) Nonavailability Statements within
a 40-mile catchment area. Unless
required by action of the Assistant
Secretary of Defense for Health Affairs
(ASD(HA)) under this paragraph (a)(9),
nonavailability statements are not
required. If they are required by
ASD(HA) action, in some geographic
locations, CHAMPUS beneficiaries not
enrolled in TRICARE Prime may be
required to obtain a nonavailability
statement from a military medical
treatment facility in order to receive
specifically identified health care
services from a civilian provider. If the
required care cannot be provided
through the Uniformed Service facility,
the hospital commander, or a designee,
will issue a Nonavailability Statement
(NAS) (DD Form 1251). Failure to secure
such a statement may waive the
beneficiary’s rights to benefits under
CHAMPUS/TRICARE.
(i) With the exception of maternity
services, the ASD(HA) may require an
NAS prior to TRICARE cost-sharing for
additional services from civilian sources
if such services are to be provided to a
beneficiary who lives within a 40-mile
catchment area of an MTF where such
services are available and the ASD(HA):
(A) Demonstrates that significant costs
would be avoided by performing
specific procedures at the affected MTF
or MTFs; or
(B) Determines that a specific
procedure must be provided at the
E:\FR\FM\26FER1.SGM
26FER1
wreier-aviles on DSK5TPTVN1PROD with RULES
Federal Register / Vol. 78, No. 38 / Tuesday, February 26, 2013 / Rules and Regulations
affected MTF or MTFs to ensure the
proficiency levels of the practitioners at
the MTF or MTFs; or
(C) Determines that the lack of NAS
data would significantly interfere with
TRICARE contract administration; and
(D) Provides notification of the
ASD(HA)’s intent to require an NAS
under this authority to covered
beneficiaries who receive care at the
MTF or MTFs that will be affected by
the decision to require an NAS under
this authority; and
(E) Provides at least 60-day
notification to the Committees on
Armed Services of the House of
Representatives and the Senate of the
ASD(HA)’s intent to require an NAS
under this authority, the reason for the
NAS requirement, and the date that an
NAS will be required.
(ii) Rules in effect at the time civilian
medical care is provided apply. The
applicable rules and regulations
regarding Nonavailability Statements in
effect at the time the civilian care is
rendered apply in determining whether
a NAS is required.
(iii) The Director, TMA is responsible
for issuing the procedural rules and
regulations regarding Nonavailability
Statements. Such rules and regulations
should address:
(A) When and for what services a
NAS is required. However, a NAS may
not be required for services otherwise
available at an MTF located within a 40mile radius of the beneficiary’s
residence when another insurance plan
or program provides the beneficiary’s
primary coverage for the services. This
requirement for an NAS does not apply
to beneficiaries enrolled in TRICARE
Prime, even when those beneficiaries
use the point-of-service option under
§ 199.17(n)(3) of this part; and
(B) When and how notifications will
be made to a beneficiary who is not
enrolled in TRICARE Prime as to
whether or not he or she resides in a
geographic area that requires obtaining
a NAS; and
(C) What information relating to
claims submissions, including the
documentation, if any, that is required
to document that a valid NAS was
issued. However, when documentation
of a NAS is required, then that
documentation shall be valid for the
adjudication of CHAMPUS claims for all
related care otherwise authorized by
this part which is received from a
civilian source while the beneficiary
resided within the Uniformed Service
facility catchment area which issued the
NAS.
(iv) In the case of any service subject
to a NAS requirement under this
paragraph (a)(9) and also subject to a
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14:06 Feb 25, 2013
Jkt 229001
preadmission (or other pre-service)
authorization requirement under § 199.4
or § 199.15 of this part, the
administrative processes for the NAS
and pre-service authorization may be
combined.
*
*
*
*
*
Dated: February 1, 2013.
Patricia L. Toppings,
OSD Federal Register Liaison Officer,
Department of Defense.
[FR Doc. 2013–03418 Filed 2–25–13; 8:45 am]
BILLING CODE 5001–06–P
12953
currently define third-party billing
agents.
Title 42 of the CFR subpart C—
Exclusions at 42 CFR 402.200(b)(1)
provides for the imposition of an
exclusion from the Medicare and
Medicaid programs (and, where
applicable, other Federal health care
programs) against persons that violate
the provisions provided in § 402.1(e)
(and further described in § 402.1(c)).
However, TRICARE had no independent
regulatory authority to sanction or
exclude third-party billing agents. This
final rule provides that authority.
DEPARTMENT OF DEFENSE
B. Summary of Major Provisions
Office of the Secretary
This final rule establishes that such
entities, when acting on behalf of a
provider, are held to an equal standard
in regard to accuracy and honesty when
filing claims for services and supplies
under the TRICARE program. As such,
these entities should be subject to the
same administrative controls applied to
providers in ensuring that funds are
disbursed appropriately. This rule will
allow TRICARE to sanction third-party
billing agents to prevent the payment of
false or improper billings.
32 CFR Part 199
[Docket ID: DOD–2011–HA–0035]
RIN 0720–AB49
TRICARE; TRICARE Sanction
Authority for Third-Party Billing Agents
Office of the Secretary,
Department of Defense.
ACTION: Final rule.
AGENCY:
SUMMARY: This final rule will provide
the Director, TRICARE Management
Activity (TMA), or designee, with the
authority to sanction third-party billing
agents by invoking the administrative
remedy of exclusion or suspension from
the TRICARE program. Such sanctions
may be invoked in situations involving
fraud or abuse on the part of third-party
billing agents that prepare or submit
claims presented to TRICARE for
payment.
DATES: Effective date: This rule is
effective March 28, 2013.
FOR FURTHER INFORMATION CONTACT: Ms.
Ann N. Fazzini, Medical Benefits and
Reimbursement Branch, TMA,
telephone, (303) 676–3803.
SUPPLEMENTARY INFORMATION:
I. Executive Summary and Overview
A. Purpose of the Regulatory Action
As stated in the proposed rule,
TRICARE has regulatory authority under
32 Code of Federal Regulations (CFR)
199.9 to invoke sanctions in situations
involving fraud or abuse on the part of
providers of TRICARE services. A
provider is defined in 32 CFR 199.2 as,
‘‘A hospital or other institutional
provider, a physician, or other
individual professional provider, or
other provider of services or supplies as
specified in § 199.6 of this part.’’ Thirdparty billing agents do not meet the
definition of a provider as stated in 32
CFR 199.2, nor do TRICARE regulations
PO 00000
Frm 00021
Fmt 4700
Sfmt 4700
C. Summary of Costs and Benefits
By expanding the scope of
sanctioning authority to include thirdparty billing agents, TRICARE costs are
not anticipated to increase in this area.
Rather, by expanding the sanctioning
authority to include third-party billing
agents in situations of fraud or abuse,
the program is safeguarding benefit
dollars from being expended for
fraudulent or abusive charges. The
anticipated result of this final rule is a
savings benefit to the program.
II. Department of Defense Inspector
General Report on TRICARE Controls
Over Claims Prepared by Third-Party
Billing Agents
The Department of Defense, Office of
Inspector General (DoD IG) initiated an
audit in February 2008 to review
TRICARE controls over claims
submitted by third-party billing agents
(Department of Defense Inspector
General Report No. D–2009–037—
‘‘TRICARE Controls Over Claims
Prepared by Third-Party Billing
Agencies’’). The DoD IG published a
report on December 31, 2008. The report
included a recommendation that the
Director, TMA strengthen internal
controls by initiating action to obtain
statutory or regulatory authority to
sanction billing agencies or any entities
that prepare or submit improper health
care claims to TRICARE contractors.
E:\FR\FM\26FER1.SGM
26FER1
]]>Agencies
[Federal Register Volume 78, Number 38 (Tuesday, February 26, 2013)]
[Rules and Regulations]
[Pages 12951-12953]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2013-03418]
=======================================================================
-----------------------------------------------------------------------
DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
[Docket ID: DOD-2011-HA-0059]
RIN 0720-AB52
TRICARE; Elimination of the Non-Availability Statement (NAS)
Requirement for Non-Emergency Inpatient Mental Health Care
AGENCY: Office of the Secretary, Department of Defense.
ACTION: Final rule.
-----------------------------------------------------------------------
SUMMARY: This final rule eliminates the requirement that states a NAS
is needed for non-emergency inpatient mental health care in order for a
TRICARE Standard beneficiary's claim to be paid. Currently, NAS are
required for non-emergency inpatient mental health care for TRICARE
Standard beneficiaries who live within a military treatment facility
catchment area. At this time, the number of NASs issued is negligible
as most mental health admissions are emergency admissions. Requiring a
NAS for a relatively few non-emergency inpatient mental health
admissions is disproportionate to the cost of maintaining the systems
necessary to process and coordinate the NAS.
DATES: Effective March 28, 2013.
FOR FURTHER INFORMATION CONTACT: Mr. Richard Hart, TRICARE Policy and
Operations, TRICARE Management Activity, 5111 Leesburg Pike, Suite 810,
Falls Church, VA 22041, 703-681-0047.
SUPPLEMENTARY INFORMATION:
Executive Summary
I. Purpose of This Regulatory Action
a. Currently, NAS are required for non-emergency inpatient mental
health care for TRICARE Standard beneficiaries who live within a
military treatment facility catchment area. Pursuant to section
1080(c)(2) of title 10, United States Code, the Secretary can waive the
requirement to obtain NASs following an evaluation of the effectiveness
of such statements in optimizing the use of
[[Page 12952]]
facilities of the uniformed services. At this time, the number of NASs
issued is negligible as most mental health admissions are emergency
admissions. Requiring a NAS for a relatively few non-emergency
inpatient mental health admissions is disproportionate to the cost of
maintaining the systems necessary to process and coordinate the NAS.
This final rule eliminates the requirement for a NAS for non-emergency
inpatient mental health care in order for the TRICARE Standard
beneficiary's claim to be paid.
b. Authority: 5 U.S.C. 301; 10 U.S.C. chapter 55.
II. Summary of the Major Provisions of This Regulatory Action
This final rule eliminates the requirement for a NAS for non-
emergency inpatient mental health care in order for the TRICARE
Standard beneficiary's claim to be paid.
The elimination of the requirement for a NAS for non-emergency
inpatient mental health care for TRICARE Standard beneficiaries is
separate and distinct from the ongoing right of first refusal for
specialty services requested by a civilian provider under TRICARE
Prime, if the services are available at the MTF, or the ongoing
statutory requirement for preadmission authorization before inpatient
mental health services may be provided. This final rule does not
eliminate the right of first refusal or requirement for preadmission
authorization.
In reviewing the proposed rule, we discovered that we had
inadvertently deleted not only the requirement to obtain a NAS for non-
emergency inpatient mental health services for TRICARE Standard
beneficiaries living within the 40-mile catchment area of a military
treatment facility, but also the Department's general implementation of
section 721 of Public Law 106-398, as amended by section 735 of Public
Law 107-107, regarding the Secretary's statutory authority to require a
NAS. We have remedied that oversight in this final rule, thereby
preserving the option to impose the requirement to obtain NASs in the
future, consistent with existing statutory authority, should
circumstances change and a demonstration be made that, by performing
specific procedures at affected military medical treatment facilities,
use of such facilities would be optimized and significant costs
avoided. Section 199.4(a)(9) is thereby amended to retain this general
authority while still eliminating the current requirement to obtain a
NAS for non-emergency inpatient mental health services.
III. Costs and Benefits of This Regulatory Action
There are no anticipated budgetary health care cost increases.
Requiring a NAS for a relatively few non-emergency inpatient mental
health admissions is disproportionate to the cost of maintaining the
systems necessary to process and coordinate the NAS.
Public Comments
The proposed rule was published in the Federal Register on
September 16, 2011 (76 FR 57690). No public comments were received.
Regulatory Procedures
Executive Order 12866, ``Regulatory Planning and Review'' and Executive
Order 13563, ``Improving Regulation and Regulatory Review''
Executive Order 12866 requires that a comprehensive regulatory
impact analysis be performed on any economically significant regulatory
action, defined as one that would result in an annual effect of $100
million or more on the national economy or which would have other
substantial impacts. This final rule is not economically significant
nor a significant regulatory action as defined under these executives
orders.
Sec. 202, Public Law 104-4, ``Unfunded Mandates Reform Act''
This rule does not contain unfunded mandates. It does not contain a
Federal mandate that may result in the expenditure by State, local and
tribal governments, in aggregate, or by the private sector, of $100
million or more in any 1 year.
Public Law 96-354, ``Regulatory Flexibility Act'' (5 U.S.C. 601)
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 final rule will not have a significant impact on a substantial
number of small entities for purposes of the RFA. Thus this final rule
is not subject to this requirement.
Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3511)
This final rule will not impose additional reporting or
recordkeeping requirements under the Paperwork Reduction Act of 1995.
Executive Order 13132, ``Federalism''
We have examined the impacts of the rule under Executive Order
13132 and it does not have policies that have federalism implications
that would have substantial direct effects on the States, on the
relationship between the National Government and the States, or on the
distribution of power and responsibilities among the various levels of
government, therefore, consultation with State and local officials is
not required.
List of Subjects in 32 CFR Part 199
Claims, Dental health, Health care, Health insurance, Individuals
with disabilities, Military personnel.
Accordingly, 32 CFR part 199 is amended as follows:
PART 199--[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 199.4 is amended by revising paragraph (a)(9) to read as
follows:
Sec. 199.4 Basic program benefits.
* * * * *
(a) * * *
(9) Nonavailability Statements within a 40-mile catchment area.
Unless required by action of the Assistant Secretary of Defense for
Health Affairs (ASD(HA)) under this paragraph (a)(9), nonavailability
statements are not required. If they are required by ASD(HA) action, in
some geographic locations, CHAMPUS beneficiaries not enrolled in
TRICARE Prime may be required to obtain a nonavailability statement
from a military medical treatment facility in order to receive
specifically identified health care services from a civilian provider.
If the required care cannot be provided through the Uniformed Service
facility, the hospital commander, or a designee, will issue a
Nonavailability Statement (NAS) (DD Form 1251). Failure to secure such
a statement may waive the beneficiary's rights to benefits under
CHAMPUS/TRICARE.
(i) With the exception of maternity services, the ASD(HA) may
require an NAS prior to TRICARE cost-sharing for additional services
from civilian sources if such services are to be provided to a
beneficiary who lives within a 40-mile catchment area of an MTF where
such services are available and the ASD(HA):
(A) Demonstrates that significant costs would be avoided by
performing specific procedures at the affected MTF or MTFs; or
(B) Determines that a specific procedure must be provided at the
[[Page 12953]]
affected MTF or MTFs to ensure the proficiency levels of the
practitioners at the MTF or MTFs; or
(C) Determines that the lack of NAS data would significantly
interfere with TRICARE contract administration; and
(D) Provides notification of the ASD(HA)'s intent to require an NAS
under this authority to covered beneficiaries who receive care at the
MTF or MTFs that will be affected by the decision to require an NAS
under this authority; and
(E) Provides at least 60-day notification to the Committees on
Armed Services of the House of Representatives and the Senate of the
ASD(HA)'s intent to require an NAS under this authority, the reason for
the NAS requirement, and the date that an NAS will be required.
(ii) Rules in effect at the time civilian medical care is provided
apply. The applicable rules and regulations regarding Nonavailability
Statements in effect at the time the civilian care is rendered apply in
determining whether a NAS is required.
(iii) The Director, TMA is responsible for issuing the procedural
rules and regulations regarding Nonavailability Statements. Such rules
and regulations should address:
(A) When and for what services a NAS is required. However, a NAS
may not be required for services otherwise available at an MTF located
within a 40-mile radius of the beneficiary's residence when another
insurance plan or program provides the beneficiary's primary coverage
for the services. This requirement for an NAS does not apply to
beneficiaries enrolled in TRICARE Prime, even when those beneficiaries
use the point-of-service option under Sec. 199.17(n)(3) of this part;
and
(B) When and how notifications will be made to a beneficiary who is
not enrolled in TRICARE Prime as to whether or not he or she resides in
a geographic area that requires obtaining a NAS; and
(C) What information relating to claims submissions, including the
documentation, if any, that is required to document that a valid NAS
was issued. However, when documentation of a NAS is required, then that
documentation shall be valid for the adjudication of CHAMPUS claims for
all related care otherwise authorized by this part which is received
from a civilian source while the beneficiary resided within the
Uniformed Service facility catchment area which issued the NAS.
(iv) In the case of any service subject to a NAS requirement under
this paragraph (a)(9) and also subject to a preadmission (or other pre-
service) authorization requirement under Sec. 199.4 or Sec. 199.15 of
this part, the administrative processes for the NAS and pre-service
authorization may be combined.
* * * * *
Dated: February 1, 2013.
Patricia L. Toppings,
OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2013-03418 Filed 2-25-13; 8:45 am]
BILLING CODE 5001-06-P
