(Added Pub. L. 102–190, div. A, title VII, § 716(a)(1),Dec. 5, 1991, 105 Stat. 1403; amended Pub. L. 105–85, div. A, title VII, § 738(a),Nov. 18, 1997, 111 Stat. 1815; Pub. L. 112–81, div. A, title VII, § 712,Dec. 31, 2011, 125 Stat. 1476.)
2011—Subsec. (b). Pub. L. 112–81
substituted “as follows:” for “not later than one year after the services are provided.” and added pars. (1) and (2).
1997—Pub. L. 105–85
substituted “: standard form; time limits” for “under CHAMPUS” in section catchline and amended text generally. Prior to amendment, text read as follows:
“(a) Submittal to Claims Processing Office.—Each provider of services under the Civilian Health and Medical Program of the Uniformed Services shall submit claims for payment for such services directly to the claims processing office designated pursuant to regulations prescribed under subsection (b). A claim for payment for services shall be submitted in a standard form (as prescribed in the regulations) not later than one year after the services are provided.
“(b) Regulations.—The regulations required by subsection (a) shall be prescribed by the Secretary of Defense after consultation with the other administering Secretaries.
“(c) Waiver.—The Secretary of Defense may waive the requirements of subsection (a) if the Secretary determines that the waiver is necessary in order to ensure adequate access for covered beneficiaries to health care services under this chapter.”
Section 716(b) ofPub. L. 102–190
provided that: “The regulations required by section
, United States Code (as added by subsection (a)), shall be prescribed to take effect not later than 180 days after the date of the enactment of this Act [Dec. 5, 1991].”
Establishment of Appeals Process for ClaimCheck Denials
Pub. L. 105–261
, div. A, title VII, § 714,Oct. 17, 1998, 112 Stat. 2060
, provided that:
“(a) Establishment of Appeals Process.—Not later than January 1, 1999, the Secretary of Defense shall establish an appeals process in cases of denials through the ClaimCheck computer software system (or any other claims processing system that may be used by the Secretary) of claims by civilian providers for payment for health care services provided under the TRICARE program.
“(b) Report.—Not later than March 1, 1999, the Secretary shall submit to Congress a report on the implementation of this section.”
National Claims Processing System for CHAMPUS
Pub. L. 102–484
, div. A, title VII, § 711,Oct. 23, 1992, 106 Stat. 2433
, provided that:
“(a) Claims Processing System Required.—(1) The Secretary of Defense, in consultation with the other administering Secretaries, shall provide by contract for the operation of a claims processing system to be known as the ‘National Claims Processing System for CHAMPUS’. The Secretary may procure the system in installments, including the use of incremental modules. The system, including completion and integration of all modules, shall be in full operation not later than seven years after the date of the enactment of this Act [Oct. 23, 1992].
“(2) The Secretary shall use competitive procedures for entering into any contract or contracts under paragraph (1).
“(b) System Functions.—The claims processing system shall include at least the following functions:
“(1) The maintenance in electronic or written form, or both, of appropriate information on health care services provided to covered beneficiaries by or through third parties under CHAMPUS or any alternative CHAMPUS program or demonstration project. Such information shall include—
“(A) the services to which such beneficiaries are entitled or eligible under an insurance plan, medical service plan, or health plan under CHAMPUS;
“(B) the insurers, medical services, or health plans that provide such services; and
“(C) the services available to beneficiaries under each insurance plan, medical service plan, or health plan, and the payment required of the beneficiaries and the insurer, medical service, or health plan for such services under the plan.
“(2) The ability to receive in electronic or written form claims submitted by insurers, medical services, and health plans for services provided to covered beneficiaries.
“(3) The ability to process, adjudicate, and pay (by electronic or other means) such claims.
“(4) The provision of the information described in paragraphs (1) and (2) and information on the matters referred to in paragraph (3) by telephone, electronic, or other means to covered beneficiaries, insurers, medical services, and health plans.
“(c) Consistency with Medicare Claims Requirements.—The Secretary of Defense shall ensure, to the maximum extent practicable, that claims submitted to the claims processing system conform to the requirements applicable to claims submitted to the Secretary of Health and Human Services with respect to medical care provided under part A of title XVIII of the Social Security Act (42
“(d) Identification Card.—The Secretary of Defense shall take appropriate actions to determine whether the use by covered beneficiaries of a standard identification card containing electronically readable information will enhance the capability of the claims processing center to carry out the activities set forth in subsection (b).
“(e) Transition to System.—After January 1, 1996, any modification or acquisition related to claims processing systems operations in the Office of the Civilian Health and Medical Program of the Uniformed Services shall contain provisions to transfer such operations to the claims processing system required by subsection (a). After January 1, 1999, any renewal or acquisition for fiscal intermediary services (including coordinated care implementations in military hospitals and clinics) shall contain provisions to transfer claims processing systems operations related to such fiscal intermediary services to the claims processing system required by subsection (a).
“(f) Definitions.—For purposes of this section:
“(1) The term ‘administering Secretaries’ has the meaning given that term in paragraph (3) of section
, United States Code.
“(2) The term ‘CHAMPUS’ means the Civilian Health and Medical Program of the Uniformed Services, as defined in paragraph (4) of such section.
“(3) The term ‘covered beneficiary’ has the meaning given that term in paragraph (5) of such section.”