a patient resides within the ZIP Code catchment
area of a uniformed services military treatment
facility (USMTF) or USTF.
If the beneficiary resides in a catchment area
and the catchment area USMTF or USTF cannot
provide the required inpatient care, a non-
availability statement (NAS) will be provided.
This statement allows patients to file a claim with
CHAMPUS for nonemergent civilian inpatient
care. The only time beneficiaries living within
catchment areas do not require an NAS is when
there is a true medical emergency and delay could
cause death or a serious threat to health or when
they have other major medical insurance provid-
ing primary coverage for a covered service. Once
again, the HBA should be consulted.
NOTE: Just because the military treatment
facility provides a beneficiary an NAS does not
mean that CHAMPUS will pay the bill. By pro-
viding an NAS, the MTF is stating that they
cannot provide the desired care. CHAMPUS
cannot pay that bill if the desired or required care
is not allowable according to statutes.
Participating providers (the person or place
providing health care) that accept CHAMPUS
assignment agree to accept the CHAMPUS
allowable charge. The allowable charge is what
most providers within a given area would have
billed for a particular service. The cost-share is
based on the allowable charge no matter what the
patient is actually billed. Often times providers
who accept CHAMPUS assignment will file the
paperwork for the patient.
Providers who do not accept assignment (non-
participating providers) will bill the patient for
their normal charges. This is often more than
the CHAMPUS allowable charge. The patient
arranges with the provider to pay the bill and
files for CHAMPUS reimbursement for the
CHAMPUS share of the allowable charge.
CHAMPUS only shares certain medical bills.
The beneficiary pays the full bill for any care or
service that is not covered by CHAMPUS.
For outpatient care, there is a yearly deductible
of for one person or a maximum of 0 for a
family. That is, the beneficiary pays their pro-
vider(s) the first (or family 0) of medical
bills each fiscal year. The deductible is the same
for all families (active duty, retired, or survivors).
After the deductible is met, active duty families
pay 20 percent of all additional CHAMPUS
allowable charges and all others pay 25 percent of
all additional CHAMPUS allowable charges.
For inpatient care, families of active duty
members pay a small fee (set yearly) for each
day in a civilian hospital or a minimum of
for each admission, whichever is greater.
Retirees, their families, and the families of
deceased service members pay 25 percent of
the cost of CHAMPUS cost-shared civilian
According to federal law, CHAMPUS is
second payer on all claims. Therefore, if the
beneficiary has another insurance in force, they
must first file with the other company. After the
other policy pays, then a CHAMPUS claim is
In filing a claim, one or more of the
following may need to be furnished. Ensure these
are attached when required, otherwise the claim
will be denied or returned.
. Nonavailability statementThis form is
required when the patient received nonemergency
inpatient care and the patient lives in a ZIP Code
catchment area (generally, within 40 miles of a
USMTF or USTF with inpatient capability).
l Statement from other insurance plans
If other insurance is in force, then a statement
of what is paid must be attached.
l Previous explanation of benefits (EOB)
If the beneficiary has already met the deductible
for the fiscal year and then uses a claims
processor in a different area, a copy of the earlier
EOB should go with the claim to show the
claims processor that the deductible has been
Claims should go to the CHAMPUS claims
processor serving for the state or country where
the care was received, no matter where the pa-
CHAMPUS claim forms should be sent to the
claims processor as soon as possible after care is
received. Claims are payable only if received by
31 December of the year following the year that
care was received.