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 provider(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 medical care.
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 permitted.
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.
Claims should go to the CHAMPUS claims processor serving for the state or country where the care was received, no matter where the pa- tient lives.
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.