There is an appeal route if a beneficiary disagrees with certain decisions made by the CHAMPUS claims processor or by OCHAMPUS (Office of the Civilian Health and Medical Program of the Uniformed Services, Aurora, Colorado).
There is no appeal allowed concerning a CHAMPUS regulation or federal law. Additionally, the amount that the claims processor determines to be the allowable charge for a particular service cannot be appealed.
Appeals concerning eligibility for medical care and CHAMPUS must be processed through the uniformed service concerned. The local HBA can advise the beneficiary on the proper appeal route.
If the beneficiary disagrees with the facts in the case (such as whether or not the diagnosis was correct or whether or not hospitalization was required) or if there appears to be a mistake in how the law, regulation, or policy was interpreted, then an appeal can be filed as follows:
If there is a disagreement concerning the decisions by the claims processor or with the EOB, then:
Write the claims processor within 90 days of the EOB date with a notice of disagreement, and
Within 60 days the claims processor will send back a reconsideration determination.
If there is still disagreement and more than is in question, OCHAMPUS can be requested to do a formal review. This request must be submitted within 60 days of the date on the reconsideration determination.
If the amount is less than, the reconsideration determination of the claims processor is final.
If there is disagreement with a reconsideration determination or with a decision made by OCHAMPUS, then:
Write OCHAMPUS within 60 days of the date of the notice or reconsideration determination, and
OCHAMPUS will provide a decision within 90 days.
If the disputed amount is less than 0, the OCHAMPUS decision is final.
If there continues to be disagreement and more than 0 is in dispute, OCHAMPUS can be requested to set up an independent hearing. This request must be made within 60 days of the date on the formal review decision.
When the formal review decision is made, it explains the steps for further appeal. If indicated and the variables are met, a decision can be appealed all the way through the Assistant Secretary of Defense (Health Affairs).
CUSTODY AND MAINTENANCE OF PATIENT RECORDS
Custody, maintenance, disposition, and retirement of patient records whether outpatient or inpatient is a semicomplex issue and is too detailed to discuss in this forum. Familiarization with the following listed instructions will assist in proper record procedures:
NAVMEDCOMINST 6150.1, Procedures for Construction and Maintenance of Health Care Treatment Records
NAVEDTRA 10669 series, HM 3 & 2 Rate Training Manual
NAVMED P-117, Manual of the Medical Department (chapters 16, 18, and 23)
BUMEDINST 6300.3B, Inpatient Data System
SECNAVINST 5211.5 series, Personal Privacy and Rights of Individuals Regarding Records Pertaining to Themselves
SECNAVINST P5212.5 series, Disposal of Navy and Marine Corps Records
NAVY MEDICINES QUALITY ASSURANCE/RISK MANAGEMENT PROGRAM
Quality assurance implies biphasic action (1) to evaluate the degree of excellence of the results of delivered care, and (2) to make