CurrentDHAPolicy N/A

CHAMPUS Claims Submission, Review, and Payment

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This policy governs the information, documentation, signatures, filing deadlines, preauthorization, review, and payment requirements for CHAMPUS claims under the Basic Program and ECHO. It affects beneficiaries, sponsors, participating and nonparticipating providers, CHAMPUS fiscal intermediaries, and OCHAMPUS.

Policy Summary

PayerDHA

PolicyCHAMPUS Claims Submission, Review, and Payment

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a complete, properly executed claim with sufficient beneficiary, service, supply, and double-coverage information before seeking CHAMPUS benefits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yearClaim filing deadline

90 daysReturned-claim resubmission period

30 daysPreauthorization validity

24 hoursRequired documentation timeframe

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CurrentDHAPolicy N/A

CHAMPUS Claims Submission, Review, and Payment

Customize your policy alerts

Sign up for all DHA policy alerts

Know when DHA releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerDHA

PolicyCHAMPUS Claims Submission, Review, and Payment

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a complete, properly executed claim with sufficient beneficiary, service, supply, and double-coverage information before seeking CHAMPUS benefits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yearClaim filing deadline

90 daysReturned-claim resubmission period

30 daysPreauthorization validity

24 hoursRequired documentation timeframe

Minimum benefit threshold

2Benefit payment pathways

CHAMPUS Coverage, Adjudication, and Payment Criteria

Administrative conditions for CHAMPUS payment

CHAMPUS cost-sharing is available only when all applicable claim, documentation, signature, filing, authorization, and review requirements are satisfied.

ALL of the following

Submit an appropriate, complete, and properly executed claim form.
Provide sufficient beneficiary identification, medical service or supply information, and double coverage information for accurate and timely adjudication.
Maintain written medical records that substantiate all care and services billed.
Obtain and document any required preauthorization before services or supplies are provided.
Obtain and submit any required Nonavailability Statement with the applicable claim, except when an emergency exception applies.
File the claim, and resubmit any returned claim with requested information, within the applicable filing deadline.
Obtain required beneficiary and provider signatures, or use an approved signature-on-file procedure.
Satisfy applicable utilization review, quality assurance, definitions, conditions, limitations, exclusions, and other program requirements.

Denial and nonpayment conditions

A claim or specific service may be denied or remain unpaid when any of the following conditions applies.

ANY of the following

Care or services billed are not documented in the medical record.
There is a pattern of inadequate documentation of medical care.
Required information or records are not furnished before adjudication.
The claim is filed after the applicable deadline without an approved exception or waiver.
A required preauthorization or Nonavailability Statement is absent.

Payment routing and participating-provider limits

Payment routing and the provider's billing responsibility depend on who submits the claim and whether the provider participates.

ANY of the following

The beneficiary or sponsor signs and submits the claim directly; payment is made to and mailed to the beneficiary or sponsor, who remains responsible to the provider for amounts billed.
An authorized provider signs the claim, indicates participation, and submits it on behalf of the beneficiary; payment is made to and mailed to the participating provider, which must accept the CHAMPUS-determined allowable charge or cost, together with applicable cost-sharing, as full payment.

Claim adjudication requirements

Before benefits may be extended, each CHAMPUS claim must meet the following adjudication requirements.

ALL of the following

The claim complies with applicable CHAMPUS definitions, conditions, limitations, and exclusions.
The claim is subject to and satisfies applicable utilization review and quality assurance standards, norms, and criteria issued by the Director, OCHAMPUS, or a designee.

Benefit payment rules

Benefit payment responsibility is determined by the claim submission route and provider participation status.

ANY of the following

The beneficiary or sponsor signs and submits the claim directly; payment is made in the name of and mailed to the beneficiary or sponsor, who remains responsible to the provider for billed amounts.
An authorized provider signs the claim, indicates participation, and submits it on behalf of the beneficiary; payment is made in the name of and mailed to the participating provider, and the beneficiary or sponsor owes only applicable deductible and cost-sharing amounts.

Explanation of benefit requirements

A CEOB is issued after claim adjudication unless an authorized privacy exception applies.

ALL of the following

The CEOB identifies the beneficiary, provider, covered services or supplies, service dates, billed amount, CHAMPUS-determined allowable charge or cost, CHAMPUS payment, payment recipient, denial reasons when applicable, and available recourse for review of the claim decision.
The CEOB is sent to the beneficiary or sponsor; a copy is also sent to the provider when the claim was submitted on a participating basis.

Exception

The Director, OCHAMPUS, or a designee authorizes a CHAMPUS fiscal intermediary to waive the CEOB to protect the beneficiary's privacy.

Overseas dental plan administration

The Active Duty Dependents Dental Plan may be extended outside the United States under administration and payment procedures adapted to overseas conditions.

ALL of the following

Overseas program elements, methods of administration, payment rates, and provider procedures may differ from Continental United States rules when the ASD(HA) or designee determines the differences are necessary for effective and efficient plan operation.
Rules for covered services and provider quality-of-care standards remain comparable to Continental United States rules and available military guidelines, subject to limitations in the capabilities of overseas Uniformed Services dental facilities and civilian-sector providers.

Filing, Preauthorization, and Payment Timeframes

Initial claim filing deadline

Filing deadlineFile the claim no later than one year after the services are provided.

Applies toServices provided on or after January 1, 1993.

Consequence of late filingUnless the requirement is waived, failure to meet the deadline waives all rights to benefits for the services or supplies.

Returned-claim resubmission deadline

Resubmission deadlineResubmit the returned claim with the requested information by the later of one year after the services are provided or 90 days from the date the claim was returned.

Initial filing requirementThe claim must have been initially submitted within the claim filing time limit.

Provider Claims and Payment Responsibilities

Documentation Required

Submit a Complete Claim

Submit an appropriate, complete, and properly executed claim form to the appropriate CHAMPUS fiscal intermediary. Include sufficient beneficiary-identification, medical-service and supply, and double-coverage information, and be able to document that the care or service was rendered.

Use the CHAMPUS claim form appropriate to the services or supplies provided.
The beneficiary, sponsor, or authorized provider acting on the beneficiary’s behalf is responsible for perfecting the claim.

Documentation Required

Obtain and Submit a Nonavailability Statement

When required, obtain a Nonavailability Statement before the beneficiary receives medical care from civilian sources and submit it with the applicable CHAMPUS claim. The requirement does not apply to emergencies; failure to secure a required statement waives CHAMPUS benefit rights, subject to appeal.

Determine whether the beneficiary’s geographic area or circumstances require a Nonavailability Statement.
Rules in effect when the civilian care is rendered determine whether the statement is required.

Key CHAMPUS Claims Terms

Appropriate claim

DefinitionAn appropriate claim is a complete and properly executed claim form.

Required informationThe claim must include sufficient information about beneficiary identification, medical services and supplies provided, and double coverage.

PurposeThe information must permit proper, accurate, and timely adjudication by the CHAMPUS contractor or OCHAMPUS.

Preauthorization

DefinitionPreauthorization is approval that must be granted before benefits can be extended when another provision specifically requires it.

ScopeAn approved preauthorization specifies the exact services or supplies authorized.

Policy Summary

PayerDHA

PolicyCHAMPUS Claims Submission, Review, and Payment

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a complete, properly executed claim with sufficient beneficiary, service, supply, and double-coverage information before seeking CHAMPUS benefits.

SourceLink

On This Page

Required inpatient absence dates and purpose information are omitted, resulting in denial of benefits and, for an ongoing case, termination of inpatient benefits at least back to the absence date.

Additional informationThe requested information must be submitted with the returned claim.

Continuing-care claim frequency

Standard frequencySubmit an appropriate claim every 30 days, or monthly, while medical services or supplies are being rendered on a continuing basis.

More frequent submissionsClaims may be submitted more frequently at the election of the beneficiary or provider, or when required by the Director, OCHAMPUS, or a designee.

DRG-based paymentFor claims subject to the CHAMPUS DRG-based payment system, submit the claim only after the beneficiary has been discharged or transferred from the hospital.

General preauthorization validity

General validityApproved preauthorizations are generally valid for 30 days.

Specific approval periodThe applicable validity period is the specific period stated when the preauthorization is approved.

New approvalIf the authorized services or supplies are not obtained or commenced within the specified time limit, a new preauthorization is required before benefits may be extended.

Minimum benefit payment

Payment ruleIf the CHAMPUS benefit is determined to be under $1, payment is waived.

ThresholdThe minimum benefit payment threshold is $1.

ApplicationThe waiver applies when the calculated CHAMPUS benefit is less than $1.

Minimum benefit payment threshold

ThresholdBenefits under $1 are waived.

Payment amountNo payment is made when the determined CHAMPUS benefit is less than $1.

Determination pointThe threshold applies after the CHAMPUS benefit is determined.

Attach the statement to the claim for services subject to the requirement.

Prior Authorization

Attach ECHO Equipment Preauthorization

For durable equipment purchased under ECHO, attach a copy of the required preauthorization to the appropriate claim form.

Also attach an explanation of the medical need for items from other authorized providers, when required.

Prior Authorization

Obtain Required Preauthorization Before Care

When another provision of CHAMPUS specifically requires preauthorization, submit and obtain approval before the services or supplies are provided. Without required preauthorization, no benefits are payable unless an authorized exception applies.

The approval authorizes only the specific services or supplies identified.
Use the approval within its specified validity period; a new preauthorization is generally required if care is not obtained or commenced within that period.

Documentation Required

Submit a Treatment Plan With the Preauthorization Request

Accompany each preauthorization request with a proposed medical treatment plan. For inpatient stays under the Basic Program, provide the clinical and planning information needed to evaluate the request.

Include the diagnosis and a detailed summary of the complete history and physical.
Include a detailed problem statement, proposed treatment modality, anticipated duration, available test results, consultant reports, and prognosis.
For a hospital-to-hospital inpatient transfer, include medical records related to the inpatient stay.

Documentation Required

Document Preauthorization on the Claim

For a claim involving preauthorized services or supplies, indicate the date the preauthorization was approved and attach a copy of the written preauthorization to the claim.

The claim must correspond to the services or supplies specifically authorized.

Unsupported block type: billing_rule ולinfo

Denial Risk

Meet Claim Filing Deadlines

File claims with the appropriate CHAMPUS contractor no later than one year after the services are provided, unless an applicable exception or waiver applies. A late claim generally waives all rights to benefits.

A claim initially filed on time and returned for additional information must be resubmitted with the requested information by the later of one year after service or 90 days after the claim was returned.
The rule applies to services provided on or after January 1, 1993.

Documentation Required

Request a Late-Filing Exception

Request an exception to the claims filing deadline from the CHAMPUS fiscal intermediary with jurisdiction over the location where the service was rendered, or as otherwise designated by the Director, OCHAMPUS. Explain the late filing completely and support the request with available documentation.

Identify the specific claim denied for late filing.
Possible bases include retroactive eligibility, administrative error, mental incompetency, qualifying delays by other health insurance, or another circumstance supporting waiver authority.
Each request is reviewed individually on its merits.

Billing Rule

Submit Continuing-Care Claims Periodically

For continuing medical services and supplies, submit an appropriate claim or claims every 30 days unless the claim is subject to the CHAMPUS DRG-based payment system. DRG-based claims may be submitted only after the beneficiary is discharged or transferred.

Claims may be submitted more frequently, and the Director, OCHAMPUS, or designee may require more frequent submission based on dollar amounts.

Documentation Required

Certify Referring-Physician Communication

For each claim for services by a marriage and family counselor, pastoral counselor, or supervised mental health counselor, certify that written communication has been made or will be made to the referring physician regarding the beneficiary’s progress.

The communication is required at the end of treatment or more frequently if required by the referring physician.

Note

Claims Utilization and Quality Review

Claims for medical services and supplies are reviewed for compliance with applicable CHAMPUS requirements and are subject to utilization review and quality assurance standards, norms, and criteria before benefits are extended.

Maintain medical records and documentation sufficient to substantiate that billed services were rendered.

Billing Rule

Participating Provider Election

To participate, sign the CHAMPUS claim form, indicate participation in the appropriate space, and submit the specific claim to the appropriate CHAMPUS fiscal intermediary on behalf of the beneficiary.

An authorized representative must sign institutional-provider claims, and the signature must be on file with and approved by the fiscal intermediary.

Billing Rule

Accept the Allowable Charge

By electing to participate and signing the claim, the provider agrees to accept the CHAMPUS-determined allowable charge or cost, even if it is lower than the amount billed. The beneficiary or sponsor is responsible only for applicable deductible and cost-sharing amounts.

Participating-provider benefit payments are made in the provider’s name and mailed to the provider.

Prior Authorization

Overseas Dental Preauthorization

For Active Duty Dependents Dental Plan care outside the United States, establish preauthorization when required, including when needed services are unavailable at a Uniformed Service overseas dental treatment facility.

Overseas program elements may establish different preauthorization requirements from those used in the Continental United States.

Billing Rule

Overseas Dental Payment Procedures

For the Active Duty Dependents Dental Plan outside the United States, follow the program-specific payment rates, payment procedures, and administrative requirements established for the overseas area. Overseas arrangements may include Department payment of certain cost-shares or other portions of billed charges.

Payment methods may differ because of the capabilities of overseas Uniformed Service dental facilities and civilian providers in the particular country.
Covered-service rules and provider quality standards remain comparable to those applicable in the Continental United States, subject to applicable law and military guidance.

LimitationBenefits cannot be extended for services or supplies provided beyond the specific authorization.

Participating provider

DefinitionA participating provider submits the claim on behalf of the beneficiary.

Payment acceptanceThe provider accepts the CHAMPUS-determined allowable charge or cost as full payment for the covered medical services or supplies.

Payment recipientCHAMPUS benefit payments due from the claim are made in the name of and mailed to the participating provider.

Nonparticipating provider

DefinitionA nonparticipating provider elects not to participate in CHAMPUS.

Claim submissionThe beneficiary or sponsor submits the claim to the CHAMPUS fiscal intermediary.

Required bill and responsibilityAn itemized provider bill must accompany the claim, and the beneficiary or sponsor remains responsible for amounts billed.

Nonavailability Statement

DefinitionA Nonavailability Statement is issued when required medical care cannot be provided through a Uniformed Services facility.

TimingExcept for emergencies, the statement must be issued before medical care is obtained from civilian sources.

Claim attachmentWhen required, the statement must be submitted along with the applicable claim form.

CEOB

DefinitionA CEOB is the explanation sent after a CHAMPUS claim is adjudicated.

Required contentIt identifies the beneficiary, provider, covered services or supplies, service dates, billed amount, allowable charge or cost, and CHAMPUS payment.

Decision informationIt identifies the payment recipient, reasons for any denial, and available recourse for review of the claim decision.

Participating provider

Provider actionAn authorized provider must sign the CHAMPUS claim form and indicate participation in the appropriate space.

Submission responsibilityThe participating provider submits the specific claim on behalf of the beneficiary to the appropriate CHAMPUS fiscal intermediary.

Payment responsibilityThe provider agrees to abide by the CHAMPUS-determined allowable charge or cost, whether or not it is lower than the amount billed.

CEOB

RecipientA CEOB is sent to the beneficiary or sponsor after the CHAMPUS claim is adjudicated.

Provider copyA copy is also sent to the provider when the claim was submitted on a participating basis.

Privacy exceptionThe Director, OCHAMPUS, or a designee may authorize a fiscal intermediary to waive a CEOB to protect the beneficiary's privacy.