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FAMILY ADVOCACY PROGRAM |
Appeal
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. Ad-
ditionally, 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 dis-
agreement, and
. Within 60 days the claims processor
will send back a reconsideration determination.
l If there is still disagreement and more
than $50 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.
l If the amount is less than $50, the
reconsideration determination of the claims
processor is final.
l If there is disagreement with a recon-
sideration determination or with a decision
made by OCHAMPUS, then:
. Write OCHAMPUS within 60 days of
the date of the notice or reconsideration deter-
mination, and
l OCHAMPUS will provide a decision
within 90 days.
l If the disputed amount is less than $300,
the OCHAMPUS decision is final.
. If there continues to be disagreement and
more than $300 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 retire-
ment 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 Them-
selves
SECNAVINST P5212.5 series, Disposal of
Navy and Marine Corps Records
NAVY MEDICINE’S 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
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