1. Registrar Division
2. Patient Personnel Services Division
3. Medical Information Services Division
4. Medical Records Processing Division
5. Outpatient Administration Division

1. Defense Enrollment Eligibility Reporting System (DEERS)
2. Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)

References

In chapter 11 we discussed the importance of personnel records and accounting systems in the Navy. In the Medical Department proper records administration is of even greater importance. We are charged with administering not only routine personnel records, but also clinical records that may affect the rights and benefits of patients and their dependents years beyond retirement or discharge.

The administrative affairs concerning inpatients and outpatients have reached such complexity that separate departments have been created to effectively administer them. As a senior hospital corpsman, you may be assigned to or be responsible for one of these departments. This chapter will provide information on the function of each department responsible for the administrative matters of hospital staff (active duty and civilian personnel), inpatients, and outpatients. It will also discuss, in brief, health care programs you may be involved with or be responsible for.

This department directs and coordinates the military personnel programs and the manpower analysis programs. The department can be divided into the Personnel Assignment Distribution Division, Staffing Division, Officer Personnel Division, Advancement and Inservice Training Division, Uniform Staffing Methodology Division, and Enlisted Personnel Division.

The Civilian Personnel Department coordinates the civilian personnel program with overall Navy, DOD, and Office of Personnel Management policies. This is accomplished by the following procedures:

1. Develops and implements a broad personnel management program comprised of employment and placement, wage and classification, employee development and training, employee benefits, incentive awards, discipline and labor management relations.
2. Provides employees and management with information and interpretations of laws, rules, regulations, and instructions pertaining to civilian personnel management, and issues both formal and informal local supplements to these directives.
3. Processes personnel documents and reports related to its program to ensure that legal requirements are met, communication facilitated, and management priorities are met.

The Navy policy for personnel administration is that each commanding officer must provide for sound management control, direction, and support of the personnel program to ensure consistent, efficient, and equitable personnel management throughout the Navy. The essential elements or functions of a comprehensive personnel program in the federal government, as described in the Federal Personnel Manual, are as follows:

1. Policy formulation and issuance
2. Position classification and pay administration
3. Staffing
4. Employee performance evaluation
5. Employee development
6. Employee relations and services
7. Employee recognition and incentives
8. Personnel records and reporting
9. Program evaluation

The assignment of responsibility for carrying out the activities of the personnel program is discussed in Navy civilian personnel instructions (NCPI) and in Office of Industrial Relations and Naval Medical Command (NAVMEDCOM) instructions and notices.

A POSITION is a specific aggregation of all the current duties and responsibilities contained in a work assignment made by a competent authority to be performed by one employee during a full working schedule, whether that schedule be full-time or part-time. Being occupied or vacant does not in itself change a position's identity or character.

All civilian positions must be established in accordance with applicable laws and regulations. At the local level the command is authorized to establish individual civilian positions within the overall civilian ceiling allowance established by NAVMEDCOM. Positions in grades GS-12 and above and some special categories require approval by NAVMEDCOM.

This department provides for and coordinates all administrative matters related to the admission and disposition of inpatients and outpatients, to include verifying patient eligibility for treatment, processing inpatient (clinical) records and medical boards, preparing correspondence, reports, and statistics pertaining to the professional care and treatment of patients, receiving, storing, and releasing patients' personal effects, and performing the personnel' records function for active duty military patients. The department may be divided into Registrar Division, Patient Personnel Services Division, Medical Information Services Division, Medical Records Processing Division, and Outpatient Administration Division. The size of the medical treatment facility will determine what divisions and branches the department is divided into. The following divisions and branches discussed here illustrate a large facility. Some functions may not be the same at another facility, but it shows a good general overview of the Patient Administration Department and their related functions.

1. Registrar Division

   This division provides and coordinates procedures for the admission and disposition of patients (including determining the eligibility of the patient for admission), receives, maintains, and stores health records on active duty personnel, arranges transportation of patients to and from other hospitals, including movement of patients through the aeromedical evacuation system, registers births with the state, operates a Medical Holding Company Branch for active duty enlisted patients, and provides general patient information and advice to the public. Some large facilities have further divided the Registrar Division into branches.

   Military Health Records Branch

   This branch receives, stores, and maintains health records of active duty patients, and prepares message and speedletter notification of active duty patient admission.

   Admission Branch

   This branch performs the clerical function of admitting inpatients, receives, tags, and maintains temporary custody of patients' baggage, maintains a file of patients scheduled for admission and completes preadmission paperwork prior to admission, verifies eligibility for admission through presentation of a valid identification card and use of the Defense Enrollment Eligibility Reporting System (DEERS), makes bed assignments with a local bed control system, prepares the daily list of admissions and dispositions, and compiles and distributes a daily list of seriously ill and very seriously ill patients and makes necessary notification to the next of kin and higher authority.

   A patient who is admitted is given one of the following admission category codes:

   • "D"-Direct. The admission should be recorded as D if the reporting facility is the first medical treatment facility to place the patient under treatment or observation for the current episode of illness or injury.
   • "FT(M)"-From Transfer (Navy, Army, or Air Force medical facility). The admission shall be considered FT(M) when the inpatient is received from a Navy, Army, or Air Force medical facility. NOTE: If the patient is referred for consultation and subsequently admitted for treatment or observation, the admission category will be D.
   • "FT(O)"-From Transfer (other medical facility). The admission shall be considered FT(O) when the inpatient is received from a civilian (U.S. or foreign) medical facility or from a government medical facility other than Navy, Army, or Air Force.
   • "LB"-Live Birth. The admission shall be recorded as LB when the birth of an infant occurs within the confines of the medical treatment facility.
   • "NBD"-Newborn With Mother Direct. If the birth of an infant occurs outside of the confines of the medical treatment facility, and the baby is then admitted with the mother, the category used will be NBD.
   • "NBFT"-Newborn With Mother From Transfer. If the birth of an infant occurs outside of the medical treatment facility, and the mother and child were previously admitted to another medical treatment facility prior to transfer, the category assigned will be NBFT.

   Medical Evacuation and Transfer Branch

   This branch arranges for the transfer of patients to and from other hospitals and facilities, and performs all procedures required in connection with the movement of patients through the medical evacuation system. Specific procedures for use of the medical evacuation system are contained in BUMEDINST 6320.1D and NAV- MEDCOMINST 6320.4 series.

   Reception and Information Branch

   This branch provides service to all persons seeking information about medical records and patient services, directs each patient for proper discharge checkout procedures, answers all telephonic inquiries and makes appropriate referral when necessary, and maintains a current alphabetical roster of patients in the hospital and those discharged from the hospital.

   Medical Holding Company Branch

   This branch provides coordination between attending physicians and Medical Holding Company Branch patients and the Military Personnel Records Branch, coordinates use of patients at work sites throughout the hospital, maintains a listing of patients assigned, and complies with reporting requirements of higher authority.

2. Patient Personnel Services Division

   This division provides decedent affairs counseling, submits death certificates to state officials, holds money and valuables of patients for safekeeping, processes third-party liability cases, coordinates personnel functions with the local Personnel Support Activity Detachment for active duty military inpatients, processes periodic physical examination cases, and processes medical correspondence. Some large facilities have further divided the Patient Personnel Services Division into branches.

   Decedent Affairs Branch

   This branch interviews the next of kin of deceased persons in appropriate cases, performs all administrative procedures in connection with the Decedent Affairs Program, maintains custody of and makes final disposition of personal effects of deceased personnel, maintains the Death Register, and closes out and makes final disposition of health and personnel records of deceased military personnel.

   Temporary Disability Retirement List Branch

   This branch schedules the periodic examinations ordered by higher authority with the individual patient, arranges for consultations with appropriate clinical departments, and compiles each case and forwards the results to the appropriate higher authority.

   Third-Party Liability Branch

   This branch compiles and submits reports in connection with injuries and third-party liability cases, maintains liaison with the Navy Area Legal Service Office, and prepares and submits claims for treatment received by active duty members from nonfederal sources.

   Medical Correspondence Branch

   This branch processes all requests for copies of inpatient records from patients, employers, and insurance companies, obtains records from other treatment facilities and Federal Record Centers, ensures compliance with the Freedom of Information and Privacy Acts, and submits to the collection agent any monies received for copying records.

3. Medical Information Services Division

   This division compiles and analyzes statistical data pertaining to the care and treatment of inpatients, maintains the Tumor Registry and cross-index of diseases and operations, prepares medical statistical reports as required for the hospital or from higher authority, assembles and files clinical records, maintains the archives of inpatient records, receives, reviews and codes inpatient charts, applies Joint Commission on Accreditation of Hospitals (JCAH) standards to medical records, and maintains inpatient chart control. Some large facilities have further divided the Medical Information Services Division into branches.

   Coding and Analysis Branch

   This branch receives, reviews, and codes inpatient records for entry to the inpatient data system, and analyzes inpatient charts to ensure compliancy with existing medical records requirements.

   Inpatient Data Systems Branch

   This branch coordinates the timely input of all inpatient entries and change documents to the inpatient data system and receives and reviews all output reports, maintains automated inpatient listings and makes changes as they occur, and maintains the listing of delinquent charts.

   Tumor Registry Branch

   This branch establishes and maintains the efficient operation of a tumor registry, registers and follows patients with a diagnosis of malignancy, retrieves and analyzes registry data, and disseminates this data in accordance with current directives.

   Chart Control Branch

   This branch receives charts from the Medical Information Services Division, Coding and Analysis Branch, routes the charts appropriately for dictation, signature, or filing in archives, assists medical practitioners seeking charts on recently discharged patients, and matches the completed dictation with the inpatient chart.

   Medical Archives Branch

   This branch files, stores, and maintains inpatient medical records and other records as directed, sorts and destroys or retires records stored in the archives as directed, and removes from the files and makes available categories of charts under study by authorized staff personnel. See NAVMEDCOMINST 6150.1 series for proper clinical record maintenance. See SECNAVINST 5212.5 series for record disposal.

4. Medical Records Processing Division

   This division coordinates procedures for the completion of medical records, including narrative summaries, medical records, periodic physical examinations, and autopsy protocols and reports, formulates dictation procedures and requirements, maintains the word processing/transcription center, and operates the central dictation system. Some large facilities have further divided the Medical Records Processing Division into branches.

   Word Processing Branch

   This branch receives dictation through the central dictation system and transcribes reports using the computerized word processing system. It also processes narrative summaries, medical board narratives, periodic examination narratives, autopsy protocols, and final reports.

   Medical Board Branch This branch receives medical board narratives, coordinates completion and final preparation of the medical board and cover sheet, makes proper disposition of medical board reports, and interviews patients to ensure correct and complete information.

5. Outpatient Administration Division

   This division provides general administrative support services to the Navy hospital's outpatient clinics and maintains close liaison and coordination with the appropriate directorates. Services of a clinical nature are provided through the appropriate clinical departments.

   The Outpatient Administration Division develops and implements a variety of administrative systems and procedures. The division administers the Health Benefits Counseling Program, maintains, controls, and coordinates the filing and distribution system for outpatient treatment records, performs functions relative to the central appointment system, reports statistical data for the naval hospital, coordinates outpatient active duty consultations referred to the com- mand, maintains all staff military health records, verifies eligibility for health care through presentation of a valid identification (ID) card and use of the Defense Enrollment Eligibility Supporting System (DEERS), and performs a variety of other administrative and clerical duties. Some large facilities have further divided the Outpatient Administration Division into branches.

   Central Appointment Branch

   This branch schedules all patient appointments for participating physicians and outpatient clinics as designated by the appropriate department head. The Central Appointment Branch prepares appointment availability reports as required, and serves all eligible beneficiaries, with active duty personnel receiving first priority in all clinics.

   Health Benefits Advisory Branch

   This branch collects, collates, and reports statistical information monthly, provides counseling and advice to patients seeking information on health benefits, ensures patients are eligible for nonfederal health care through DEERs and ID card verification, and prepares and coordinates the issuance of nonavailability statements.

   Patient Contact Point Management Branch

   This branch coordinates the various clinic patient contact points, and serves as the patient contact point for the Outpatient Administration Division.

   Outpatient Registration Branch

   This branch provides for the referral of outpatients to the appropriate outpatient clinic, maintains and utilizes DEERS, establishes new terminal digit outpatient treatment records on outpatients in accordance with NAVMEDCOM- INST 6150.1 series, prepares outpatient recording cards as required, maintains the locator media for outpatient records in the terminal digit filing system, provides initial information to new outpatients regarding the ambulatory health care services provided at the naval hospital, provides the administrative support necessary for the receipt, transfer, and retirement of all outpatient medical records, coordinates and controls active duty consultations referred to the command, and processes consultation requirements expeditiously.

   Active Duty Health Records Branch

   This branch provides referral of active duty members to the appropriate outpatient clinics, ensures priority is given to active duty members who present for treatment, maintains custody of all staff military health records, screens military health records for completeness and conformity with JCAH standards, and accomplishes annual verification of military health records to ensure that they are in compliance with NAVMEDCOMINST 6150.1 and other directives pertaining to such issues as immunizations.

The fact that a person seeking treatment is or was connected with the federal government does not automatically entitle him or her to treatment at a naval medical treatment facility. A number of factors determine eligibility to certain types of medical attention and the source and amount of remuneration for that treatment. The following section deals with eligibility verification by presentation of a valid ID card and utilization of DEERS. Further guidance can also be obtained by familiarizing yourself with the following sources:

• SECNAVINST 6320.8 series, Uniformed Services Health Benefits Program
• NAVMEDCOMINST 6320.3 series, Medical Care for Eligible Persons at Naval Medical Facilities
• NAVMEDCOMINST 6320.1 series, Nonnaval Medical Care
• NAVMED P-5020, Resources Management Handbook

1. Defense Enrollment Eligibility Reporting System (DEERS)

   The Defense Enrollment Eligibility Reporting System (DEERS) was developed following 1974 congressional initiatives that instructed the Department of Defense to develop a program for:

   • Improving control and distribution of military health care services
   • Improving the ability to project and allocate cost for health care programs
   • Minimizing the fraudulent receipt of health benefits that was estimated as $20,000,000 through the direct care system and $40,000,000 through CHAMPUS

   Following a period of development (1975 through 1978), the DEERS Program Office was established and began implementation of DEERS policy in 1979 under the cognizance of the Assistant Secretary of Defense (Health Affairs) and the Assistant Secretary of Defense (Manpower, Reserve Affairs, and Logistics).

   Beginning in 1979, there was a phased intensified enrollment of beneficiaries in the contiguous 48 United States. In 1983 Alaska and Hawaii were subjected to an intensified enrollment. There are plans for facilities in Puerto Rico, Cuba, and Panama to be brought into the DEERS system during 1985, with other overseas activities to begin DEERS enrollment in 1986.

   The intensified enrollment project occurred through completion and submission of a special DD-1172, Application for Uniformed Services Identification and Privilege Card. Present enrollment is accomplished likewise for the seven uniformed services covered by DEERS (Army, Air Force, Marine Corps, Navy, Coast Guard, Public Health Service, and National Oceanic and Atmospheric Administration). That is, when a new ID card is obtained for a member's dependents, a copy of the identification card application is sent to the DEERS office in Monterey, California, or the personnel office may accomplish an on-line update if they have access to a DEERS computer terminal. Active duty members are enrolled by their respective finance centers. If problems exist within a patient's data base, active duty personnel and their dependents are to be referred to the sponsor's personnel office. All other beneficiaries are to be referred to the nearest personnel office.

   Direct Care System Procedures

   Effective I October 1984, the DEERS checking policy was expanded to include a dental policy based upon beneficiary information versus the previous policy that was based upon sponsor information. This was due in part to the increased accuracy of the data base as well as to the percentage of personnel enrolled. As an example, at the time of the change there were approximately 2,850,000 Navy and Marine Corps (active and retired) personnel, their dependents, and survivors enrolled.

   Although DEERS and the ID card system are related, there are instances where the beneficiary is in possession of a valid ID card and the DEERS system shows the patient as ineligible or the beneficiary is not in the DEERS data base. In these instances, eligibility verification using the ID card shall not override DEERS without some other type of collateral documentation. It must be stressed that military treatment facilities (MTFs) are to verify eligibility. Establishment of eligibility is under the cognizance of the respective service personnel offices.

   Patients who present for nonemergency treatment without a valid ID card but are in the DEERS data base will not be provided medical care without first signing a statement that they are eligible and giving the reason why a valid ID card is not in their possession. If a valid ID card is not provided within 30 calendar days, the patient is referred for billing as a Civilian Humanitarian Nonindigent in accordance with the Resources Management Handbook, NAVMED P-5020. Such billing may be delayed if the commanding officer of the facility is convinced proof is delayed for reasons beyond the control of the patient or sponsor. In all cases where a patient presents without an ID card and does not appear in the DEERS data base, nonemergency care will be denied.

   Patients presenting for treatment must be processed in accordance with DEERS checking requirements of 25 percent of outpatient visits, 100 percent of admissions, 100 percent of pharmacy outpatients presenting new prescriptions written by civilian providers, and 100 percent of nonactive duty patients at dental treatment facilities in areas designated as dentally under served. Prospective checks are to be used to the maximum extent possible and are required for pharmacy outpatients presenting prescriptions written by civilian providers.

   When a DEERS check is performed and the patient is found ineligible for any of the listed reasons, routine nonemergency health care will be denied (except as noted later in this section).

   • Sponsor not enrolled in DEERS
   • Dependent not enrolled in DEERS
   • Ineligible due to passed terminal (end) eligibility date
   • Sponsor has separated from active duty
   • Spouse is divorced from sponsor and is not entitled to benefits as a former spouse
   • Dependent child is married
   • Dependent becomes an active duty member of a uniformed service (only CHAMPUS benefits are lost)

   Under no circumstances will the clerk performing the eligibility check deny the requested care. Only command designated supervisory personnel will perform this function.

   Listed are nine "DEERS Eligibility Overrides." Unless otherwise stated, all overrides must be supported by a valid ID card.

   1. DD 1172-The patient presents an original or a copy of the DD 1172 used for DEERS enrollment. There are specific items required for verification and current service directives must be checked.
   2. All Other Dependents Recently Becoming Eligible For Benefits-Patients who become eligible for benefits in the previous 120 days may be treated upon presentation of a valid ID card. For children under 10 years of age, a valid parent's or guardian's ID card is acceptable. Upon application for care beyond 120 days, the procedure in number 1 must be used.
   3. New Identification Card-Patients presenting with a new valid ID card issued within the previous 120 days will not be denied care.
   4. Ineligible due to ID Card Expiration- When the data dase shows a patient as ineligible due to ID card expiration, care may be rendered as long as the patient has a new ID card issued within the previous 120 days. After 120 days, the procedure in number 1 must be used.
   5. Sponsors Entering Active Duty Status for a Period of Greater than 30 Days-A copy of orders ordering a reservist or guardsman to an active duty period of greater than 30 days may be accepted for the first 120 days of the active duty period. After that, the procedure in number I must be used.
   6. Newborns-Newborns will not be denied care for a period of 1 year following birth. The patient's birth certificate suffices when presented with a parent's valid ID card.
   7. Emergency Care-This is a medical decision and shall be determined by criteria established within the command.
   8. Sponsor's Duty Station is Outside the 50 United States or has an APO/FPO Address- Dependents whose sponsors are assigned outside the 50 United States or to a duty station with an APO/FPO address will not be denied care as long as the sponsor is enrolled and eligible in DEERS.
   9. Survivors-When an eligibility check indicates that a deceased sponsor is not enrolled in DEERS or the survivor is listed as the sponsor, the survivor will be treated on the first visit and referred to the appropriate personnel office for correction of the DEERS data base. For second and subsequent visits the survivor will be required to follow the procedure in number 1.

   The following beneficiaries are categorized as "DEERS Eligibility Exceptions." Although authorized care, they are not authorized to be enrolled in the DEERS system and will not be denied care based upon a DEERS check.

   • Secretary of the Navy Designees- Secretary of the Navy Designees will be treated as indicated on their letter of designation.
   • Foreign Military Personnel-These personnel, assigned through the Personnel Exchange Programs or through other means, are or may be eligible through Public Law or DOD agreements. As such, they will be treated in accordance with current service directives.

   Other categories of patients such as Red Cross Workers, Secret Service Agents, and Federal Aviation Administration personnel, to name a few, are also in this category. Ensure current eligibility requirements are met for these personnel prior to treatment.

   CHAMPUS has instituted similar checking policies at their fiscal intermediaries. Health benefits advisors (HBAs) and other personnel should encourage beneficiaries to review their enrollment status to prevent a claim denial.

   Future of DEERS

   DEERS is continuing to expand to assist military treatment facilities in accomplishing several functions. Those under consideration include:

   • On-line issuing of nonavailability statements for CHAMPUS that accomplishes a DEERS check at the same time
   • Automated patient regulating through the aeromedical evacuation system
   • Locating outpatient health records
   • Establishing a central tumor registry
   • Tracking third-party liability
   • Enrollment of eligible foreign military personnel

   Summary

   DEERS is here to stay. Only by assisting our beneficiaries and our beneficiaries assisting us can use of this system continue to assure that only those personnel eligible for benefits receive them.

2. Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)

   The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) is a medical benefits program established to cost-share charges for medically necessary civilian services and supplies required in the diagnosis and treatment of illness or injury when the required services are not available from the direct care system of Department of Defense treatment facilities or designated uniformed services treatment facilities (USTFs) (former PHS hospitals).

   The information contained in this section is general. Specific guidance should be requested from the nearest HBA when dealing with CHAMPUS matters.

   Eligibility

   CHAMPUS is a health benefits program covering certain beneficiaries of all seven uniformed services-the Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Service, and the National Oceanic and Atmospheric Administration.

   Active duty dependents, retirees and their dependents, unremarried spouses and children of deceased personnel, dependents of reservists on active duty for greater than 30 days, and unremarried former spouses meeting certain additional eligibility requirements are covered. Active duty members, beneficiaries eligible for Medicare (Part A), and remarried widows or widowers are ineligible; and parents and parents- in-law, even though dependent upon the sponsor, are also ineligible.

   Extent of Care

   In general, CHAMPUS helps pay most medical bills associated with inpatient and outpatient care. This includes most hospital bills for semiprivate rooms, meals (including special diets), diagnostic tests and treatment, and medical supplies such as prostheses. CHAMPUS will also help pay for treatment in health care centers other than hospitals such as psychiatric care facilities, drug detoxification centers, residential treatment centers for emotionally disturbed children, and marriage counseling. Some care requires prior approval from CHAMPUS, so the HBA must be consulted.

   Examples of care not generally covered includes acupuncture, biofeedback, postmortem examinations, chiropractic, electrolysis, orthopedic shoes and arches, private hospital rooms, sex changes, and surgical sterilization reversals. There are many others and often some of the above treatments are permitted under extenuating circumstances. Once again, the HBA should be consulted for specifics.

   Where To Get Care

   Outpatient care and emergency inpatient care requires no prior approval. However, nonemergent inpatient care requires that if the beneficiary lives within certain ZIP Code defined catchment areas around a military treatment facility or uniformed services treatment facility (USTF), they must first apply at that facility. The nearest HBA should be consulted to determine if 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 nonavailability 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 providing 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.

   Assignment

   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.

   Cost-Share

   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 $50 for one person or a maximum of $100 for a family. That is, the beneficiary pays their provider(s) the first $50 (or family $100) 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 $25 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.

   Claims Processing

   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.

   • Nonavailability statement-This 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).
   • Statement from other insurance plans- If other insurance is in force, then a statement of what is paid must be attached.
   • 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 met.

   Claims should go to the CHAMPUS claims processor serving for the state or country where the care was received, no matter where the patient 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.

   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. 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 $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.
     • If the amount is less than $50, 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 $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, 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

Quality assurance implies biphasic action (1) to evaluate the degree of excellence of the results of delivered care, and (2) to make improvements so that care in the future will result in a higher degree of quality. Quality assurance activities reflect what patients and providers expect of each other. In past years various means of reviewing and evaluating patient care have been introduced by JCAH. In 1979 the JCAH Boards of Commissioners imposed the requirement for hospitals to coordinate quality assurance activities and to use an ongoing monitoring system to review and evaluate the quality and appropriateness of care. This approach is effective in identifying important patient-related problems and is applicable in every health care delivery situation. Many of the principles, standards, and organizational requirements of JCAH have been adopted and are contained in NAVMEDCOMINST 6320.7 (Quality Assurance Program Guide) as required elements for quality assurance programs of naval hospitals, medical clinics, and dental clinics.

Navy health care professionals have long understood the need for good communication and rapport between the patient and the medical department staff. The atmosphere in which patient care is given has a tremendous effect on the patient's perception of the quality of care. The quality of medical care rendered to Navy beneficiaries is superb; however, too frequently the medical care is perceived by the patient to be poor because personnel manning critical patient contact points are not adequately trained in interpersonal relations. Good patient rapport is an essential element of health care delivery. Many complaints voiced by patients would not occur if personnel manning critical patient contact points presented a courteous, positive, and knowledgeable attitude, an attitude that reflects a genuine concern for the patient. To this end, the Patient Contact Program was instituted. The program's primary goal is to provide assistance by intervention in and resolu- tion of patient's complaints or problems. As a covert to this goal, the program strives to enhance the channels of communications between the hospital and our patient population, as well as our own internal lines of communication.

The purpose of the Family Advocacy Program is to identify, treat, and monitor Navy personnel engaging in spouse or child abuse/neglect or sexual abuse, whether physical or psychological. The program, a responsibility of the Navy Military Personnel Command, is guided by SECNAVINST 1752.3. In each geographical location, a Family Advocacy Representative (FAR), usually a Naval hospital staff member, manages the local program. A basewide committee composed of medical, line, chaplain, and Family Service Center personnel reviews abuse cases and determines whether each case is established, suspected, or unfounded. Established cases are reported at the central registry at the Headquarters, Naval Medical Command, where service statistics are compiled and the future assignment of established abusers monitored and controlled.

The Navy has established a "zero tolerance" standard for drug usage. The major emphasis is on detection and deterrence of illicit drug use. This involves the use of urinalysis, drug detection dogs, and physical inspections of personnel and property on military facilities. The general categories of drugs are marijuana, cocaine, amphetamines, PCP, LSD, barbiturates, and heroin. While treatment is occasionally offered to the individual drug abuser, the most likely outcome is appropriate disciplinary action and separation from the service, especially after the second offense. Individuals with alcohol abuse or alcoholism are viewed as having a disease. They are often offered treatment at a variety of settings, ranging from local outpatient care to a 6-week residential program at one of the Navy-run facilities. However, all individuals, either with alcohol or drug-related problems, are totally accountable for their actions and the consequences of them in accordance with UCMJ and other relevant federal, state, and local laws.

The Navy Weight Control and Physical Fitness activities are a responsibility of the Health and Physical Readiness section of the Naval Military Personnel Command (NMPC). The policies governing this program are outlined in OPNAVINST 6110. 1B. Currently physical fitness testing is required for all personnel on at least an annual basis. Test components are 1.5-mile run-walk (500-yard swim and 3-minute run in place as command options), sit-reach for flexibility, sit-ups, and percent body fat. Testing, education and training advice are provided through a network of collateral duty command fitness coordinators. In addition to the requirement for program implementation by each subordinate command, Medical Department responsibilities are (1) providing technical assistance to NAVMILPERSCOM, (2) conducting lifestyle, fitness, and obesity research, (3) reviewing health status and granting waivers for those individuals unable to safely participate in physical fitness testing or training, and (4) assisting in the development of exercise prescriptions.

The Navy Blood Program exists to support the daily operations of Navy hospitals and clinics, the operational forces, and the Military Blood Program Office (MBPO) through the Armed Services Whole Blood Processing Laboratories (ASWBPL) (see table 15-1). It establishes policies for donor recruitment at all Navy treatment facilities, and establishes guidelines for dealing with civilian facilities.

Blood is necessary to support the daily operations of Navy treatment facilities as well as the unforeseen. The Navy Blood Program, along with the Air Force and Army Blood Programs, comprise the MBPO. This triservice program supports and supplies ASWBPL with both personnel and blood. Each service has an assigned weekly quota of blood that enables the military to support itself in all contingency roles.

More detailed information may be found in NAVMEDCOMINST 6530.1, OPNAVINST 6530.2B, and NAVMED P-5123.

Table 15-1. - Military Blood Program

References:

1. NAVMEDCOMINST 5450.1, Organizational Manual for Geographic Naval Medical Commands, Naval Hospitals, Naval Medical Clinics, and Naval Dental Clinics
2. NAVMED P-5127, Patient Affairs and Outpatient Services Officers Handbook
3. BUMEDINST 6320.58, The Civilian Health and Medical Program of the Uniformed Services
4. NAVMEDCOMINST 6320.3, Medical and Dental Care for Eligible Persons at Navy Medical Department Facilities

Naval Education and Training Command: Hospital Corpsman 1 & C: August 1986

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Operational Medicine 2001

Health Care in Military Settings

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