10 U.S.C. § 1106 — Submittal of claims: standard form; time

Page 1163 TITLE 10—ARMED FORCES § 1106 ficiary to receive the service outside of the pro- gram. (f) PAYMENT OF COSTS RELATED TO CARE IN SPECIALIZED TREATMENT FACILITIES.—(1) Subject to paragraph (2), in connection with the treat- ment of a covered beneficiary under the special- ized treatment facility program, the Secretary may provide the following benefits: (A) Full or partial reimbursement of a mem- ber of the uniformed services for the reason- able expenses incurred by the member in transporting a covered beneficiary to or from a health care facility of the uniformed services or a civilian health care facility at which spe- cialized health care services are provided pur- suant to this chapter. (B) Full or partial reimbursement of a per- son (including a member of the uniformed services) for the reasonable expenses of trans- portation, temporary lodging, and meals (not to exceed a per diem rate determined in ac- cordance with implementing regulations) in- curred by such person in accompanying a cov- ered beneficiary as a nonmedical attendant to a health care facility referred to in subpara- graph (A). (C) In-kind transportation, lodging, or meals instead of reimbursements under subpara- graph (A) or (B) for transportation, lodging, or meals, respectively. (2) The Secretary may make reimbursements for or provide transportation, lodging, and meals under paragraph (1) in the case of a cov- ered beneficiary only if the total cost to the De- partment of Defense of doing so and of providing the health care in such case is less than the cost to the Department of providing the health care to the covered beneficiary by other means au- thorized under this chapter. (g) COVERED BENEFICIARY DEFINED.—In this section, the term ‘‘covered beneficiary’’ means a person covered under section 1079 or 1086 of this title. (Added Pub. L. 102–190, div. A, title VII, § 715(a), Dec. 5, 1991, 105 Stat. 1403; amended Pub. L. 103–160, div. A, title VII, § 716(a)(1), Nov. 30, 1993, 107 Stat. 1691; Pub. L. 104–106, div. A, title VII, § 706, Feb. 10, 1996, 110 Stat. 373; Pub. L. 113–291, div. A, title VII, § 703(c)(3), Dec. 19, 2014, 128 Stat. 3412.) Editorial Notes AMENDMENTS 2014—Subsec. (c). Pub. L. 113–291 substituted ‘‘section 1079(a)(6)’’ for ‘‘section 1079(a)(7)’’. 1996—Subsec. (h). Pub. L. 104–106 struck out subsec. (h) which read as follows: ‘‘EXPIRATION OF PROGRAM.— The Secretary may not carry out the specialized treat- ment facility program authorized by this section after September 30, 1995.’’ 1993—Pub. L. 103–160 substituted ‘‘Specialized treat- ment facility program’’ for ‘‘Issuance of nonavail- ability of health care statements’’ as section catchline and amended text generally. Prior to amendment, text read as follows: ‘‘In determining whether to issue a nonavailability of health care statement for any person entitled to health care in facilities of the uniformed services under this chapter, the commanding officer of such a facility may consider the availability of health care services for such person pursuant to any contract or agreement entered into under this chapter for the provision of health care services within the area served by that facility.’’ § 1106. Submittal of claims: standard form; time limits (a) STANDARD FORM.—The Secretary of De- fense, after consultation with the other admin- istering Secretaries, shall prescribe by regula- tion a standard form for the submission of claims for the payment of health care services provided under this chapter. (b) TIME FOR SUBMISSION.—A claim for pay- ment for services provided under this chapter shall be submitted as provided in such regula- tions as follows: (1) In the case of services provided outside the United States, the Commonwealth of Puerto Rico, or the possessions of the United States, by not later than three years after the services are provided. (2) In the case of any other services, by not later than one year after the services are pro- vided. (Added Pub. L. 102–190, div. A, title VII, § 716(a)(1), Dec. 5, 1991, 105 Stat. 1403; amended Pub. L. 105–85, div. A, title VII, § 738(a), Nov. 18, 1997, 111 Stat. 1815; Pub. L. 112–81, div. A, title VII, § 712, Dec. 31, 2011, 125 Stat. 1476.) Editorial Notes AMENDMENTS 2011—Subsec. (b). Pub. L. 112–81 substituted ‘‘as fol- lows:’’ for ‘‘not later than one year after the services are provided.’’ and added pars. (1) and (2). 1997—Pub. L. 105–85 substituted ‘‘: standard form; time limits’’ for ‘‘under CHAMPUS’’ in section catch- line and amended text generally. Prior to amendment, text read as follows: ‘‘(a) SUBMITTAL TO CLAIMS PROCESSING OFFICE.—Each provider of services under the Civilian Health and Med- ical Program of the Uniformed Services shall submit claims for payment for such services directly to the claims processing office designated pursuant to regula- tions prescribed under subsection (b). A claim for pay- ment for services shall be submitted in a standard form (as prescribed in the regulations) not later than one year after the services are provided. ‘‘(b) REGULATIONS.—The regulations required by sub- section (a) shall be prescribed by the Secretary of De- fense after consultation with the other administering Secretaries. ‘‘(c) WAIVER.—The Secretary of Defense may waive the requirements of subsection (a) if the Secretary de- termines that the waiver is necessary in order to en- sure adequate access for covered beneficiaries to health care services under this chapter.’’ Statutory Notes and Related Subsidiaries REGULATIONS Pub. L. 102–190, div. A, title VII, § 716(b), Dec. 5, 1991, 105 Stat. 1404, provided that: ‘‘The regulations required by section 1106 of title 10, United States Code (as added by subsection (a)), shall be prescribed to take effect not later than 180 days after the date of the enactment of this Act [Dec. 5, 1991].’’ ESTABLISHMENT OF APPEALS PROCESS FOR CLAIMCHECK DENIALS Pub. L. 105–261, div. A, title VII, § 714, Oct. 17, 1998, 112 Stat. 2060, provided that: ‘‘(a) ESTABLISHMENT OF APPEALS PROCESS.—Not later than January 1, 1999, the Secretary of Defense shall es- Page 1164 TITLE 10—ARMED FORCES § 1107 tablish an appeals process in cases of denials through the ClaimCheck computer software system (or any other claims processing system that may be used by the Secretary) of claims by civilian providers for pay- ment for health care services provided under the TRICARE program. ‘‘(b) REPORT.—Not later than March 1, 1999, the Sec- retary shall submit to Congress a report on the imple- mentation of this section.’’ NATIONAL CLAIMS PROCESSING SYSTEM FOR CHAMPUS Pub. L. 102–484, div. A, title VII, § 711, Oct. 23, 1992, 106 Stat. 2433, provided that: ‘‘(a) CLAIMS PROCESSING SYSTEM REQUIRED.—(1) The Secretary of Defense, in consultation with the other administering Secretaries, shall provide by contract for the operation of a claims processing system to be known as the ‘National Claims Processing System for CHAMPUS’. The Secretary may procure the system in installments, including the use of incremental mod- ules. The system, including completion and integration of all modules, shall be in full operation not later than seven years after the date of the enactment of this Act [Oct. 23, 1992]. ‘‘(2) The Secretary shall use competitive procedures for entering into any contract or contracts under para- graph (1). ‘‘(b) SYSTEM FUNCTIONS.—The claims processing sys- tem shall include at least the following functions: ‘‘(1) The maintenance in electronic or written form, or both, of appropriate information on health care services provided to covered beneficiaries by or through third parties under CHAMPUS or any alter- native CHAMPUS program or demonstration project. Such information shall include— ‘‘(A) the services to which such beneficiaries are entitled or eligible under an insurance plan, med- ical service plan, or health plan under CHAMPUS; ‘‘(B) the insurers, medical services, or health plans that provide such services; and ‘‘(C) the services available to beneficiaries under each insurance plan, medical service plan, or health plan, and the payment required of the beneficiaries and the insurer, medical service, or health plan for such services under the plan. ‘‘(2) The ability to receive in electronic or written form claims submitted by insurers, medical services, and health plans for services provided to covered beneficiaries. ‘‘(3) The ability to process, adjudicate, and pay (by electronic or other means) such claims. ‘‘(4) The provision of the information described in paragraphs (1) and (2) and information on the matters referred to in paragraph (3) by telephone, electronic, or other means to covered beneficiaries, insurers, medical services, and health plans. ‘‘(c) CONSISTENCY WITH MEDICARE CLAIMS REQUIRE- MENTS.—The Secretary of Defense shall ensure, to the maximum extent practicable, that claims submitted to the claims processing system conform to the require- ments applicable to claims submitted to the Secretary of Health and Human Services with respect to medical care provided under part A of title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.). ‘‘(d) IDENTIFICATION CARD.—The Secretary of Defense shall take appropriate actions to determine whether the use by covered beneficiaries of a standard identi- fication card containing electronically readable infor- mation will enhance the capability of the claims proc- essing center to carry out the activities set forth in subsection (b). ‘‘(e) TRANSITION TO SYSTEM.—After January 1, 1996, any modification or acquisition related to claims proc- essing systems operations in the Office of the Civilian Health and Medical Program of the Uniformed Services shall contain provisions to transfer such operations to the claims processing system required by subsection (a). After January 1, 1999, any renewal or acquisition for fiscal intermediary services (including coordinated care implementations in military hospitals and clinics) shall contain provisions to transfer claims processing systems operations related to such fiscal intermediary services to the claims processing system required by subsection (a). ‘‘(f) DEFINITIONS.—For purposes of this section: ‘‘(1) The term ‘administering Secretaries’ has the meaning given that term in paragraph (3) of section 1072 of title 10, United States Code. ‘‘(2) The term ‘CHAMPUS’ means the Civilian Health and Medical Program of the Uniformed Serv- ices, as defined in paragraph (4) of such section. ‘‘(3) The term ‘covered beneficiary’ has the meaning given that term in paragraph (5) of such section.’’ § 1107. Notice of use of an investigational new drug or a drug unapproved for its applied use (a) NOTICE REQUIRED.—(1) Whenever the Sec- retary of Defense requests or requires a member of the armed forces to receive an investigational new drug or a drug unapproved for its applied use, the Secretary shall provide the member with notice containing the information specified in subsection (d). (2) The Secretary shall also ensure that health care providers who administer an investiga- tional new drug or a drug unapproved for its ap- plied use, or who are likely to treat members who receive such a drug, receive the information required to be provided under paragraphs (3) and (4) of subsection (d). (b) TIME OF NOTICE.—The notice required to be provided to a member under subsection (a)(1) shall be provided before the investigational new drug or drug unapproved for its applied use is first administered to the member. (c) FORM OF NOTICE.—The notice required under subsection (a)(1) shall be provided in writ- ing. (d) CONTENT OF NOTICE.—The notice required under subsection (a)(1) shall include the fol- lowing: (1) Clear notice that the drug being adminis- tered is an investigational new drug or a drug unapproved for its applied use. (2) The reasons why the investigational new drug or drug unapproved for its applied use is being administered. (3) Information regarding the possible side effects of the investigational new drug or drug unapproved for its applied use, including any known side effects possible as a result of the interaction of such drug with other drugs or treatments being administered to the mem- bers receiving such drug. (4) Such other information that, as a condi- tion of authorizing the use of the investiga- tional new drug or drug unapproved for its ap- plied use, the Secretary of Health and Human Services may require to be disclosed. (e) RECORDS OF USE.—The Secretary of Defense shall ensure that the medical records of mem- bers accurately document— (1) the receipt by members of any investiga- tional new drug or drug unapproved for its ap- plied use; and (2) the notice required by subsection (a)(1). (f) LIMITATION AND WAIVER.—(1) In the case of the administration of an investigational new drug or a drug unapproved for its applied use to a member of the armed forces in connection