The act of fraud or abuse had an adverse bodily, psychological, or monetary impact on one or more CHAMPUS beneficiaries. The fraudulent act involved in the criminal conviction or civil judgment, or comparable acts, have been committed over a major time frame; that is, one 12 months or extra. The prohibition in opposition to dual compensation does not apply to individuals under contract to the Uniformed Services or the Government.

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In addition, the year-end adjustment additionally could incorporate a possible upward adjustment for inpatient services based on a GTMCPA for TRICARE community hospitals beneath paragraph of this section. TRICARE payments for hospital outpatient diagnostic providers are primarily based on the allowable charge method underneath paragraph of the part. In the case of diagnostic companies for which the CMAC charges are established underneath that paragraph, a fee price for the technical part of the diagnostic companies is provided.

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The cost-sharing requirement for a beneficiary enrolled in TRICARE Prime who does not get hold of a referral for care when it is required, together with care from a non-network provider, is as provided in paragraph of this part concerning point of service care. Categories of health care providers. This paragraph describes the classes of well being care providers relevant to determining copayment amounts. Under inside resource sharing agreements, the double coverage requirements of § 199.8 shall get replaced by the Third Party Collection procedures of 32 CFR half 220, to the extent permissible beneath such part.