A cost that exceeds the CHAMPUS Maximum Allowable Charge may be determined to be allowable only when unusual circumstances or medical complications justify the higher charge. The allowable charge could not exceed the billed cost underneath any circumstances. For functions of a special locality-based phase-in provision similar to that established by paragraph of this section, the CMAC in a locality is not going to be less than 85 p.c of the utmost charge level in effect for that locality during the base interval. For purposes of comparability to Medicare allowable fee quantities pursuant to paragraph of this section, the Medicare national laboratory fee limitation amounts shall be used. The calculation of national prevailing cost ranges, nationwide acceptable charge levels and national CMACs for laboratory service shall begin in calendar yr 1993. For every overpriced process, the level shall be decreased by fifteen p.c.

Authorized Situations And Phrases

Programs treating children and adolescents should guarantee the supply of a state certified instructional component which assures that patients don’t fall behind in educational placement whereas receiving partial hospital therapy. CHAMPUS won’t fund the price of educational services separately from the per diem rate. The hours dedicated to training don’t depend toward the therapeutic intensive outpatient program or full day program. Services and provides that are medically or psychologically essential to diagnose and deal with the psychological dysfunction for which the affected person was admitted to the RTC. Covered providers and necessities for qualifications of providers are as listed in paragraph of this section.

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Such billing must be itemized fully and described sufficiently, even when CHAMPUS cost is determined beneath the CHAMPUS DRG-based cost system, so that CHAMPUS can determine whether advantages are approved by this half. Except for claims subject to the CHAMPUS DRG-based cost system, whenever continuing costs are involved, claims should be submitted to the appropriate CHAMPUS fiscal intermediary at least each 30 days either by the beneficiary or sponsor or immediately by the provider. For claims subject to the CHAMPUS DRG-based payment system, claims may be submitted solely after the beneficiary has been discharged or transferred from the hospital. General quality assurance, utilization review, and preauthorization requirements beneath the TRICARE program.

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