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Electronic Code of Federal Regulations
Title 32: National Defense
PART 732—NONNAVAL MEDICAL AND DENTAL CARE
§732.13 Sources of care.
§732.14 Authorized care.
§732.15 Unauthorized care.
§732.16 Emergency care requirements.
§732.17 Nonemergency care requirements.
§732.18 Notification of illness or injury.
§732.20 Adjudication authorities.
§732.21 Medical board.
§732.22 Recovery of medical care payments.
§732.23 Collection for subsistence.
§732.24 Appeal procedures.
§732.25 Accounting classifications for nonnaval medical and dental care expenses.
§732.26 Standard document numbers.
Authority: 5 U.S.C. 301; 10 U.S.C. 1071-1088, 5031, 6148, 6201-6203, and 8140; and 32 CFR 700.1202.
Source: 52 FR 32297, Aug. 27, 1987, unless otherwise noted.
When a U.S. Navy or Marine Corps member or a Canadian Navy or Marine Corps member receives authorized care from other than a Navy treatment facility, care is under the cognizance of the uniformed service medical treatment facility (USMTF) providing care, the USMTF referring the member to another treatment source, or under the provisions of this part. If such a member is not receiving care at or under the auspices of a Federal source, responsibility for health and welfare, and the adjudication of claims in connection with their care, remains within the Navy Medical Department. Part 728 of this chapter and NAVMEDCOMINST 6320.18 contain guidelines concerning care for other eligible beneficiaries, not authorized care by this part.
Ensure that personnel under your cognizance are made aware of the contents of this part. Failure to comply with contents may result in delayed adjudication and payment or may result in denial of Navy financial responsibility for expenses of maternity, medical, or dental care obtained.
Subpart B—Medical and Dental Care From Nonnaval Sources
Unless otherwise qualified in this part the following terms when used throughout are defined as follows:
(a) Active duty. Full-time duty in the active military service of the United States. Includes full-time training duty; annual training duty; and attendance, while in the active military service, at a school designated as a service school by law or by the Secretary of the military department concerned.
(b) Active duty for training. A specified tour of active duty for Reserves for training under orders that provides for automatic reversion to non-active duty status when the specified period of active duty is completed. It includes annual training, special tours, and the initial tour performed by enlistees without prior military service. The period of duty includes travel to and from training duty, not in excess of the allowable constructive travel time prescribed by SECNAVINST 1770.3 and paragraphs 10242 and 10243 of DOD Military Pay and Allowances Entitlements Manual.
(c) Constructive return. For purposes of medical and dental care, an unathorized absentee's return to military control may be accomplished through notification of appropriate military authorities as outlined below.
(1) For members in an unauthorized absentee (UA) status, constructive return to military control for the purpose of providing medical or dental care at Navy expense is effected when one of the following has occurred:
(i) A naval activity informs a civilian provider of medical or dental care that the Navy accepts responsibility for a naval member's care. The naval activity providing this information must also provide documentation of such notification to the appropriate adjudication authority in §732.20.
(ii) A member has been apprehended by civil authorities at the specific request of naval authorities and naval authorities have been notified that the member can be released to military custody.
(iii) A naval member has been arrested, while in a UA status, by civil authorities for a civil offense and a naval authority has been notified that the member can be released to military control.
(2) When a naval member has been arrested by civil authorities for a civil offense while in a UA status and the offense does not allow release to military control, constructive return is not accomplished. The individual is responsible for medical and dental care received prior to arrest and the incarcerating jurisdiction is responsible for care required after arrest.
(d) Designated Uniformed Services Treatment Facilities (Designated USTFs). Under Pub. L. 97-99, the following facilities are “designated USTFs” for the purpose of rendering medical and dental care to all categories of individuals entitled to care under this part.
(1) Sisters of Charity of the Incarnate Word Health Care System, 6400 Lawndale, Houston, TX 77058 (713) 928-2931 operates the following facilities:
(i) St. John Hospital, 2050 Space Park Drive, Nassau Bay, TX 77058, telephone (713) 333-5503. Inpatient and outpatient services.
(ii) St. Mary's Hospital Outpatient Clinic, 404 St Mary's Boulevard, Galveston, TX 77550, telephone (409) 763-5301. Outpatient services only.
(iii) St. Joseph Hospital Ambulatory Care Center, 1919 La Branch, Houston, TX 77002, telephone (713) 757-1000. Outpatient services only.
(iv) St Mary's Hospital Ambulatory Care Center, 3600 Gates Boulevard, Port Arthur, TX 77640 (409) 985-7431. Outpatient services only.
(2) Inpatient and outpatient services. (i) Wyman Park Health System, Inc., 3100 Wyman Park Drive, Baltimore, MD 21211, telephone (301) 338-3693.
(ii) Alston-Brighton Aid and Health Group, Inc., Brighton Marine Public Health Center, 77 Warren Street, Boston, MA 02135, telephone (617) 782-3400.
(iii) Bayley Seton Hospital, Bay Street and Vanderbilt Avenue, Staten Island, NY 10304, telephone (718) 390-5547 or 6007.
(iv) Pacific Medical Center, 1200 12th Avenue South, Seattle, WA 98144, telephone (206) 326-4100.
(3) Outpatient services only. (i) Coastal Health Service, 331 Veranda Street, Portland, ME 04103 (207) 774-5805.
(ii) Lutheran Medical Center, Downtown Health Care Services, 1313 Superior Avenue, Cleveland, OH 44113, telephone (216) 363-2065.
(e) Duty status. The situation of the claimant when maternity, medical, or dental care is received. Members, including reservists, on leave or liberty are considered in a duty status. Reservists, performing active duty for training or inactive duty training, are also considered in a duty status during their allowable constructive travel time to and from training.
(f) Emergency care. Medical treatment of severe life threatening or potentially disabling conditions which result from accident or illness of sudden onset and necessitates immediate intervention to prevent undue pain and suffering or loss of life, limb, or eyesight and dental treatment of painful or acute conditions.
(g) Federal facilities. Navy, Army, Air Force, Coast Guard, Veterans Administration, and USTFs (former U.S. Public Health Service facilities listed in §732.11(d).
(h) Inactive duty training. Duty prescribed for Reserves by the Secretary of the Navy under Section 206 of Title 37, United States Code, or any other provision of law. Also includes special additional duties authorized for Reserves by an authority designated by the Secretary of the Navy and performed by Reserves on a voluntary basis in connection with the prescribed training or maintenance activities of units to which they are assigned.
(i) Maternity emergency. A condition commencing or exacerbating during pregnancy when delay caused by referral to a uniformed services medical treatment facility (USMTF) or designated USTF would jeopardize the welfare of the mother or unborn child.
(j) Member. United States Navy and Marine Corps personnel, Department of National Defence of Canada Navy and Marine Corps personnel, and Navy and Marine Corps personnel of other NATO Nations meeting the requirements for care under this part.
(k) Non-federal care. Maternity, medical, or dental care furnished by civilian sources (includes State, local, and foreign MTFs).
(l) Nonnaval care. Maternity, medical, or dental care provided by other than Navy MTFs. Includes care in other USMTFs, designated USTFs, VA facilities, as well as from civilian sources.
(m) Office of Medical Affairs (OMA) or Office of Dental Affairs (ODA). Designated offices, under program management control of COMNAVMEDCOM and direct control of regional medical commands, responsible for administrative requirements delineated in this part. Responsibilities and functional tasks of OMAs and ODAs are outlined in NAVMEDCOMINST 6010.3.
(n) Prior approval. Permission granted for a specific episode of necessary but nonemergent maternity, medical, or dental care.
(o) Reservist. A member of the Naval or Marine Corps Reserve.
(p) Supplemental care—(1) Operation and maintenance funds, Navy. Supplemental care of all uniformed services members, at Navy expense, encompasses only inpatient or outpatient care augmenting the capability of a naval MTF treating a member. Such care is usually obtained from civilian sources through referral by the treating naval MTF. If a member, authorized care under this part, is admitted to or is being treated on an outpatient basis at any USMTF, all supplemental care is the financial responsibility of that facility regardless of whether the facility is organized or authorized to provide needed health care. The cost of such care is chargeable to operation and maintenance funds (OM&N) available for operation of the USMTF requesting the care regardless of service affiliation of the member (see part 728 of this chapter for such care under Navy Medical Department facilities).
(2) Nonnaval medical and dental care program funds. Adjudication authorities will pay claims, under this part, for care received as a result of a referral when:
(i) A United States Navy or Marine Corps member or a Canadian Navy or Marine Corps member requires care beyond the capability of the referring USMTF and care is obtained for such a member not admitted to or not being treated on an outpatient basis by a USMTF, and
(ii) The referring USMTF is not organized nor authorized to provide the needed health care.
(3) Other uniformed services supplemental care programs. In addition to services that augment other USMTF's capabilities, supplemental care programs of the other uniformed services include care and services comparable to those authorized by this part, e.g., emergency care and pre-approved nonemergency care.
(q) Unauthorized absence. Absence or departure without authority from a member's command or assigned place of duty.
(r) Uniformed Services Medical Treatment Facilities (USMTF). Health care facilities of the Navy, Army, Air Force, Coast Guard, and the former U.S. Public Health Service facilities listed in paragraph (d) of this section designated as USTFs per DOD and Department of Health and Human Services directives.
(a) Regular members. To be eligible for non-Federal medical, dental, or emergency maternity care at Government expense, Regular active duty United States naval members and Canadian Navy and Marine Corps members must be in a duty status when care is provided.
(b) Reservists. (1) Reservists on active duty for training and inactive duty training, including leave and liberty therefrom, are considered to be in a duty status while participating in training. Accordingly, they are entitled to care for illnesses and injuries occurring while in that status.
(2) Reservists are entitled to care for injuries and illnesses occurring during direct travel enroute to and from active duty training (ACDUTRA) and to and from inactive duty training.
(c) NATO naval members. Naval members of the NATO Status of Forces Agreement (SOFA) nations of Belgium, Denmark, Federal Republic of Germany, France, Greece, Iceland, Italy, Luxembourg, the Netherlands, Norway, Portugal, Spain, Turkey, and the United Kingdom, are authorized outpatient care only under the provisions of this part when stationed in or passing through the United States in connection with official duties. Public Law 99-591 prohibits inpatient care of these foreign military members in the United States at the expense of the United States Government. The other NATO SOFA Nation, Canada, entered into a comparable care agreement with the United States requiring the United States to provide inpatient and outpatient care under the provisions of this part to members of the Department of National Defence of Canada receiving care in the United States.
(d) Absent without authority. Naval members absent without authority during an entire episode of treatment are not eligible for non-Federal medical, dental, or emergency maternity care at Government expense. The only exception occurs when a member's illness or injury is determined to have been the direct cause of the unauthorized absentee status. In such an instance, eligibility will be:
(1) Determined to have existed from the day and hour of such injury or illness provided the member was not in an unauthorized absentee status prior to the onset of the illness or injury and initiation of treatment.
(2) Retained when the member is returned directly to military control.
(3) Terminated should the member return to an unauthorized absentee status immediately after completion of treatment. Departmental level (MEDCOM-333 for medical and MEDCOM-06 for dental) review is required before benefits may be extended.
(e) Constructive return. When constructive return, defined in §732.11(c), is effected, entitlement will be determined to have existed from 0001 hours of the day of constructive return, not necessarily the day and hour care was initiated.
§732.13 Sources of care.
(a) Initial application. If a member requires maternity, medical, or dental care and naval facilities are unavailable, make initial application to other available Federal medical or dental facilities or USTFs. When members are stationed in or passing through a NATO SOFA nation and U.S. facilities are unavailable, ensure that members make initial application for emergency and nonemergency care to military facilities of the host country, or if applicable, to civilian sources under the NATO SOFA nation's health care program. When hospitalized in Hawaii, Alaska, or in a foreign medical facility, members and responsible commands will comply with OPNAVINST 6320.6.
(b) Secondary sources. When either emergency or nonemergency care is required and there are no Federal or NATO SOFA facilities available, care may be obtained from non-Federal sources under this part.
§732.14 Authorized care.
(a) Medical. (1) Consultation and treatment provided by physicians or at medical facilities, and procedures not involving treatment when directed by COMNAVMEDCOM, are authorized. Such care includes, but is not limited to: treatment by physicians, hospital inpatient and outpatient care, surgery, nursing, medicine, laboratory and x-ray services, physical therapy, eye examinations, etc. See §732.17 for prior approval of these services in nonemergency situations.
(2) When transplant (including bone-marrow) is the treatment of choice, COMNAVMEDCOM approval is required. If time permits, telephone (A) 294-1102, (C) (202) 653-1102 during regular hours or (A) 294-1327, (C) 653-1327 after regular duty hours, and followup with a message. Request approval via message in nonemergency situations.
(b) Maternity episode. If a member authorized care under this part qualifies for care under the provisions of §732.17(c) and delivers in a civilian hospital, routine newborn care (i.e., nursery, newborn examination, PKU test, etc.) is a part of the mother's admission expenses. Regardless of circumstances necessitating delivery in a civilian facility or how charges are separated on the bill, charges will be paid from funds available for care of the mother. If the infant becomes a patient in his or her own right—through an extension of the birthing hospital stay because of complications, transfer to another facility, or subsequent admission—the provisions of part 728 of this chapter and NAVMEDCOMINST 6320.18 are applicable, and the sponsor becomes responsible for a part of the medical expenses incurred.
(c) Dental. (1) With prior approval, the following may be provided:
(i) All types of treatment (including operative, restorative, and oral surgical) to relieve pain and abort infection.
(ii) Prosthetic treatment to restore extensive loss of masticatory function or the replacement of anterior teeth for esthetic reasons.
(iii) Repair of existing dental prostheses when neglect of the repair would result in unserviceability of the appliance.
(iv) Any type of treatment adjunctive to medical or surgical care.
(v) All x-rays, drugs, etc., required for treatment or care in paragraphs (c)(1) (i) through (iv) of this section.
(2) In emergencies (no prior approval), only measures appropriate to relieve pain or abort infection are authorized.
(d) Eye refractions and spectacles. Includes refractions of eyes by physicians and optometrists and furnishing and repairing spectacles.
(1) Refractions. A refraction may be obtained from a civilian source at Government expense only when Federal facilities are not available, no suitable prescription is in the member's Health Record, and the cognizant OMA or referring USMTF has given prior approval.
(2) Spectacles. When a member has no suitable spectacles and the lack thereof, combined with the delay in obtaining suitable ones from a Federal source would prevent performance of duty; repair, replacement, or procurement from a civilian source may be authorized upon initiation of an after-the-fact request per §732.17. Otherwise, the prescription from the refractionist, with proper facial measurements, must be sent for fabrication to the appropriate dispensing activity set forth in NAVMED COMINST 6810.1. See §732.15(g) concerning contact lenses.
§732.15 Unauthorized care.
The following are not authorized by this part:
(a) Chiropractic services.
(c) Tubal ligations.
(d) Breast augmentations or reductions.
(e) Psychiatric care, beyond the initial evaluation.
(f) Court ordered care.
(g) Contact lenses.
(h) Other elective procedures.
§732.16 Emergency care requirements.
Only in a bona fide emergency will medical, maternity, or dental services be obtained under this part by or on behalf of eligible personnel without prior authority as outlined below.
(a) Medical or dental care. A situation where the need or apparent need for medical or dental attention does not permit obtaining approval in advance.
(b) Maternity care. When a condition commences or exacerbates during pregnancy in a manner that a delay, caused by referral to a USMTF or USTF, would jeopardize the welfare of the mother or unborn child, the following constitutes indications for admission to or treatment at a non-Federal facility:
(1) Medical or surgical conditions which would constitute an emergency in the nonpregnant state.
(2) Spontaneous abortion, with first trimester hemorrhage.
(3) Premature or term labor with delivery.
(4) Severe pre-eclampsia.
(5) Hemorrhage, second and third trimester.
(6) Ectopic pregnancy with cardiovascular instability.
(7) Premature rupture of membrames with prolapse of the umbilical cord.
(8) Obstetric sepsis.
(9) Any other obstetrical condition that, by definition, constitutes an emergency circumstance.
§732.17 Nonemergency care requirements.
Members are cautioned not to obtain nonemergency care from civilian sources without prior approval from the cognizant adjudication authority in §732.20. Obtaining nonemergency care, other than as specified herein, without documented prior approval may result in denial by the Government of responsibility for claims arising from such care.
(a) Individual prior approval. (1) Submit requests for prior approval of nonemergency care (medical, dental, or maternity) from non-Federal sources to the adjudication authority (§732.20) serving the geographic area where care is to be obtained. When the requirements of §732.14(d)(2) are met and spectacles have been obtained, request after-the-fact approval per this paragraph.
(2) Submit requests on a NAVMED 6320/10. Statement of Civilian Medical/Dental Care, with blocks 1 through 7 and 19 through 25 completed. Assistance in completing the NAVMED 6320/10 can be obtained from the health benefits advisor (HBA) at the nearest USMTF.
(3) Upon receipt, the adjudication authority will review the request and, if necessary, forward it to the appropriate chief of service with an explanation of non-Federal care regulations pertaining to the request. The chief of service will respond to the request within 24 hours. The adjudication authority will then complete blocks 26 and 27, and return the original of the approved/disapproved NAVMED 6320/10 to the member.
(b) Blanket prior approval. (1) Recruiting offices and other activities far removed from USMTFs, uniformed services dental treatment facilities (USDTFs), designated USTFs, and VA facilities may request blanket approval for civilian medical and dental care of assigned active duty personnel. Letter requests should be submitted to the adjudication authority (§732.20) assigned responsibility for the geographic area of the requestor.
(2) With full realization that such blanket approval is an authorization to obligate the Government without individual prior approval, adjudication authorities will ensure that:
(i) Each blanket approval letter specifies a maximum dollar amount allowable in each instance of care.
(ii) The location of the activity receiving blanket approval authority is clearly delineated.
(iii) Travel distance and time required to reach the nearest USMTF, USDTF, designated USTF, or VA facility have been considered.
(iv) Certain conditions are specifically excluded, e.g., psychiatric care and elective surgical procedures. These conditions will continue to require individual prior approval.
(v) COMNAVMEDCOM (MEDCOM-333) is made an information addressee on each letter of authorization.
(c) Maternity care. (1) Pregnant active duty members residing outside Military Health Services System (MHSS) inpatent catchment areas of uniformed services facilities (including USTFs), designated in Volumes I, II, and III of MHSS Catchment Area Directories, are permitted to choose whether to deliver in a closer civilian hospital or travel to a USMTF or USTF for delivery. If the Government is to assume financial responsibility for non-Federal maternity care of any member regardless of where she resides, the member must obtain individual prior approval as outlined in paragraph (a) of this section. Adjudication authorities should not approve requests from members residing within an inpatient MHSS catchment area unless:
(i) Capability does not (did not) exist at the USMTF or other Federal MTF serving her catchment area.
(ii) An emergency situation necessitated delivery or other treatment in a non-Federal facility (§732.16(b)).
(2) Normal delivery at or near the expected delivery date should not be considered an emergency for members residing within an MHSS inpatient catchment area where delivery was expected to occur and, unless provided for in this part, will not be reason for delivery in a civilian facility at Government expense.
(3) When granted leave that spans the period of an imminent delivery, the pregnant member should request a copy of her complete prenatal care records from the prenatal care physician. The physician should note in the record whether the member is clear to travel. If receiving prenatel care from a USMTF, the HBA will assist the member in obtaining a statement bearing the name of the MTF (may be an OMA) with administrative responsibility for the geographic area of her leave address, including the telephone number of the head of the patient administration department or HBA, if available. If a member is receiving prenatal care from other than a USMTF, she should avail herself of the services of the nearest HBA to effect the aforestated services. This statement should be attached to the approved leave request. In normal deliveries, requests for after-the-fact approval should be denied when members have not attempted to adhere to the provisions of this part.
(4) Upon arrival at the designated leave address, members should contact the MTF indicated on the statement attached to their leave request. The MTF will make a determination whether the member's leave address falls within the inpatient catchment area of a USMTF or USTF with the capability of providing needed care. If no such USMTF or USTF exists, the member will be given the opportunity to choose to deliver in a civilian hospital closer to her leave address or travel to the most accessible USMTF or USTF with capability for maternity care.
(5) Upon determination that civilian sources will be used for maternity care, the MTF listed on the attachment to the leave papers will inform the member that she (or someone acting in her behalf) must notify that MTF of the member's admission for delivery or other inpatient care so that medical cognizance can be initiated.
(6) Automatically grant prior or retroactive approval, as the situation warrants, to members requiring maternity care while in a travel status in the execution of permanent change of station (PCS) orders.
(d) Nonemergency care without prior approval. (1) If it becomes known that a member intends to seek medical or dental care (inpatient or outpatient) from a non-Federal source and prior approval has not been granted for the use of the Nonnaval Medical and Dental Care Program, the member must be counseled by, or in the presence of, a Medical Department officer. Request that the member sign a statement on an SF 600, Chronological Record of Medical Care, or an SF 603 or 603A, Health Record, Dental as appropriate, for inclusion in the member's Health Record. The statement must specify that counseling has been accomplished, and that the member understands the significance of receiving unauthorized civilian care. This must be accomplished when either personal funds or third party payor (insurance) funds are intended to be used to defray the cost of care. Counseling will include:
(i) Availability of care from a Federal source.
(ii) The requirement for prior approval if the Government may be expected to defray any of the cost of such care.
(iii) Information regarding possible compromise of disability benefits should a therapeutic misadventure occur.
(iv) Notification that should hospitalization become necessary, or other time is lost from the member's place of duty, such lost time may be chargeable as “ordinary leave.”
(v) Notification that the Government cannot be responsible for out-of-pocket expenses which may be required by the insurance carrier or when the member does not have insurance which covers the cost of contemplated care.
(vi) Direction to report to a uniformed services medical officer (preferably Navy) upon completion of treatment for determination of member's fitness for continued service.
(2) If it becomes known that a member has already received non-Federal medical care without prior authorization, refer the member to a uniformed services medical officer (preferably Navy) to determine fitness for continued service. At this time, counseling measures delineated in paragraph (d)(1)(iii), (iv), and (v) of this section must be taken.
§732.18 Notification of illness or injury.
(a) Member's responsibility. (1) If able, members must notify or cause their parent command, the nearest naval activity, or per OPNAVINST 6320.6, the nearest U.S. Embassy or consulate when hospitalized in a foreign medical facility to be notified as soon as possible of the circumstances requiring medical or dental attention in a non-Federal facility. The member will also assure (request the facility to make notification if unable to do so personally) that the following information is passed to the adjudication authority serving the area of the source of care (§732.20). This notification is in addition to the requirements of article 4210100 of the Military Personnel Command Manual (MILPERSMAN) or Marine Corps Order 6320.3B, as appropriate. The adjudication authority will then arrange for transfer of the member and, if appropriate, newborn infant(s), to a Federal facility or for such other action as is appropriate.
(i) Name, grade or rate, and social security number of patient.
(ii) Name of non-Federal medical or dental facility rendering treatment.
(iii) Date(s) of such treatment.
(iv) Nature and extent of treatment or care already furnished.
(v) Need or apparent need for further treatment (for maternity patients, need or apparent need for further care of infant(s) also).
(vi) Earliest date on which transfer to a Federal facility can be effected.
(vii) Telephone number of attending physician and patient.
(2) Should movement be delayed due to actions of the member or the member's family, payment may be denied for all care received after provision of written notification by the adjudication authority.
(3) The denial is §732.18(a)(2) will be for care received after the member's condition has stabilized and after the cognizant adjudication authority has made a request to the attending physician and hospital administration for the member's release from the civilian facility. This notification must specify:
(i) Date and time the Navy will terminate its responsibility for payment.
(ii) That care rendered subsequent to receipt of the written notification is at the expense of the member.
(b) Adjudication authority. As soon as it is ascertained that a member is being treated in a nonnaval facility, adjudication authorities must make the notifications required in MILPERSMAN, article 4210100.11. See part 728 of this chapter on message drafting and information addressees.
(1) Article 4210100.11 of the MILPERSMAN requires submission of a personnel casualty report, by priority message, to the primary and secondary next of kin (PNOK/SNOK) of Navy members seriously or very seriously ill or injured, and on those terminally ill (diagnosed and confirmed). While submission of the personnel casualty report to the PNOK and SNOK is a responsibility of the member's command, adjudication authorities must advise the member's command when such a member is being treated or diagnosed by non-Federal sources. The message will also request forwarding of the member's service and medical records to the personnel support detachment (PSD) supporting the activity in which the OMA is located. Additionally, the notification should contain a request for appropriate orders, either temporary additional duty (TEMADD) or temporary duty (TEMPDU).
(i) Request TEMADD orders if care is expected to terminate within the time constraints imposed for these orders.
(ii) Request TEMDU Under Treatment orders for members hospitalized in a NMTF within the adjudication authority's area of responsibility.
(2) Make prompt message notification to the member's commanding officer when apprised of any medical condition, including pregnancy, which will now or in the foreseeable future result in loss of a member's full duty services in excess of 72 hours. Mark the message “Commanding Officer's Eyes Only.”
(a) Member's responsibility. Members receiving care are responsible for preparation and submission of claims to the cognizant adjudication authority identified in §732.20. A complete claim includes:
(1) NAVMED 6320/10, Statement of Civilian Medical/Dental Care. In addition to its use as an authorization document, the original and three copies of a NAVMED 6320/10 are required to adjudicate claims in each instance of sickness, injury, or maternity care when treatment is received from a non-Federal source under the provisions of this part. The form should be prepared by a naval medical or dental officer, when practicable, by the senior officer present where a naval medical or dental officer is not on duty, or by the member receiving care when on detached duty where a senior officer is not present.
(i) For nonemergency care with prior approval, submit the NAVMED 6320/10 containing the prior approval, after completing blocks 8 through 18.
(ii) For emergency care (or nonemergency care without prior approval), submit a NAVMED 6320/10 after completing blocks 1 through 18. Assure that the diagnosis is listed in block 10. If prior approval was not obtained, state in block 11 circumstances necessitating use of non-Federal facilities.
(iii) Signature by the member in block 17 implies agreement for release of information to the responsible adjudication authority receiving the claim for processing. Signature by the certifying officer in block 18 will be considered certification that documentation has been entered in the member's Health Record as directed in article 16-24 of MANMED.
(2) Itemized bills. The original and three copies of itemized bills to show:
(i) Dates on or between which services were rendered or supplies furnished.
(ii) Nature of and charges for each item.
(iv) Acknowledgment of receipt of the services or supplies on the face of the bill or by separate certificate. The acknowledgment must include the statement. “Services were received and were satisfactory.”
(3) Claims for reimbursement. To effect reimbursement, also submit the original and three copies of paid receipts and an SF 1164. Claim for Reimbursement for Expenditures on Official Business, completed per paragraphs 046377-2 a and b of the Naval Comptroller Manual (NAVCOMPT MAN).
(4) Notice of eligibility (NOE) and line of duty (LOD) determination. When a reservist claims benefits for care received totally after the completion of either an active duty or active duty for training period, the claim should also include:
(i) An NOE issued per SECNAVINST 1770.3.
(ii) An LOD determination from the member's commanding officer.
(b) Adjudicating authority's responsibility. Reviewing and processing properly completed claims and forwarding approved claims to the appropriate disbursing office should be completed within 30 days of receipt. Advice may be requested from COMNAVMEDCOM (MEDCOM-333 (A/V 294-1127)) for medical or MEDCOM-06 (A/V 294-1250)) for dental on unusual or questionable instances of care. Advise claimants of any delay experienced in processing claims.
(1) Review. The receiving adjudication authority will carefully review each claim submitted for payment or reimbursement to verify whether:
(i) Claimant was entitled to benefits (i.e., was on active duty, active duty for training, inactive duty training, was not an unauthorized absentee, etc.). As required by part 728 of this chapter, a Defense Enrollment Eligibility Reporting System (DEERS) eligibility check must be performed on claims to all claimants required to be enrolled in DEERS.
(ii) Care rendered was due to a bona fide emergency. (Note: When questions arise as to the emergency nature of care, forward the claim and all supporting documentation to the appropriate clinical specialist at the nearest naval hospital for review.)
(iii) Prior approval was granted if a bona fide emergency did not exist. (Note: If prior approval was not obtained and the condition treated is determined to have been nonemergent, the claim may be denied.) Consideration should always be given to cases that would have received prior approval but, due to lack of knowledge of the program, the member did not submit a request.
(iv) Care rendered was authorized under the provisions of this part.
(v) Care rendered was appropriate for the specific condition treated. (NOTE: When questions arise regarding appropriateness of care, forward all documentation to a clinical specialist at the nearest naval hospital for review. If care is determined to have been inappropriate, the claim may be denied to the extent the member was negligent.)
(vi) Claimed benefits did not result from a referral by a USMTF. If the member was an inpatient or an outpatient in a USMTF immediately prior to being referred to a civilian source of care, the civilian care is supplemental and may be the responsibility of the referring USMTF. See §732.11(p) for the definition of supplemental care.
(2) Dispproval. If a determination is made to disapprove a claim, provide the member (and provider of care, when applicable) a prompt and courteous letter stating the reason for the disapproval and the appropriate avenues of appeal as outlined in §732.24.
(3) Processing. Subpart C contains the chargeable accounting classifications and Standard Document Numbers (SDN) to be cited on the NAVCOMPT 2277, Voucher for Disbursement and/or Collection, on an SF 1164 submitted per paragraph (a)(3) of this section, and on supporting documents of approved claims before submission to disbursing offices.
(i) For payment to providers of care, a NAV COMPT 2277 will be prepared and certified approved for payment by the adjudicating authority. This form must accompany the NAVMED 6320/10 and supporting documentation per paragraph 046393-1 of the NAVCOMPTMAN.
(ii) Where reimbursement is requested, the SF 1164 submitted per §732.19(a)(3) will be completed, per paragraph 046377 of the NAVCOMPTMAN, and certified approved for payment by the adjudicating authority. This form must accompany the NAVMED 6320/10 and supporting documentation.
(c) Amount payable. Amounts payable are those considered reasonable after taking into consideration all facts. Normally, payment should be approved at rates generally prevailing within the geographic area where services or supplies were furnished. Although rates specially established by the Veterans Administration, CHAMPUS, or those used in Medicare are not controlling, they should be considered along with other facts.
(1) Excessive charges. If any charge is excessive, the adjudication authority will advise the provider of care of the conclusion reached and afford the provider an opportunity to voluntarily reduce the amount of the claim. If this does not result in a proper reduction and the claim is that of a physician or dentist, refer the difference in opinions to the grievance committee of the provider's professional group for an opinion of the reasonableness of the charge. If satisfactory settlement of any claim cannot thus be made, forward all documentation to COMNAVMEDCOM (MEDCOM-333) for decision. Charges determined to be above the allowed amount or charges for unauthorized services are the responsibility of the service member.
(2) Third party payment. Do not withhold payment while seeking funds from health benefit plans or from insurance policies for which premiums are paid privately by service members (see §732.22 for possible recovery of payments action).
(3) No-fault insurance. In States with no-fault automobile insurance requirements, adjudication authorities will notify the insurance carrier identified in item 16 of the NAVMED 6320/10 that Federal payment of the benefits in this part is secondary to any no-fault insurance coverage available to the potentially covered member.
(d) Duplicate payments. Adjudication authorities and disbursing activities should take precautions against duplicate payments per paragraph 046073 of the NAVCOMPTMAN.
§732.20 Adjudication authorities.
(a) General. Controlling activities for medical care in the United States are designated as “offices of medical affairs” (OMA) and for dental care, “offices of dental affairs” (ODA). NAVMEDCOMINST 6010.3 delineates responsibilities and functional tasks of OMAs and ODAs, including monthly reporting of receipt of claims and claims payment. Commanders of geographic naval medical commands must communicate with all activities in their regions to ensure that messages and medical cognizance reports are properly furnished per higher authority directives.
(b) Within the United States (less Hawaii). For the 48 contiguous United States, the District of Columbia, and Alaska, the following six regions are responsible for care rendered or to be rendered within their areas of responsibility.
(1) Northeast Region. The States of Connecticut, Delaware, Illinois, Indiana, Iowa, Kentucky, Maine, Massachusetts, Michigan, Minnesota, Missouri, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, Rhode Island, Vermont, and Wisconsin are served by 1 ODA and 1 OMA:
(i) Responsibility for dental matters for States in the Northeast Region is vested in: Commander, Naval Medical Command, Northeast Region, Office of Dental Affairs, Great Lakes, IL 60088, Tele: (A/V) 792-3940 or (C) (312) 688-3940.
(ii) Responsibility for medical matters for States in the Northeast Region is vested in: Commander, Naval Medical Command, Northeast Region, Office of Medical Affairs, Great Lakes, IL 60088, Tele: (A/V) 792-3950 or (C) (312) 688-3950.
(2) National Capital Region. For the States of Maryland and West Virginia; the Virginia counties of Arlington, Fairfax, Loudoun, and Prince William; the Virginia cities of Alexandria, Falls Church, and Fairfax; and the District of Columbia, responsibility for medical and dental matters is vested in: Commander, Naval Medical Command, National Capital Region, Office of Medical Affairs, Bethesda, MD 20814, Tele: (A/V) 295-5322 or (C) (301) 295-5322.
(3) Mid-Atlantic Region. For the States of North Carolina, South Carolina, and all areas of Virginia south and west of Prince William and Loudoun counties, responsibility for medical and dental matters is vested in: Commander, Naval Medical Command, Mid-Atlantic Region, 6500 Hampton Boulevard, Norfolk, VA 23502, Attn: Office of Medical/Dental Affairs, Tele: (A/V) 565-1074/1075 or (C) (804) 445-1074 or 1075.
(4) Southeast Region. For the States of Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Oklahoma, Tennessee, and Texas, medical and dental responsibilities are vested in: Commanding Officer, Naval Medical Clinic, Code O1A, New Orleans, LA 70146, Tele: (A/V) 485-2406/7/8 or (C) (504) 361-2406 2407 or 2408.
(5) Southwest Region. For the States of Arizona and New Mexico; the counties of Kern, San Bernadino, San Luis Obispo, Santa Barbara, and all other California counties south thereof; the community of Bridgeport, California (Marine Corps cold-weather training site); and Nevada, except for NAS Fallon and its immediate area; medical and dental responsibilities are vested in: Commander, Naval Medical Command, Southwest Region, Office of Medical Affairs, San Diego, CA 92134-7000, Tele: (A/V) 987-2611 or (C) 233-2611.
(6) Northwest Region. The States of Alaska, Colorado, Idaho, Kansas, Montana, Nebraska, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming; the counties of Inyo, Kings, Tulare, and all other counties of California north thereof; and NAS Fallon, Nevada and its immediate area are served by 2 OMAs and 1 ODA:
(i) Responsibility for dental matters for the area of responsibility of the Northwest Region is vested in: Commander, Naval Medical Command, Northwest Region, Office of Dental Affairs, Oakland, CA 94267-5025, Tele: (A/V) 855-6200 or (C) (415) 633-6200.
(ii) Responsibility for medical matters for the States of Colorado, Kansas, and Utah; the California counties of Inyo, Kings, Tulare, and all other counties of California north thereof; and NAS Fallon, Nevada and its immediate area is vested in: Commander, Naval Medical Command, Northwest Region, Oakland, CA 94627-5025, Attn: Office of Medical Affairs, Tele: (A/V) 855-5705 or (C) (415) 633-5705.
(iii) Responsibility for medical matters for the States of Alaska, Idaho, Montana, Nebraska, North Dakota, Oregon, South Dakota, Washington, and Wyoming is vested in: Commanding Officer, Naval Medical Clinic, Naval Station, Seattle, WA 98115, Attn: Office of Medical Affairs, Tele: (A/V) 941-3823 or (C) (206) 526-3823.
(c) Outside the United States (plus Hawaii). For all areas outside the United States plus Hawaii, the following activities are vested with responsibility for approval or disapproval of requests and claims for maternity, medical, and dental care:
(1) Executive Director, OCHAMPUSEUR, U.S. Army Medical Command, APO New York 09102, for care rendered within the U.S. European Command, Africa, the Malagasy Republic, and the Middle East.
(2) Commanding Officer, U.S. Naval Hospital, FPO San Francisco 96652-1600 (U.S. Naval Hospital, Subic Bay, Luzon, Republic of the Philippines), for care rendered in Afghanistan, Bangladesh, Hong Kong, India, Nepal Pakistan, the Philippines, Southeast Asia, Sri Lanka and Taiwan.
(3) Commanding Officer, U.S. Naval Hospital, FPO Seattle 98765-1600 (U.S. Naval Hospital, Yokosuka, Japan), for care rendered in Japan, Korea, and Okinawa.
(4) Commanding Officer, U.S. Naval Hospital, FPO San Francisco 96630-1600 (U.S. Naval Hospital, Guam, Mariana Islands), for care rendered in New Zealand and Guam.
(5) Commanding Officer, U.S. Naval Communications Station, FPO San Francisco 96680-1800 (U.S. Naval Communications Station, Harold E. Holt, Exmouth, Western Australia), for care rendered in Australia.
(6) Commanding Officer, U.S. Naval Air Station, FPO New York 09560 (U.S. Naval Air Station, Bermuda), for care rendered in Bermuda.
(7) Commanding Officer, U.S. Naval Hospital, FPO Miami 34051 (U.S. Naval Hospital, Roosevelt Roads, Puerto Rico), for maternity and medical care, and Commanding Officer, U.S. Naval Dental Clinic, FPO Miami 34051 (U.S. Naval Dental Clinic, Roosevelt Roads, PR), for dental care rendered in Puerto Rico, the Virgin Islands, and other Caribbean Islands.
(8) Commanding Officer, Naval Medical Clinic, Box 121, Pearl Harbor, HI 96860, for maternity and medical care, and Commanding Officer, Naval Dental Clinic, Box 111, Pearl Harbor, HI 96860, for dental care rendered in the State of Hawaii, Midway Island, and the Central Pacific basin.
(9) The OMA for either the Southeast Region or the Southwest Region for care rendered in Mexico to members stationed within the respective areas of responsibility of these OMAs. Forward claims for care rendered in Mexico to all other personnel to Commander, Naval Medical Command, Washington, DC 20372-5120 (MEDCOM-333).
(10) Commander, Naval Medical Command, Washington, DC 20372-5120 (MEDCOM-333) for inpatient and outpatient emergency and nonemergency care of active duty Navy and Marine Corps members in Canada and under the circumstances outlined in paragraph (d) of this section.
(11) Outside the 50 United States, commanding officers of operational units may either approve claims and direct payment by the disbursing officer serving the command or forward claims to the appropriate naval medical command in paragraphs (b)(1) through (c)(9) of this section. This is a local policy decision to enhance the maintenance of good public relations.
(12) The appropriate command in paragraphs (b)(1) through (c)(9) of this section for care rendered aboard commercial vessels en route to a location within the geographic areas listed.
(13) The commanding officer authorizing care in geographical areas not specifically delineated elsewhere in this section.
(d) The Commander, Naval Medical Command (MEDCOM-333), Navy Department, Washington, DC 20372-5120. Under the following circumstances, responsibility is vested in COMNAVMEDCOM for adjudication of claims:
(1) For reservists who receive treatment after completion of their active duty or inactive duty training as prescribed in §732.12(b).
(2) For care rendered in Mexico to personnel stationed outside the areas of responsibility of the Southeast and Southwest Regions.
(3) For care rendered to members stationed in or passing through countries in Central and South America.
(4) For outpatient care rendered NATO active duty members.
(5) When Departmental level review is required prior to approval, adjudication, or payment. These claims:
(i) Will be considered on appeal.
(ii) Must be forwarded by the member through the adjudication authority chain of command (In instances of unusual or controversial denial of claims, the adjudication authority may forward claims to COMNAVMEDCOM on appeal, via the chain of command, with notification to the member.).
(6) For all inpatient and outpatient care of active duty Navy and Marine Corps members stationed in the United States who receive care in Canada.
§732.21 Medical board.
When adjudication authorities uncover conditions which may be chronic or otherwise potentially disabling, they should make a determination (with help from appropriate clinical specialists) as to the need for a medical board. Chapter 18 of MANMED and Medical Disposition and Physical Standards Notes, available from COMNAVMEDCOM (MEDCOM-25), provide guidance.
(a) Chronic conditions requiring a medical board include (but are not limited to):
(5) Heart disease,
(7) Peptic ulcer disease,
(8) Psychiatric conditions, and
(9) Allergic conditions requiring desensitization.
(b) Other potentially disabling or chronic conditions may be referred to a medical board by the adjudication authority with the concurrence of an appropriate naval clinical specialist and the commander of the regional medical command.
§732.22 Recovery of medical care payments.
Adjudication authorities must submit evidence of payment to the action JAG designee per chapter 24 of the Manual of the Judge Advocate General (JAGMAN), in each instance of payment where a third party may be legally liable for causing the injury or disease treated, or when a Government claim is possible under workers compensation, no-fault insurance, or under medical payments insurance (all automobile accident cases).
(a) To assist in identifying possible third party liability cases, item 16 of each NAVMED 6320/10 must be completed whenever benefits are received in connection with a vehicle accident. Adjudication authorities should return for completion, as applicable, any claim received without item 16 completed.
(b) The front of a NAVJAG Form 5890/12 (Hospital and Medical Care, 3rd Party Liability Case) must be completed and submitted by adjudication authorities with evidence of payment. Block 4 of this form requires an appended statement of the patient or an accident report, if available. To ensure that Privacy Act procedures are accomplished and documented, the person securing such a statement from a recipient of care must show the recipient the Privacy Act statement printed at the bottom of the form prior to securing such a statement. The member should be asked to sign his or her name beneath the statement.
(c) For care rendered in States with no-fault insurance laws, comply with procedures outlined in §732.19(c)(3).
§732.23 Collection for subsistence.
The Navy Pay and Personnel Procedures Manual provides guidance regarding pay account checkage procedures to liquidate subsistence charges incurred by members entitled to care under the provisions of this part. Such members must also be entitled to basic allowance for subsistence (BAS) while hospitalized at Government expense. The responsible activity (the adjudication authority or the naval MTF to which such a member is transferred) should follow procedures outlined in the Navy Pay and Personnel Procedures Manual when an eligible officer or enlisted member of the naval service is subsisted at Department of the Navy expense while hospitalized in a nonnaval treatment facility. Subpart C contains the creditable accounting classification for inpatient subsistence collections.
§732.24 Appeal procedures.
When a claim for care or a request for prior approval for nonemergency care is initially denied by an adjudication authority, the member may appeal the denial as outlined below. Any level in the appeal process may over-rule the previous decision and order payment of the claim in whole or in part or grant the request for prior approval of care.
(a) Level I—Reconsideration by the adjudication authority making the initial denial. The member should submit any additional information that may mitigate the initial denial.
(b) Level II—Consideration by the commander of the regional medical command having cognizance over the adjudication authority which upheld the initial denial on reconsideration.
(c) Level III—Consideration by COMNAVMEDCOM (MEDCOM-333).
Subpart C—Accounting Classifications for Nonnaval Medical and Dental Care Expenses and Standard Document Numbers
§732.25 Accounting classifications for nonnaval medical and dental care expenses.
*For the third digit of the appropriation, enter the last digit of the fiscal year current at the time claim is approved for payment.
**Refer to NAVCOMPT Manual par. 027003 for appropriate Expenditure Category Codes when disbursement or collection involves a foreign or U.S. Contractor abroad.
1Not applicable when care is procured from non-DOD sources for a patient receiving either inpatient or outpatient care at a naval medical facility. In such instances, the expenses incurred are payable from operations and maintenance funds available for support of the naval medical facility.
2Service expenses include: hospital, emergency room clinic, office fees; physician and dentist professional fees; laboratory, radiology, operating room, anesthesia, physical therapy, and other services provided.
3Supply expenses include: medications and pharmacy charges; IV solutions; whole blood and blood products; bandages; crutches; prosthetic devices; needles and syringes; and other supplies provided.
§732.26 Standard document numbers.
Adjudication authorities will assign to each claim approved for payment, a unique 15 position alpha/numeric standard document number (SDN). Prominently display this number on the NAVMED 6320/10, the NAVCOMPT 2277 (Voucher for Disbursement and/or Collection), NAVCOMPT 1164 (Claim for Reimbursement for Expenditures on Official Business) and on all other documentation accompanying claims. Compose SNDs per the following example: N0016887MD00001 or N0016887RV00001.