Title 42
SECTION 110.60
110.60 Documentation a requester who is determined to be eligible must submit for the Secretary to make a determination of medical benefits.
§ 110.60 Documentation a requester who is determined to be eligible must submit for the Secretary to make a determination of medical benefits.(a) A requester determined by the Secretary to be eligible for Program benefits and who seeks payment or reimbursement for medical services or items must provide the following, in addition to the documentation submitted under subpart F of this part:
(1) List of third-party payers. The requester must submit a list of all third-party payers that may have an obligation to pay for or provide any medical services or items to the injured countermeasure recipient for which payment or reimbursement is being sought under this Program. Such third-party payers may include, but are not limited to, health maintenance organizations, health insurance companies, workers' compensation programs, Medicare, Medicaid, Department of Veterans Affairs, military treatment facilities (MTFs), and any other entities obligated to provide medical services or items or reimburse individuals for medical expenses. Such a list must include the injured countermeasure recipient's account numbers and other applicable information. If the requester knows of no such third-party payer, he or she must so certify in writing. If the requester becomes aware that a third-party payer may have such an obligation, the requester must inform the Secretary within ten business days of becoming aware of this information, even after benefits have been paid by the Program.
(2) Documents for medical services or items provided since the onset of the covered injury. A requester seeking payment or reimbursement for medical services or items already provided for a covered injury or its health complications must submit an itemized statement from each healthcare provider or entity (e.g., clinic, hospital, doctor, or pharmacy) and third-party payer listing the services or items provided to diagnose or treat the covered injury or its health complications and the amounts paid or expected to be paid by third parties for such services or items (e.g., an Explanation of Benefits from the individual's health insurance company). If no third-party payer has an obligation to pay for or provide such services or items, the requester must so certify in writing and submit an itemized list of the services or items provided (including the total cost of such services or items). To assist the Secretary in making a determination as to whether such services or items were reasonable and necessary to diagnose or treat a covered injury, or to diagnose, treat, or prevent its health complications, the requester may submit, in addition to the required medical records, documentation showing that a health-care provider prescribed or recommended such services or items. The medical records must support the requested services and items.
(3) Documents for medical services and items expected to be provided in the future. A requester seeking payments for medical services or items resulting from a covered injury or its health complications expected to be provided in the future must submit a statement from each healthcare provider (e.g., a treating neurologist for neurological issues and a treating cardiologist for cardiac issues) describing those services and items that appear likely to be needed to diagnose or treat the covered injury, or to diagnose, treat, or prevent its health complications, in the future. The medical records must support the requested services and items. A requester must submit documentation, if available, concerning the likely cost of, and the amount expected to be covered by third-party payers for, such services or items. Consent for the Program to communicate directly with the healthcare providers may also be required.
(b) [Reserved]