[Federal Register Volume 59, Number 89 (Tuesday, May 10, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-11164]
[[Page Unknown]]
[Federal Register: May 10, 1994]
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OFFICE OF PERSONNEL MANAGEMENT
5 CFR Part 890
RIN 3206-AG03
Federal Employees Health Benefits Program: Debarment
AGENCY: Office of Personnel Management.
ACTION: Interim regulations with request for comments.
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SUMMARY: The Office of Personnel Management (OPM) is issuing interim
regulations to incorporate into regulations the statutory requirement
that carriers in the Federal Employees Health Benefits (FEHB) Program
may not deny claims for services or supplies due to the debarment of
the providers who supplied them if the claimants could not have known
that the provider was debarred. The purpose of these regulations is to
comply with the provision of law that requires OPM to prescribe
regulations on this issue.
DATES: These interim regulations are effective June 9, 1994. Comments
must be received on or before July 11, 1994.
ADDRESSES: Written comments may be sent to Lucretia F. Myers, Assistant
Director for Insurance Programs, Retirement and Insurance Group, Office
of Personnel Management, P.O. Box 57, Washington, DC 20044, or
delivered to OPM, room 3415, 1900 E Street NW., Washington, DC.
FOR FURTHER INFORMATION CONTACT:
Margaret Sears (202) 606-0191.
SUPPLEMENTARY INFORMATION: On October 30, 1989, OPM published interim
regulations in the Federal Register (54 FR 43939) implementing title I
of Public Law 100-654, which allowed OPM to exclude from further
participation in the FEHB Program any health care provider (1)
convicted of fraud or various other cited examples of unethical
professional conduct, or (2) determined by OPM to have committed
various cited offenses against the FEHB Program.
Public Law 100-654 contained a provision requiring OPM to prescribe
regulations allowing payment of claims for service or supplies
furnished by debarred providers if the claimant could not reasonably
have known of the debarment. This issue was inadvertently not addressed
by the regulations published October 30, 1989. Therefore, in compliance
with the requirements of 5 U.S.C. 8902a(i) OPM is now issuing these
interim regulations.
Under these interim regulations, carriers cannot deny claims based
on debarment if there was no reasonably way the claimant could have
known that the provider was debarred. When an individual who has not
previously been notified of a provider's debarment, submits a claim for
services or supplies furnished by a debarred provider, the carrier must
(1) honor the claim under the terms of its contract with OPM, and (2)
inform the individual about the debarment of the provider and the
minimum period of time remaining under the terms of the debarment.
In practical terms, this generally means that the first claim(s) an
enrollee submits for services or supplies received after a provider has
been debarred, but before the enrollee has been informed of the
debarment, is (are) paid to the same extent it (they) would have been
paid had the provider not been debarred. The carrier must, at the same
time, inform the enrollee concerning the debarment. The carrier will
deny any subsequent claims for service or supplies furnished during the
period the provider is debarred.
Waiver of Notice of Proposed Rulemaking
Pursuant to section 553(b)(3)(B) of title 5 of the U.S. code, I
find that good cause exists for waiving the general notice of
rulemaking because this regulation primarily affects Federal employees
and annuitants and merely incorporates statutory requirements into
regulation.
Regulatory Flexibility Act
I certify that these regulations will not have a significant
economic impact on a substantial number of small entities because it
primarily affects Federal employees and annuitants.
E.O. 12866, Regulatory Review
This rule has been reviewed by OMB in accordance with E.O. 12866.
List of Subjects in 5 CFR Part 890
Administrative practice and procedure, Government employees, Health
facilities, Health insurance, Health professions, Hostages, Reporting
and recordkeeping requirements, Retirement.
U.S. Office of Personnel Management.
Lorraine A. Green,
Deputy Director.
Accordingly, OPM is amending 5 CFR Part 890 as follows:
PART 890--FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM
1. The authority citation for part 890 continues to read as
follows:
Authority: 5 U.S.C. 8913; sec. 890.803 also issued under 50
U.S.C. 403p, 22 U.S.C. 4069c and 4069c-1; subpart L also issued
under sec. 599C of Pub. L. 101-513, 104 Stat. 2064.
2. In subpart J, a new Sec. 890.1006 is added to read as follows:
Sec. 890.1006 Payment of claims for service or supplies furnished by
debarred providers.
Health plans may not deny claims for services or supplies based on
debarment of the provider under this subpart if the claimant did not
know or could not reasonably be expected to have known of the
debarment. In any such instance, the carrier involved must take
appropriate measures to ensure that the individual is informed of the
debarment and the minimum period of time remaining under the terms of
the debarment.
[FR Doc. 94-11164 Filed 5-9-94; 8:45 am]
BILLING CODE 6325-01-M
