Federal Register / Vol. 78, No. 38 / Tuesday, February 26, 2013 / Rules and Regulations 12953 

affected MTF or MTFs to ensure the 

proficiency levels of the practitioners at 

the MTF or MTFs; or 

(C) Determines that the lack of NAS 

data would significantly interfere with 

TRICARE contract administration; and 

(D) Provides notification of the 

ASD(HA)’s intent to require an NAS 

under this authority to covered 

beneficiaries who receive care at the 

MTF or MTFs that will be affected by 

the decision to require an NAS under 

this authority; and 

(E) Provides at least 60-day 

notification to the Committees on 

Armed Services of the House of 

Representatives and the Senate of the 

ASD(HA)’s intent to require an NAS 

under this authority, the reason for the 

NAS requirement, and the date that an 

NAS will be required. 

(ii) Rules in effect at the time civilian 

medical care is provided apply. The 

applicable rules and regulations 

regarding Nonavailability Statements in 

effect at the time the civilian care is 

rendered apply in determining whether 

a NAS is required. 

(iii) The Director, TMA is responsible 

for issuing the procedural rules and 

regulations regarding Nonavailability 

Statements. Such rules and regulations 

should address: 

(A) When and for what services a 

NAS is required. However, a NAS may 

not be required for services otherwise 

available at an MTF located within a 40- 

mile radius of the beneficiary’s 

residence when another insurance plan 

or program provides the beneficiary’s 

primary coverage for the services. This 

requirement for an NAS does not apply 

to beneficiaries enrolled in TRICARE 

Prime, even when those beneficiaries 

use the point-of-service option under 

§ 199.17(n)(3) of this part; and 

(B) When and how notifications will 

be made to a beneficiary who is not 

enrolled in TRICARE Prime as to 

whether or not he or she resides in a 

geographic area that requires obtaining 

a NAS; and 

(C) What information relating to 

claims submissions, including the 

documentation, if any, that is required 

to document that a valid NAS was 

issued. However, when documentation 

of a NAS is required, then that 

documentation shall be valid for the 

adjudication of CHAMPUS claims for all 

related care otherwise authorized by 

this part which is received from a 

civilian source while the beneficiary 

resided within the Uniformed Service 

facility catchment area which issued the 

NAS. 

(iv) In the case of any service subject 

to a NAS requirement under this 

paragraph (a)(9) and also subject to a 

preadmission (or other pre-service) 

authorization requirement under § 199.4 

or § 199.15 of this part, the 

administrative processes for the NAS 

and pre-service authorization may be 

combined. 

* * * * * 

Dated: February 1, 2013. 

Patricia L. Toppings, 

OSD Federal Register Liaison Officer, 

Department of Defense. 

[FR Doc. 2013–03418 Filed 2–25–13; 8:45 am] 

BILLING CODE 5001–06–P 

DEPARTMENT OF DEFENSE 

Office of the Secretary 

32 CFR Part 199 

[Docket ID: DOD–2011–HA–0035] 

RIN 0720–AB49 

TRICARE; TRICARE Sanction 

Authority for Third-Party Billing Agents 

AGENCY: Office of the Secretary, 

Department of Defense. 

ACTION: Final rule. 

SUMMARY: This final rule will provide 

the Director, TRICARE Management 

Activity (TMA), or designee, with the 

authority to sanction third-party billing 

agents by invoking the administrative 

remedy of exclusion or suspension from 

the TRICARE program. Such sanctions 

may be invoked in situations involving 

fraud or abuse on the part of third-party 

billing agents that prepare or submit 

claims presented to TRICARE for 

payment. 

DATES: Effective date: This rule is 

effective March 28, 2013. 

FOR FURTHER INFORMATION CONTACT: Ms. 

Ann N. Fazzini, Medical Benefits and 

Reimbursement Branch, TMA, 

telephone, (303) 676–3803. 

SUPPLEMENTARY INFORMATION: 

I. Executive Summary and Overview 

A. Purpose of the Regulatory Action 

As stated in the proposed rule, 

TRICARE has regulatory authority under 

32 Code of Federal Regulations (CFR) 

199.9 to invoke sanctions in situations 

involving fraud or abuse on the part of 

providers of TRICARE services. A 

provider is defined in 32 CFR 199.2 as, 

‘‘A hospital or other institutional 

provider, a physician, or other 

individual professional provider, or 

other provider of services or supplies as 

specified in § 199.6 of this part.’’ Thirdparty billing agents do not meet the 

definition of a provider as stated in 32 

CFR 199.2, nor do TRICARE regulations 

currently define third-party billing 

agents. 

Title 42 of the CFR subpart C— 

Exclusions at 42 CFR 402.200(b)(1) 

provides for the imposition of an 

exclusion from the Medicare and 

Medicaid programs (and, where 

applicable, other Federal health care 

programs) against persons that violate 

the provisions provided in § 402.1(e) 

(and further described in § 402.1(c)). 

However, TRICARE had no independent 

regulatory authority to sanction or 

exclude third-party billing agents. This 

final rule provides that authority. 

B. Summary of Major Provisions 

This final rule establishes that such 

entities, when acting on behalf of a 

provider, are held to an equal standard 

in regard to accuracy and honesty when 

filing claims for services and supplies 

under the TRICARE program. As such, 

these entities should be subject to the 

same administrative controls applied to 

providers in ensuring that funds are 

disbursed appropriately. This rule will 

allow TRICARE to sanction third-party 

billing agents to prevent the payment of 

false or improper billings. 

C. Summary of Costs and Benefits 

By expanding the scope of 

sanctioning authority to include thirdparty billing agents, TRICARE costs are 

not anticipated to increase in this area. 

Rather, by expanding the sanctioning 

authority to include third-party billing 

agents in situations of fraud or abuse, 

the program is safeguarding benefit 

dollars from being expended for 

fraudulent or abusive charges. The 

anticipated result of this final rule is a 

savings benefit to the program. 

II. Department of Defense Inspector 

General Report on TRICARE Controls 

Over Claims Prepared by Third-Party 

Billing Agents 

The Department of Defense, Office of 

Inspector General (DoD IG) initiated an 

audit in February 2008 to review 

TRICARE controls over claims 

submitted by third-party billing agents 

(Department of Defense Inspector 

General Report No. D–2009–037— 

‘‘TRICARE Controls Over Claims 

Prepared by Third-Party Billing 

Agencies’’). The DoD IG published a 

report on December 31, 2008. The report 

included a recommendation that the 

Director, TMA strengthen internal 

controls by initiating action to obtain 

statutory or regulatory authority to 

sanction billing agencies or any entities 

that prepare or submit improper health 

care claims to TRICARE contractors. 


wreier-aviles on DSK5TPTVN1PROD with RULES
12954 Federal Register / Vol. 78, No. 38 / Tuesday, February 26, 2013 / Rules and Regulations 

III. Review of Public Comments 

In the Federal Register of September 

20, 2011, (76 FR 58202), the Office of 

the Secretary of Defense published for 

public comment a Proposed Rule 

regarding sanction authority for thirdparty billing agents. 

We received one comment on the 

proposed rule. The commenter 

recommended that the Code of Federal 

Regulations (CFR) rule be expanded to 

prohibit sanctioned providers or third 

party billing agents from pursing 

collection activities against patients in 

the event that sanctions are 

implemented. We appreciate this 

comment and note that there is 

presently policy and regulations that 

address this issue. By their very nature, 

third-party billing agents have a 

contractual relationship with the health 

care provider that requires them to file 

claims on behalf of the provider. This 

should normally require that the thirdparty billing agreement meet the claims 

filing requirements of the entity or 

agency that would be paying the claim. 

In the case of a DoD beneficiary, claims 

must be filed in accordance with the 

Code of Federal Regulations, including 

the requirements relating to the 

maximum allowable payments and any 

balance billing limitations. 

Additionally, TRICARE benefit 

payments are payable directly to the 

provider, not the third-party billing 

agent, as federal regulations prohibit the 

general assignment of claims. The agent 

has no independent right to payment 

from either TRICARE or the beneficiary. 

Per 32 CFR 199.9(h)(4)(i)(c), 

participating providers are considered 

to have forfeited or waived any right or 

entitlement to bill TRICARE 

beneficiaries for care involved in claims 

for services furnished on or after the 

effective date of the provider’s exclusion 

or suspension. As a result, any thirdparty billing agent purporting to act on 

behalf of a sanctioned provider would 

also be prohibited from billing TRICARE 

beneficiaries on behalf of that provider. 

Additionally, if the proposed authority 

to sanction third-party billing agents is 

invoked, a suspended or excluded thirdparty billing agent would also be 

prohibited from submitting a claim to 

TRICARE on behalf of any authorized 

provider or to bill any TRICARE 

beneficiary directly. Any claim received 

from an excluded third-party billing 

agent would be returned to the provider 

with instructions to resubmit the claim 

directly or through another third-party 

billing agent. As long as the provider of 

services has not been sanctioned and 

remains an authorized TRICARE 

provider pursuant to the requirements 

in 32 CFR 199.6, the provider remains 

entitled to reimbursement for covered 

services. Under either of these 

scenarios, TRICARE beneficiaries 

should not be subject to collection 

actions. 

It is also important to note that the 

authority sought under the proposed 

rule to sanction third-party billing 

agents by invoking administrative 

remedies under 32 CFR 199.9 is in 

addition to, and not in lieu of, any other 

remedies or sanctions authorized by law 

or regulation, including potential 

criminal convictions and civil 

judgments for fraud and abuse. 

IV. Regulatory Procedures 

Executive Order 12866, ‘‘Regulatory 

Planning and Review’’ and Executive 

Order 13563, ‘‘Improving Regulation 

and Regulatory Review’’ 

Sec. 801 of Title 5, United States Code 

(U.S.C.), and Executive Orders 12866 

and 13563 require certain regulatory 

assessments and procedures for any 

major rule or significant regulatory 

action, defined as one that would result 

in an annual effect of $100 million or 

more on the national economy of which 

would have other substantial impacts. 

This final rule is not a significant 

regulatory action. 

Public Law 104–4, Section 202, 

‘‘Unfunded Mandates Reform Act’’ 

Section 202 of Public Law 104–4, 

‘‘Unfunded Mandates Reform Act,’’ 

requires that an analysis be performed 

to determine whether any Federal 

mandate may result in the expenditure 

by State, local and tribal governments, 

in the aggregate, or by the private sector 

of $100 million in any one year. It has 

been certified that this final rule does 

not contain a Federal mandate that may 

result in the expenditure by State, local 

and tribal governments, in aggregate, or 

by the private sector of $100 million or 

more in any one year, and thus this rule 

is not subject to this requirement. 

Public Law 96–354, ‘‘Regulatory 

Flexibility Act’’ (RFA) (5 U.S.C. 601) 

Public Law 96–351, ‘‘Regulatory 

Flexibility Act’’ (RFA) (5 U.S.C. 601), 

requires each Federal agency to prepare 

a regulatory flexibility analysis when 

the agency issues a regulation which 

would have a significant impact on a 

substantial number of small entities. 

This final rule is not an economically 

significant regulatory action, and it has 

been certified that it will not have a 

significant impact on a substantial 

number of small entities. Therefore, this 

final rule is not subject to the 

requirements of RFA. 

Public Law 96–511, ‘‘Paperwork 

Reduction Act’’ (44 U.S.C. Chapter 35) 

This final rule does not contain a 

‘‘collection of information’’ 

requirement, and will not impose 

additional information collection 

requirement on the public under Public 

Law 96–511, ‘‘Paperwork Reduction 

Act’’ (44 U.S.C. Chapter 35). 

Executive Order 13132, ‘‘Federalism’’ 

E.O. 13132, ‘‘Federalism,’’ requires 

that an impact analysis be performed to 

determine whether the rule has 

federalism implications that would have 

substantial direct effects on the States, 

on the relationship between the national 

government and the States, or on the 

distribution of power and 

responsibilities among the various 

levels of government. It has been 

certified that this final rule does not 

have federalism implications, as set 

forth in E.O. 13132. 

List of Subjects in 32 CFR Part 199 

Claims, Dental health, Health care, 

Health insurance, Individuals with 

disabilities, Military personnel. 

Accordingly, DoD amends 32 CFR 

part 199 as follows: 

PART 199—CIVILIAN HEALTH AND 

MEDICAL PROGRAM OF THE 

UNIFORMED SERVICES (CHAMPUS) 

■ 1. The authority citation for part 199 

continues to read as follows: 

Authority: 5 U.S.C. 301; 10 U.S.C. chapter 

55. 

■ 2. Section 199.2 is amended by adding 

in alphabetical order to paragraph (b), a 

definition of ‘‘Third-party billing agent’’ 

to read as follows: 

§ 199.2 Definitions 

* * * * * 

(b) * * * 

Third-party billing agent. Any entity 

that acts on behalf of a provider to 

prepare, submit and monitor claims, 

excluding those entities that act solely 

as a collection agency. 

* * * * * 

■ 3. Section 199.9 is amended by adding 

paragraph (n) to read as follows: 

§ 199.9 Administrative remedies for fraud, 

abuse, and conflict of interest 

* * * * * 

(n) Third-party billing agents as 

defined in § 199.2(b) of this part, while 

not considered providers, are subject to 

the provisions of this section to the 

same extent as such provisions apply to 

providers. 


wreier-aviles on DSK5TPTVN1PROD with RULES
Federal Register / Vol. 78, No. 38 / Tuesday, February 26, 2013 / Rules and Regulations 12955 

Dated: February 1, 2013. 

Patricia L. Toppings, 

OSD Federal Register Liaison Officer, 

Department of Defense. 

[FR Doc. 2013–03416 Filed 2–25–13; 8:45 am] 

BILLING CODE 5001–06–P 

DEPARTMENT OF EDUCATION 

34 CFR Chapter IV 

[Docket ID ED–2012–OVAE–0053] 

Final Requirements, Definitions, and 

Selection Criteria—Native American 

Career and Technical Education 

Program (NACTEP) 

[Catalog of Federal Domestic Assistance 

(CFDA) Number: 84.101A.] 

AGENCY: Office of Vocational and Adult 

Education, Department of Education. 

ACTION: Final requirements, definitions, 

and selection criteria. 

SUMMARY: The Assistant Secretary for 

Vocational and Adult Education 

announces requirements, definitions, 

and selection criteria under the Native 

American Career and Technical 

Education Program (NACTEP). The 

Assistant Secretary may use these 

requirements, definitions, and selection 

criteria for a competition in fiscal year 

(FY) 2013 and possibly in later years. 

We take this action to notify all 

interested parties and eligible applicants 

in particular, of the requirements, 

definitions, and selection criteria that 

we may use in upcoming competitions 

under section 116 of the Carl D. Perkins 

Career and Technical Education Act of 

2006 (the Act). 

DATES: Effective Date: March 28, 2013. 

FOR FURTHER INFORMATION CONTACT: 

Gwen Washington, by telephone: (202) 

245–7790, or by email: 

gwen.washingon@ed.gov; or Linda 

Mayo, by telephone: (202) 245–7792, or 

by email: linda.mayo@ed.gov. 

If you use a telecommunications 

device for the deaf (TDD) or a text 

telephone (TTY), call the Federal Relay 

Service (FRS), toll free, at 1–800–877– 

8339. 

SUPPLEMENTARY INFORMATION: 

Purpose of Program: Under NACTEP, 

the Secretary provides grants, 

cooperative agreements, or enters into 

contracts with Indian tribes, tribal 

organizations, or Alaska Native entities 

to improve career and technical 

education programs that are consistent 

with the purposes of the Act and that 

benefit Native Americans and Alaska 

Natives. 

Program Authority: 20 U.S.C. 2301 et 

seq., particularly 2326(a)–(g). 

We published a notice of proposed 

requirements, definitions, and selection 

criteria for this program in the Federal 

Register on November 20, 2012 (77 FR 

69579) (November 20, 2012 Notice), 

which contained background 

information and our reasons for 

proposing our requirements, definitions, 

and selection criteria. Except for minor 

technical changes, there are no 

differences between the proposed 

requirements, definitions, and selection 

criteria and the final requirements, 

definitions and selection criteria. 

Public Comment: In response to our 

invitation in the November 20, 2012 

Notice, we received three comments in 

support of our proposals and one 

request for clarification of certain 

elements of our Notice. The following is 

a discussion of those comments with 

our responses. We made no changes in 

response to comments we received. 

Analysis of Comments: 

Comment: Two comments we 

received were from current NACTEP 

grantees supporting our proposed 

requirements, definitions, and selection 

criteria. These commenters indicated 

that their current NACTEP grants had 

enabled them to serve the career and 

technical education needs of their 

Indian student populations in the face 

of high unemployment rates and great 

need for career and technical education. 

One of the commenters represented a 

reservation with an unemployment rate 

of 66 percent where most reservation 

inhabitants are living in poverty. This 

commenter indicated that its current 

NACTEP grant had had a considerable 

positive effect on the reservation and 

members of the commenters’ tribe by 

preparing the tribe’s students to fulfill 

expected local workforce needs during 

the period covered by the current grant. 

Both commenters agreed with the 

Department’s proposed approach of 

retaining programmatic elements 

developed for the first NACTEP 

competition following enactment of the 

Act for grant competitions funded with 

appropriations under this statute. 

Discussion: We agree with the 

commenters, and in this notice we 

announce as final the NACTEP 

requirements, definitions, and selection 

criteria we proposed in our November 

20, 2012 Notice. 

Change: None. 

Comment: We received one comment 

saying that the approach of retaining 

current requirements developed 

following the 2006 reauthorization of 

the Act was one of consistency and 

strength and would provide for program 

continuity. This commenter expressed 

the view that the Department’s approach 

had worked well for NACTEP and that 

there was no need to make changes. 

The commenter also requested that 

the Department not impose a page limit 

for applications in the next competition 

so as to allow applicants the greatest 

flexibility in their applications. 

Discussion: With regard to the 

comment about our overall approach, 

we agree with the commenter, and in 

this notice we announce as final the 

NACTEP requirements, definitions, and 

selection criteria we proposed in our 

November 20, 2012 Notice. 

The commenter requested that we not 

impose application page limitations. We 

do not do so through these 

requirements, definitions, or selection 

criteria. 

Change: None. 

Comment: We received one comment 

requesting clarification of the November 

20, 2012 Notice’s ‘‘Authorized 

Programs, Services, and Activities’’ 

section, (subsection II within the 

‘‘Proposed Requirements’’ section), 

asking whether applicants would be 

required to meet all three elements 

under ‘‘Authorized programs’’ or any 

combination of those elements. Also 

with regard to ‘‘Authorized Programs, 

Services, and Activities,’’ the 

commenter asked for clarification on 

challenging academic standards in 

reading/language arts and in 

mathematics, stating that the November 

20, 2012 Notice proposed the 

integration of academics with career and 

technical education only at the 

secondary level. This commenter also 

asked where the term ‘‘special 

population’’ is defined. 

Discussion: Yes, applicants are 

required to meet all three elements 

under ‘‘Authorized programs.’’ To 

ensure consistency with the Act, in the 

‘‘Authorized Programs, Services, and 

Activities’’ section of our November 20, 

2012 Notice, we require alignment of 

NACTEP projects with other programs 

authorized under the Act, including 

requirements that recipients of Perkins 

funds provide individuals with coherent 

and rigorous content aligned with 

challenging academic standards and 

relevant technical knowledge and skills 

and improve career and technical 

education programs. Section 116(e) of 

the Act requires the Assistant Secretary 

to ensure that activities funded under 

NACTEP will improve career and 

technical education programs. And, 

section 3(5) of the Act defines the term 

‘‘career and technical education’’ as 

requiring certain elements. 

Therefore, we require that NACTEP 

programs meet all of the elements of the 

Act’s definition of ‘‘career and technical 

education.’’ In addition, we require 


wreier-aviles on DSK5TPTVN1PROD with RULES