Federal Register / Vol. 62, No. 189 / Tuesday, September 30, 1997 / Rules and Regulations 51281

(c) Definitions.—(1) Vietnam veteran.

For the purposes of this section, the

term ‘‘Vietnam veteran’’ means a

veteran who performed active military,

naval, or air service in the Republic of

Vietnam during the Vietnam era. Service

in the Republic of Vietnam includes

service in the waters offshore and

service in other locations if the

conditions of service involved duty or

visitation in the Republic of Vietnam.

(2) Child. For the purposes of this

section, the term ‘‘child’’ means a

natural child of a Vietnam veteran,

regardless of age or marital status,

conceived after the date on which the

veteran first served in the Republic of

Vietnam during the Vietnam era.

Notwithstanding the provisions of

§ 3.204(a)(1), VA shall require the types

of evidence specified in §§ 3.209 and

3.210 sufficient to establish in the

judgment of the Secretary that a child is

the natural child of a Vietnam veteran.

(3) Spina bifida. For the purposes of

this section, the term ‘‘spina bifida’’

means any form and manifestation of

spina bifida except spina bifida occulta.

(d)(1) VA shall determine the level of

disability suffered by the child in

accordance with the following criteria:

(i) Level I. The child is able to walk

without braces or other external support

(although gait may be impaired), has no

sensory or motor impairment of upper

extremities, has an IQ of 90 or higher,

and is continent of urine and feces.

(ii) Level II. Provided that none of the

child’s disabilities are severe enough to

be evaluated at Level III, and the child:

is ambulatory, but only with braces or

other external support; or, has sensory

or motor impairment of upper

extremities, but is able to grasp pen,

feed self, and perform self care; or, has

an IQ of at least 70 but less than 90; or,

requires drugs or intermittent

catheterization or other mechanical

means to maintain proper urinary

bladder function, or mechanisms for

proper bowel function.

(iii) Level III. The child is unable to

ambulate; or, has sensory or motor

impairment of upper extremities severe

enough to prevent grasping a pen,

feeding self, and performing self care;

or, has an IQ of 69 or less; or, has

complete urinary or fecal incontinence.

(2) Provided that they are adequate for

assessing the level of disability due to

spina bifida under the provisions of

paragraph (d)(1) of this section, VA may

accept statements from private

physicians, or examination reports from

government or private institutions, for

the purpose of rating spina bifida claims

without further examination. In the

absence of such information, VA will

schedule an examination for the

purpose of assessing the level of

disability.

(3) Unless or until VA is able to obtain

medical evidence adequate to assess the

level of disability due to spina bifida, or

to reassess the level of disability when

required to do so under the provisions

of paragraph (d)(4) or (5) of this section,

VA will rate the disability of a person

eligible for this monetary allowance at

no higher than Level I.

(4) Children under the age of one year

will be rated at Level I unless a pediatric

neurologist or a pediatric neurosurgeon

certifies that, in his or her medical

judgment, there is a neurological deficit

that will prevent the child from

ambulating; from grasping a pen,

feeding him or herself, or performing

self care; or from achieving urinary or

fecal continence. If such a deficit is

present, the child will be rated at Level

III. In either case, VA will reassess the

level of disability when the child

reaches the age of one year.

(5) VA will reassess the level of

disability due to spina bifida whenever

it receives medical evidence indicating

that a change is warranted. For

individuals between the ages of one and

twenty-one, however, it will reassess the

level of disability at intervals of not

more than five years. Thereafter, it will

reassess the level of disability only if

evidence indicates there has been a

material change in the level of disability

or that the current rating may be

incorrect.

(Paperwork requirements were

approved by the Office of Management

and Budget under control number 2900–

0572.)

(Authority: 38 U.S.C. 501, 1805)

PART 3—[AMENDED]

13. The Cross Reference following

§ 3.57 is amended by removing

‘‘§ 3.403(a)’’ and ‘‘§ 3.503(c)’’ and

adding, in their places, ‘‘§ 3.403(a)(1)’’

and ‘‘§ 3.503(a)(3)’’, respectively.

14. Each Cross Reference following

§§ 3.659 and 3.703 is amended by

removing ‘‘§ 3.503(g)’’ and adding, in its

place, ‘‘§ 3.503(a)(7)’’.

15. The Cross Reference following

§ 3.707 is amended by removing

‘‘§ 3.503(h)’’ and adding, in its place,

‘‘§ 3.503(a)(8)’’.

16. The Cross Reference following

§ 3.807 is amended by removing

‘‘§ 3.503(h)’’ and adding, in its place,

‘‘§ 3.503(a)(8).’’.

[FR Doc. 97–25663 Filed 9–29–97; 8:45 am]

BILLING CODE 8320–01–P

DEPARTMENT OF VETERANS

AFFAIRS

38 CFR Part 17

RIN 2900–AI65

Provision of Health Care to Vietnam

Veterans’ Children With Spina Bifida

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

SUMMARY: This document establishes

regulations regarding Vietnam veterans’

children with spina bifida. The

regulations concern the provision of

health care needed for the spina bifida

or any disability that is associated with

such condition. This action is necessary

to establish a mechanism for providing

health care to such children in

accordance with recently enacted

legislation.

DATES: Effective Date: October 1, 1997.

FOR FURTHER INFORMATION CONTACT:

Robert De Vesty, Health Systems

Specialist, Office of Public Health and

Environmental Hazards (13),

Department of Veterans Affairs, 810

Vermont Avenue, NW, Washington DC,

20420, telephone (202) 273–8575.

SUPPLEMENTARY INFORMATION: In a

document published in the Federal

Register on May 1, 1997 (62 FR 23731),

we proposed to amend the ‘‘Medical’’

regulations (38 CFR part 17) by setting

forth new §§ 17.900–17.905 regarding

the provision of health care to Vietnam

veterans’ children with spina bifida.

Spina bifida is a congenital birth defect,

characterized by defective closure of the

bones surrounding the spinal cord. The

spinal cord and its covering (the

meninges) may protrude through the

defect.

The provisions of 38 U.S.C. Chapter

18 (Pub. L. 104–204, section 421,

September 26, 1996) provide for three

separate types of benefits for Vietnam

veterans’ children who suffer from spina

bifida: (1) Monthly monetary

allowances, (2) provision of health care

needed for the spina bifida or any

disability that is associated with such

condition, and (3) provision of

vocational training and rehabilitation.

This document establishes a final rule

to set forth a mechanism regarding

provision of health care to Vietnam

veterans’ children with spina bifida.

We requested that comments to the

proposed rule be submitted on or before

June 30, 1997. We received 33

comments. Based on the rationale set

forth in the proposed rule and this

document, the proposed rule is adopted

as a final rule with changes explained

below.
51282 Federal Register / Vol. 62, No. 189 / Tuesday, September 30, 1997 / Rules and Regulations

Comments regarding issues

concerning monthly monetary

allowances for Vietnam veterans’

children who suffer from spina bifida

and the provision of vocational training

and rehabilitation for such children will

be addressed in separate final rules that

specifically concern these issues.

Some of the suggested changes cannot

be made because they would be

inconsistent with statutory authorities.

There is no authority for VA to pay for

services provided before October 1,

1997, or to pay for services prior to the

date of receipt of application. There is

no authority to provide comprehensive

health care coverage or insurance

(health care is limited to care for spina

bifida or disabilities associated with

such condition). There is no authority to

provide such health care unless the

child is a child of a Vietnam veteran

who was not dishonorably discharged

(see Pub. L. 104–204, 38 U.S.C. 101,

1801–1806).

Commenters asserted that the final

rule should state specifically that the

provision of health care would cover

durable medical equipment and medical

supplies, including catheters, diapers,

pads, etc. Because this appeared to be a

concern from many of the commenters,

the final rule is clarified, consistent

with the intent of the proposed rule, to

state specifically that these types of

equipment and supplies are covered

when provided by VA or authorized by

an approved health care provider (see

§ 17.900(b) and the definition of ‘‘health

care’’ in § 17.901).

One commenter questioned what

standard would apply for replacing

durable medical equipment, particularly

when a child has outgrown medical

equipment. In this regard, the

provisions of § 17.902 provide that

medical equipment will be covered

based on a demonstrated medical need.

Commenters questioned whether the

final rule would cover adaptive housing

and vehicles. VA is authorized to

provide health care determined to be

medically necessary. In our view,

coverage for adaptive housing and

vehicles is outside the scope of this

authorization.

One commenter questioned whether

treatment of behavioral problems such

as attention deficit disorder would be

covered under the final rule. This would

have to be determined on a case-by-case

basis. Any health care determined to be

needed for the spina bifida or any

disability that is associated with such

condition would be covered.

One commenter questioned whether

payment would be made for services if

the child suffering from spina bifida has

died. Covered services provided for an

eligible child prior to death would be

paid even if the child died after the

services were provided.

One commenter questioned whether

complications during pregnancy of a

Vietnam veterans’ child who suffer from

spina bifida would be covered. Another

commenter questioned whether

hydrocephalus and Arnold-Chiari

malformation would be covered for such

children. Another questioned whether

other abnormalities would be covered.

These conditions would be covered

insofar as they constitute a disability

associated with spina bifida.

One commenter questioned whether

care at the Department of Defense (DOD)

facilities would be paid by VA. Costs for

care provided by DOD is the

responsibility of DOD.

One commenter asserted that

preventive care should be listed

specifically as a covered benefit. No

changes are made based on this

comment. The definition of ‘‘health

care’’ in § 17.901 specifically states that

‘‘preventive care’’ is covered.

One commenter asserted that payment

should be made for experimental or

investigative care. No changes are made

based on this comment. We have no

way to determine whether such care

would be effective and not harmful.

Commenters asserted that payment for

respite care and home care (including

attendant care) and case management

services should not be limited to

approved health care providers and

should include health care providers

that are not certified or licensed. The

terms ‘‘health care provider’’ and

‘‘approved health care provider’’ are

defined in § 17.901. No changes are

made based on these comments. This

final rule does not preclude services

from individuals who do not qualify as

‘‘approved health care providers.’’

However, VA will pay only for services

rendered by ‘‘approved health care

providers.’’ We believe that the

utilization of approved health care

providers as defined in § 17.901 is

necessary to ensure appropriate quality

standards for services paid by VA.

A number of commenters expressed

concern that their ability to utilize

Medicaid, Medicare, or other health

insurance would be limited by the spina

bifida program. In this regard, the spina

bifida regulations provide for VA to be

the exclusive payer only for services

paid under the spina bifida regulations.

Also, by statute monetary benefits are

not considered income or resources in

determining eligibility for or the amount

of benefits under any Federal or

Federally-assisted program, including

Medicaid and Medicare. Consistent with

these concepts, we added language to

the final rule to state that in the usual

case claims for health care for other than

covered services for spina bifida and

disabilities associated with spina bifida

would be submitted to an insurer,

Medicare, Medicaid, health plan, or

other program providing health care

coverage.

One commenter expressed concern

that charges could exceed the amount

reimbursed by VA and that providers

would charge patients for the excess. In

this regard, the regulations state that VA

is the exclusive payer for services paid

under the spina bifida regulations.

Accordingly, the amount paid by VA

would constitute payment in full.

Several commenters questioned

whether they could have a choice

regarding their provider. Recipients will

be able to choose any provider meeting

the criteria in § 17.901.

One commenter suggested that the

preauthorization procedures are

unnecessarily restrictive and

burdensome, and that there should be

an emergency exception for

preauthorization. The preauthorization

procedures apply to that type of care

most likely to cause disagreement with

respect to medical need. These

procedures will help avoid unexpected

liabilities for noncovered services.

Further, it would be rare that an

emergency would arise for the types of

care requiring preauthorization. Even

so, we have added provisions stating

that preauthorization would not be

required for a condition for which

failure to receive immediate treatment

poses a serious threat to life or health.

A provision also is added stating that

such emergency care should be reported

by telephone within 72 hours of the

emergency. These provisions would

ensure that preauthorization procedures

would not impede the provisions of

emergent health care and would help

ensure that recipients understand in a

timely manner what health care is

covered under this final rule.

The preauthorization provisions state

that care will be authorized only in

those cases where there is a

demonstrated medical need. One

commenter asserted that the burden of

proof should rest on VA regarding

whether care is medically necessary. No

changes are made based on this

comment. The statutory provisions of 38

U.S.C. 1803(a) state that the Secretary

shall provide ‘‘such health care as the

Secretary determines is needed for the

child for the spina bifida or any

disability associated with such

condition.’’ Even so, VA will consider

any evidence from providers or others

that might support a claim.
Federal Register / Vol. 62, No. 189 / Tuesday, September 30, 1997 / Rules and Regulations 51283

One commenter asserted that Vietnam

veterans’ children who suffer from spina

bifida should have the same appeal

rights as other VA claimants. In this

regard, § 17.904 sets forth an appeal

process and the note to this section

states that there are further appellate

rights for an appeal to the Board of

Veterans’ Appeals. This is equivalent to

the appellate process afforded veterans

for other matters.

The proposed regulations provided

that ‘‘if a health care provider, Vietnam

veteran’s child or representative

disagrees with a determination

concerning provision of health care or a

health care provider disagrees with a

determination concerning payment, the

person or entity may request

reconsideration.’’ The proposed

regulations further provided that ‘‘such

request must be submitted in writing

within one year of the date of the initial

determination to the Chief,

Administrative Division, Health

Administration Center, P.O. Box 65025,

Denver, CO 80206–9025.’’ Moreover, the

proposed regulations provided that ‘‘if

the person or entity seeking

reconsideration is still dissatisfied,

within 30 days of the date of the

decision he or she may make a written

request for review by the Director,

Health Administration Center, P.O. Box

65025, Denver, CO 80206–9025.’’

Commenters asserted that the 30-day

period for further reconsideration

should be extended to 90 or 180 days.

In this regard, they argued that 30 days

might not be enough time for

individuals on travel or who get their

mail irregularly. The final rule extends

the time period from 30 days to 90 days.

This should be adequate to allow

sufficient time for the preparation of an

appeal.

One commenter asserted that the date

for satisfying the period for filing an

appeal be the date the appeal is

postmarked. The provisions of § 17.904

are amended to state that an appeal

would be filed at the time it was

delivered to VA or the time it was

released for submission to VA (postmark

would constitute evidence of release for

submission to VA).

One commenter asserted that the

review appeal decisions should be

required to include a statement of

findings and reasons. The regulations

are clarified to specifically require

inclusion of findings and reasons.

One commenter asserted that ID cards

should be issued so that children

suffering from spina bifida could more

easily identify themselves to health care

providers as eligible for benefits under

the VA’s spina bifida regulations. It is

anticipated that ID cards will be issued.

One commenter requested that the

comment period for this rule making

proceeding be extended until the end of

the comment period for the proposed

rule regarding vocational training and

rehabilitation for Vietnam veterans’

children who suffer from spina bifida.

Such an extension is unwarranted. An

understanding of the issues in the rule

making proceeding regarding vocational

training and rehabilitation is not

necessary to make informed comments

regarding this rule making proceeding.

Additional changes are made to the

final rule for purposes of clarification.

Executive Order 12866

This final rule has been reviewed by

OMB under Executive Order 12866.

Administrative Procedure Act

There is good cause for making this

final rule effective without regard to a

30 day delay. This final rule does not

adversely affect anyone and the affected

children need the benefits from the rule

as soon as possible.

Paperwork Reduction Act

Information collection and

recordkeeping requirements associated

with this final rule (38 CFR 17.902,

17.903, 17.904) have been approved by

the Office of Management and Budget

(OMB) under the provisions of the

Paperwork Reduction Act (44 U.S.C.

3501–3520) and have been assigned

OMB control number 2900–0577.

The provisions of 38 CFR 17.902 will

require individuals to submit to a

preauthorization specialist of the Health

Administration Center a

preauthorization application for health

care consisting of case management,

durable medical equipment, home care,

professional counseling, mental health

services, respite care, training,

substance abuse treatment, dental

services, transplantation services or

travel (other than mileage at the General

Services Administration rate for

privately owned automobiles). The

preauthorization application will

contain the child’s name and social

security number; the type of service

requested; the medical justification; the

estimated cost; and the name, address,

and telephone number of the provider.

Such information is necessary to make

preauthorization determinations in

accordance with § 17.902.

The provisions of 38 CFR 17.903 will

require that, as a condition of payment,

claims from ‘‘approved health care

providers’’ for health care provided

under 38 CFR 17.900 must include the

following information, as appropriate:

with respect to patient identification

information: the veteran’s and patient’s

full name, social security numbers,

patient’s address, and date of birth; with

respect to patient treatment information

(inpatient and outpatient services): full

name and address (such as hospital or

physician), remittance address, physical

location where services were rendered,

individual provider’s professional status

(M.D., Ph.D., R.N., etc.), and provider

tax identification number (TIN) or social

security number (SSN); with respect to

patient treatment information (inpatient

institutional services): dates of service

(specific and inclusive); summary level

itemization (by revenue code); dates of

service for all absences from a hospital

or other approved institution during a

period for which inpatient benefits are

being claimed; principal diagnosis

established, after study, to be chiefly

responsible for causing the patient’s

hospitalization; all secondary diagnoses;

all procedures performed; discharge

status of the patient; and institution’s

Medicare provider number; with respect

to patient treatment information for all

other health care providers and

ancillary outpatient services: diagnosis,

procedure code for each procedure,

service or supply for each date of

service, and individual billed charge for

each procedure, service or supply for

each date of service; with respect to

prescription drugs and medicines: name

and address of pharmacy where drug

was dispensed, name of drug, National

Drug Code (NDC) for drug provided,

strength, quantity, date dispensed, and

pharmacy receipt for each drug

dispensed. Such information will be

necessary to make payment

determinations in accordance with 38

CFR 17.903.

The provisions of 38 CFR 17.904 will

establish a review process regarding

disagreements by a Vietnam veteran’s

child or representative with a

determination concerning authorization

of health care or a health care provider’s

disagreement with a determination

regarding payment. The person or entity

requesting reconsideration of such

determination will be required to

submit such request to the Chief,

Administrative Division, Health

Administration Center, in writing

within one year of the date of initial

determination. The request must state

why the decision is in error and include

any new and relevant information not

previously considered. After reviewing

the matter, a benefits advisor will issue

a written determination to the person or

entity seeking reconsideration. If such

person or entity remains dissatisfied

with the determination, the person or

entity will be permitted to make a

written request for review by the
51284 Federal Register / Vol. 62, No. 189 / Tuesday, September 30, 1997 / Rules and Regulations

Director, Health Administration Center.

The information to be collected under

§ 17.904 is necessary to make review

and appeal determinations.

Interested parties were invited to

submit comments on the collection of

information. However, no comments

were received.

OMB assigns a control number for

each collection of information it

approves. VA may not conduct or

sponsor, and a person is not required to

respond to, a collection of information

unless it displays a currently valid OMB

control number. The valid OMB control

number assigned to the collections of

information in this final rule is

displayed at the end of each of the

affected sections of the regulations.

Regulatory Flexibility Act

The Secretary hereby certifies that

this final rule will not have a significant

impact on a substantial number of small

entities as they are defined in the

Regulatory Flexibility Act, 5 U.S.C. 601–

612. It is estimated that there are only

between 600 and 2,000 Vietnam

veterans’ children who suffer from spina

bifida. They are widely geographically

diverse and the health care provided to

them would not have a significant

impact on any small businesses.

Therefore, pursuant to 5 U.S.C. 605(b),

the final rule is exempt from the initial

and final regulatory flexibility analysis

requirements of §§ 603 and 604.

There are no Catalog of Federal

Domestic Assistance numbers for this

final rule.

List of Subjects in 38 CFR Part 17

Administrative practice and

procedure, Alcohol abuse, Alcoholism,

Claims, Day care, Dental health, Drug

abuse, Foreign relations, Government

contracts, Grant programs-health, Grant

programs-veterans, Health care, Health

facilities, Health professions, Health

records, Homeless, Medical and dental

schools, Medical devices, Medical

research, Mental health programs,

Nursing homes, Philippines, Reporting

and recordkeeping requirements,

Scholarships and fellowships, Travel

and transportation expenses, Veterans.

Approved: September 11, 1997.

Hershel W. Gober,

Acting Secretary of Veterans Affairs.

For the reasons set forth in the

preamble, 38 CFR part 17 is amended as

follows:

PART 17—MEDICAL

1. The authority citation for part 17

continues to read as follows:

Authority: 38 U.S.C. 501(a), 1721, unless

otherwise noted.

2. In part 17, an undesignated center

heading and new §§ 17.900 through

17.905 are added to read as follows:

Health Care for a Vietnam Veteran’s Child

With Spina Bifida

Sec.

17.900 Spina bifida—provision of health

care.

17.901 Definitions.

17.902 Preauthorization.

17.903 Payment.

17.904 Review and appeal process.

17.905 Medical records.

Health Care for a Vietnam Veteran’s

Child With Spina Bifida

§ 17.900 Spina bifida—provision of health

care.

(a) VA shall provide a Vietnam

veteran’s child who has been

determined under § 3.814 of this title to

suffer from spina bifida with such

health care as the Secretary determines

is needed by the child for the spina

bifida or any disability that is associated

with such condition. This is not

intended to be a comprehensive

insurance plan and does not cover

health care unrelated to spina bifida.

(b) Health care provided under this

section shall be provided directly by

VA, by contract with an approved

health care provider, or by other

arrangement with an approved health

care provider. VA may inform spina

bifida patients, parents, or guardians

that health care may be available at notfor-profit charitable entities.

(Authority: 38 U.S.C. 101(2), 1801–1806)

Note to § 17.900: VA provides payment

under this section only for health care

relating to spina bifida or a disability that is

associated with such condition. VA is the

exclusive payer for services paid under this

section regardless of any third party insurer,

Medicare, Medicaid, health plan, or any

other plan or program providing health care

coverage. Any third-party insurer, Medicare,

Medicaid, health plan, or any other plan or

program providing health care coverage

would be responsible according to its

provisions for payment for health care not

relating to spina bifida and not constituting

a disability that is associated with such

condition (accordingly, in the usual case

claims for health care for other than covered

services for spina bifida and disabilities

associated with spinal bifida would be

submitted to an insurer, Medicare, Medicaid,

health plan, or other program providing

health care coverage).

§ 17.901 Definitions.

For purposes of §§ 17.900 through

17.905—

Approved health care provider means

a health care provider approved by the

Health Care Financing Administration

(HCFA), Department of Defense Civilian

Health and Medical Program of the

Uniformed Services (CHAMPUS),

Civilian Health and Medical Program of

the Department of Veterans Affairs

(CHAMPVA), Joint Commission on

Accreditation of Health Care

Organizations (JCAHO), or any health

care provider approved for providing

health care pursuant to a state license or

certificate. An entity or individual shall

be deemed to be an approved health

care provider only when acting within

the scope of the approval, license, or

certificate.

Child means the same as defined at

§ 3.814(c) of this title.

Habilitative and rehabilitative care

means such professional counseling,

guidance services and treatment

programs (other than vocational training

under 38 U.S.C. 1804) as are necessary

to develop, maintain, or restore, to the

maximum extent practicable, the

functioning of a disabled person.

Health care means home care,

hospital care, nursing home care,

outpatient care, preventive care,

habilitative and rehabilitative care, case

management, and respite care; and

includes the training of appropriate

members of a child’s family or

household in the care of the child; and

the provision of such pharmaceuticals,

supplies (including continence-related

supplies such as catheters, pads, and

diapers), equipment (including durable

medical equipment), devices,

appliances, assistive technology, direct

transportation costs to and from

approved health care providers

(including any necessary costs for meals

and lodging en route, and

accompaniment by an attendant or

attendants), and other materials as the

Secretary determines necessary.

Health care provider means any entity

or individual who furnishes health care,

including specialized spina bifida

clinics, health care plans, insurers,

organizations, and institutions.

Home care means medical care,

habilitative and rehabilitative care,

preventive health services, and healthrelated services furnished to an

individual in the individual’s home or

other place of residence.

Hospital care means care and

treatment furnished to an individual

who has been admitted to a hospital as

a patient.

Nursing home care means care and

treatment furnished to an individual

who has been admitted to a nursing

home as a resident.

Outpatient care means care and

treatment, including preventive health

services, furnished to an individual

other than hospital care or nursing

home care.
Federal Register / Vol. 62, No. 189 / Tuesday, September 30, 1997 / Rules and Regulations 51285

Preventive care means care and

treatment furnished to prevent disability

or illness, including periodic

examinations, immunizations, patient

health education, and such other

services as the Secretary determines

necessary to provide effective and

economical preventive health care.

Respite care means care furnished on

an intermittent basis for a limited period

to an individual who resides primarily

in a private residence when such care

will help the individual continue

residing in such private residence.

Spina bifida means all forms and

manifestations of spina bifida except

spina bifida occulta (this includes

complications or associated medical

conditions which are adjunct to spina

bifida according to the scientific

literature).

Vietnam veteran means the same as

defined at § 3.814(c) of this title.

(Authority: 38 U.S.C. 101(2), 1801–1806)

§ 17.902 Preauthorization.

(a) Preauthorization from a

preauthorization specialist of the Health

Administration Center is required for

health care consisting of case

management, durable medical

equipment, home care, professional

counseling, mental health services,

respite care, training, substance abuse

treatment, dental services,

transplantation services, or travel (other

than mileage at the General Services

Administration rate for privately owned

automobiles). This care will be

authorized only in those cases where

there is a demonstrated medical need.

Applications for provision of health care

requiring preauthorization shall either

be made by telephone at (800) 733–

8387, or in writing to Health

Administration Center, P.O. Box 65025,

Denver, CO 80206–9025. The

application shall contain the following:

(1) Name of child,

(2) Child’s social security number,

(3) Name of veteran,

(4) Veteran’s social security number,

(5) Type of service requested,

(6) Medical justification,

(7) Estimated cost, and

(8) Name, address, and telephone

number of provider.

(b) Notwithstanding the provisions of

paragraph (a) of this section,

preauthorization shall not be required

for a condition for which failure to

receive immediate treatment poses a

serious threat to life or health. Such

emergency care should be reported by

telephone at (800) 733–8387 to the

Health Administration Center, Denver,

CO within 72 hours of the emergency.

(Paperwork requirements were approved by

the Office of Management and Budget under

control number 2900–0577.)

(Authority: 38 U.S.C. 101(2), 1801–1806)

§ 17.903 Payment.

(a)(1) Payment under this section will

be determined utilizing the same

payment methodologies as provided for

under the Civilian Health and Medical

Program of the Department of Veterans

Affairs (CHAMPVA) (see 38 CFR 17.84).

(2) As a condition of payment, the

services must have occurred on or after

October 1, 1997, and must have

occurred on or after the date the child

was determined eligible for benefits

under § 3.814 of this title. Also, as a

condition of payment, claims from

approved health care providers for

health care provided under this section

must be filed with the Health

Administration Center, P.O. Box 65025,

Denver, CO 80206–9025, no later than:

(i) One year after the date of service;

or

(ii) In the case of inpatient care, one

year after the date of discharge; or

(iii) In the case of retroactive approval

for health care, 180 days following

beneficiary notification of authorization.

(3) Claims for health care provided

under the provisions of §§ 17.900

through 17.905 shall contain, as

appropriate, the information set forth in

paragraphs (a)(3)(i) through (a)(3)(v) of

this section.

(i) Patient identification information:

(A) Full name,

(B) Address,

(C) Date of birth, and

(D) Social Security number.

(ii) Provider identification

information (inpatient and outpatient

services):

(A) Full name and address (such as

hospital or physician),

(B) Remittance address,

(C) Address where services were

rendered,

(D) Individual provider’s professional

status (M.D., Ph.D., R.N., etc.), and

(E) Provider tax identification number

(TIN) or Social Security number.

(iii) Patient treatment information

(long-term care or institutional services):

(A) Dates of service (specific and

inclusive),

(B) Summary level itemization (by

revenue code),

(C) Dates of service for all absences

from a hospital or other approved

institution during a period for which

inpatient benefits are being claimed,

(D) Principal diagnosis established,

after study, to be chiefly responsible for

causing the patient’s hospitalization,

(E) All secondary diagnoses,

(F) All procedures performed,

(G) Discharge status of the patient,

and

(H) Institution’s Medicare provider

number.

(iv) Patient treatment information for

all other health care providers and

ancillary outpatient services such as

durable medical equipment, medical

requisites and independent laboratories:

(A) Diagnosis,

(B) Procedure code for each

procedure, service or supply for each

date of service, and

(C) Individual billed charge for each

procedure, service or supply for each

date of service.

(v) Prescription drugs and medicines

and pharmacy supplies:

(A) Name and address of pharmacy

where drug was dispensed,

(B) Name of drug,

(C) Drug Code for drug provided,

(D) Strength,

(E) Quantity,

(F) Date dispensed,

(G) Pharmacy receipt for each drug

dispensed (including billed charge), and

(H) Diagnosis.

(b) Health care payment shall be

provided in accordance with the

provisions of §§ 17.900 through 17.905.

However, the following are specifically

excluded from payment:

(1) Care as part of a grant study or

research program,

(2) Care considered experimental or

investigational,

(3) Drugs not approved by the U.S.

Food and Drug Administration for

commercial marketing,

(4) Services, procedures or supplies

for which the beneficiary has no legal

obligation to pay, such as services

obtained at a health fair,

(5) Services provided outside the

scope of the provider’s license or

certification, and

(6) Services rendered by providers

suspended or sanctioned by a Federal

agency.

(c) Payments made in accordance

with the provisions of §§ 17.900 through

17.905 shall constitute payment in full.

Accordingly, the health care provider or

agent for the health care provider may

not impose any additional charge for

any services for which payment is made

by VA.

(d) Explanation of benefits (EOB).

When a claim under the provisions of

§§ 17.900 through 17.905 is adjudicated,

an EOB will be sent to the beneficiary

or guardian and the provider. The EOB

provides at a minimum, the following

information:

(1) Name and address of recipient,

(2) Description of services and/or

supplies provided,

(3) Dates of services or supplies

provided,
51286 Federal Register / Vol. 62, No. 189 / Tuesday, September 30, 1997 / Rules and Regulations

(4) Amount billed,

(5) Determined allowable amount,

(6) To whom payment, if any, was

made, and

(7) Reasons for denial (if applicable).

(Paperwork requirements were approved by

the Office of Management and Budget under

control number 2900–0577.)

(Authority: 38 U.S.C. 101(2), 1801–1806)

§ 17.904 Review and appeal process.

If a health care provider, Vietnam

veteran’s child or representative

disagrees with a determination

concerning provision of health care or a

health care provider disagrees with a

determination concerning payment, the

person or entity may request

reconsideration. Such request must be

submitted in writing within one year of

the date of the initial determination to

the Chief, Administrative Division,

Health Administration Center, P.O. Box

65025, Denver, CO 80206–9025. The

request must state why it is concluded

that the decision is in error and must

include any new and relevant

information not previously considered.

Any request for reconsideration that

does not identify the reason for dispute

will be returned to the sender without

further consideration. After reviewing

the matter, including any relevant

supporting documentation, a benefits

advisor will issue a written

determination (with a statement of

findings and reasons) to the person or

entity seeking reconsideration that

affirms, reverses or modifies the

previous decision. If the person or entity

seeking reconsideration is still

dissatisfied, within 90 days of the date

of the decision he or she may make a

written request for review by the

Director, Health Administration Center,

P.O. Box 65025, Denver, CO 80206–

9025. The Director will review the claim

and any relevant supporting

documentation and issue a decision in

writing (with a statement of findings

and reasons) that affirms, reverses or

modifies the previous decision. An

appeal under this section would be

considered as filed the time it was

delivered to the VA or at the time it was

released for submission to the VA (for

example, this could be evidenced by the

postmark, if mailed).

Note to § 17.904: The final decision of the

Director will inform the claimant of further

appellate rights for an appeal to the Board of

Veterans Appeals.

(Paperwork requirements were approved by

the Office of Management and Budget under

control number 2900–0577.)

(Authority: 38 U.S.C. 101(2), 1801–1806)

§ 17.905 Medical records.

Copies of medical records generated

outside VA that relate to activities for

which VA is asked to provide payment,

and that VA determines are necessary to

adjudicate claims under §§ 17.900

through 17.905, must be provided to VA

at no cost.

(Authority: 38 U.S.C. 101(2), 1801–1806)

[FR Doc. 97–25664 Filed 9–29–97; 8:45 am]

BILLING CODE 8320–01–P

DEPARTMENT OF VETERANS

AFFAIRS

38 CFR Part 21

RIN 2900–AI72

Provision of Vocational Training and

Rehabilitation to Vietnam Veterans’

Children With Spina Bifida

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

SUMMARY: This document establishes

Department of Veterans Affairs (VA)

regulations for providing vocational

training and rehabilitation to Vietnam

veterans’ children with spina bifida.

This is necessary for providing

vocational training and rehabilitation to

these children under recently enacted

legislation that authorizes this benefit.

EFFECTIVE DATE: October 1, 1997.

FOR FURTHER INFORMATION CONTACT:

Charles A. Graffam, Veterans Claims

Examiner, Vocational Rehabilitation and

Counseling Service (28), Department of

Veterans Affairs, 810 Vermont Ave.,

NW, Washington, DC 20420; (202) 273–

7410.

SUPPLEMENTARY INFORMATION: In a

document published in the Federal

Register on July 1, 1997 (62 FR 35454),

we proposed to amend the Vocational

Rehabilitation and Education

regulations (38 U.S.C. part 21) to add a

new subpart M regarding the provision

of vocational training, services, and

assistance to Vietnam veterans’ children

with spina bifida. Spina bifida is a

congenital birth defect, characterized by

defective closure of the bones

surrounding the spinal cord. The spinal

cord and its covering (the meninges)

may protrude through the defect.

The provisions of 38 U.S.C. chapter

18 (Public Law 104–204, sections 421

and 422, September 26, 1996) provide

for three separate types of benefits for

Vietnam veterans’ children who suffer

from spina bifida: (1) Monthly monetary

allowances, (2) provision of health care

needed for the spina bifida or any

disability that is associated with such

condition, and (3) provision of

vocational training and rehabilitation.

This document establishes a final rule

to set forth a mechanism regarding

provision of vocational training and

rehabilitation to Vietnam veterans’

children with spina bifida.

We requested that comments on the

proposed rule be submitted on or before

September 2, 1997. We received five

comments. VA appreciates the

comments submitted in response to the

proposed rule. Based on the rationale

set forth in the proposed rule and this

document, the provisions of the

proposed rule are adopted with the

changes discussed below.

Comments regarding issues

concerning monthly monetary

allowances for Vietnam veterans’

children who suffer from spina bifida

and provision of health care for such

children are addressed in separate final

rules that specifically concern these

issues.

Commenters recommended that we

reimburse children for vocational

training received prior to October 1,

1997; pay for the purchase and ongoing

expenses of owning and operating a

vehicle; provide automobile adaptive

equipment; provide for specially

adapted housing; pay a subsistence

allowance to individuals receiving

vocational training; allow concurrent

receipt of benefits under 38 U.S.C.

chapter 35 and the vocational training

program; provide comprehensive

medical and dental care for conditions

unrelated to spina bifida; provide a

work-study program; and provide

vocational training for children of

certain individuals who do not meet the

statutory definition of the term

‘‘veteran.’’ No changes are made based

on these comments since VA has no

legal authority to do so.

Commenters asserted that benefits

should be provided to grandchildren

and other direct descendants of Vietnam

veterans. No changes are made based on

these comments. Under the provisions

of 38 U.S.C. 1801, benefits are limited

to natural children of a Vietnam veteran.

In our view, this includes only the

immediate offspring of a Vietnam

veteran and does not include

grandchildren or other descendants.

One commenter asserted that all

Vietnam veterans’ children suffering

from spina bifida should receive

vocational training and that there

should be a gradation of vocational

training benefits based on disability so

that the most in need would receive the

maximum benefit. No changes are made

based on this comment. The vocational

training regulations are designed to

provide for training based on the