Federal Employees Health Benefits Program: Debarment

summary: The Office of Personnel Management (OPM) is issuing final

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.

effective date: November 10, 1994.

for further information contact: Margaret Sears (202) 606-0191.

supplementary information: On May 10, 1994, OPM published interim

regulations in the Federal Register (59 FR 24030) clarifying that

carriers cannot deny claims based on debarment if there was no

reasonable 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.

OPM received no comments on the interim regulations.

Regulatory Flexibility Act

I certify that these regulations will not have a significant

economic impact on a substantial number of small entities because they

primarily affect 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.

Office of Personnel Management.

James B. King,

Director.

Accordingly, under authority of 5 U.S.C. 8913, OPM is adopting its

interim regulations under 5 CFR part 890 as published on May 10, 1994

(59 FR 24030) as final rules without change.

[FR Doc. 94-24953 Filed 10-7-94; 8:45 am]

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