[Code of Federal Regulations]
[Title 5, Volume 2]
[Revised as of January 1, 2005]
From the U.S. Government Printing Office via GPO Access
[CITE: 5CFR890.1049]

[Page 499]
 
                    TITLE 5--ADMINISTRATIVE PERSONNEL
 
          CHAPTER I--OFFICE OF PERSONNEL MANAGEMENT (CONTINUED)
 
PART 890_FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM--Table of Contents
 
Subpart J_Administrative Sanctions Imposed Against Health Care Providers
 
Sec. 890.1049  Claims for non-emergency items or services furnished by a 
debarred or suspended provider.

    (a) Covered individual unaware of debarment or suspension. FEHBP 
funds may be paid for items or services furnished by a debarred or 
suspended provider if, at the time the items or services were furnished, 
the covered individual did not know, and could not reasonably be 
expected to have known, that the provider was debarred or suspended. 
This provision is intended solely to protect the interests of FEHBP-
covered persons who obtain services from a debarred or suspended 
provider in good faith and without knowledge that the provider has been 
sanctioned. It does not authorize debarred or suspended providers to 
submit claims for payment to FEHBP carriers.
    (b) Notice sent by carrier. When paying a claim under the authority 
of paragraph (a) of this section, an FEHBP carrier must send a written 
notice to the covered individual, stating:
    (1) That the provider is debarred or suspended and is prohibited 
from receiving payment of FEHBP funds for items or services furnished 
after the effective date of the debarment or suspension;
    (2) That claims may not be paid for items or services furnished by 
the debarred or suspended provider after the covered individual is 
informed of the debarment or suspension;
    (3) That the current claim is being paid as a legally-authorized 
exception to the effect of the debarment or suspension in order to 
protect covered individuals who obtain items or services without 
knowledge of their provider's debarment or suspension;
    (4) That FEHBP carriers are required to deny payment of any claim 
for items or services rendered by a debarred or suspended provider 15 
days or longer after the date of the notice described in paragraph (b) 
of this section, unless the covered individual had no knowledge of the 
provider's debarment or suspension when the items or services were 
rendered;
    (5) The minimum period remaining in the provider's debarment or 
suspension; and
    (6) That FEHBP funds cannot otherwise be paid to the provider until 
OPM terminates the debarment or suspension.

[69 FR 9920, Mar. 3, 2004]