ARTICLE
1
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Recitals
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1.1
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IDENTIFICATION
OF PARTIES
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This
Participation Agreement is between the United States of America
through the Department of Defense (DoD), Defense Health Agency (hereinafter
DHA), the administering activity for TRICARE and _________________________________________________________(hereinafter designated
the OTP).
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1.2
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AUTHORITY
FOR OPIOID TREATMENT CARE
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The
implementing regulations for DHA, 32 Code of Federal Regulations
(CFR), Part 199, provides for cost-sharing of OTP care under certain
conditions.
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1.3
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PURPOSE
OF PARTICIPATION AGREEMENT
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It
is the purpose of this Participation Agreement to recognize the
undersigned OTP as an authorized provider of opioid treatment care,
subject to the terms and conditions of this agreement, and applicable
federal law and regulation.
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ARTICLE
2
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DEFINITIONS
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2.1
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AUTHORIZED
DHA REPRESENTATIVES
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The
authorized representative(s) of the Director, DHA, may include,
but are not limited to, DHA staff, DoD personnel, and contractors,
such as private sector accounting/audit firm(s) and/or utilization
review and survey firm(s). Authorized representatives will be specifically
designated as such.
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2.2
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BILLING
NUMBER
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The
billing number for all OTP services is the OTP’s Employer’s Identification
Number (EIN). In most situations, each EIN must enter into a separate
Participation Agreement with the Director, DHA, or designee. This
number must be used until the provider is officially notified by
DHA or a designee of a change. The OTP’s billing number is shown
on the face sheet of this agreement.
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2.3
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ADMISSION
AND DISCHARGE
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(a)
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An
admission occurs upon the formal acceptance by the OTP of a beneficiary
for the purpose of participating in the therapeutic program with
the registration and assignment of a patient number or designation.
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(b)
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A
discharge occurs at the time that the OTP formally releases the
patient from active treatment status; or when the patient is admitted
to another level of care.
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2.4
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MENTAL
DISORDER
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As
defined in the 32 CFR 199.2:
For the purposes of the payment of benefits, a mental disorder is
a nervous or mental condition that involves a clinically significant
behavioral or psychological syndrome or pattern that is associated
with a painful symptom, such as distress, and that impairs a patient’s
ability to function in one or more major life activities. A Substance
Use Disorder (SUD) is a mental condition that involves a maladaptive
pattern of substance use leading to clinically significant impairment
or distress; impaired control over substance use; social impairment;
and risky use of a substance(s). Additionally, the mental disorder
must be one of those conditions listed in the current edition of
the Diagnostic and Statistical Manual of Mental Disorders (DSM).
“Conditions Not Attributable to a Mental Disorder,” or V codes
( Z codes in the International Classification of Diseases,
10th Revision, Clinical Modification (ICD-10-CM)), are not considered diagnosable
mental disorders. Co-occurring mental and substance use disorders
are common and assessment should proceed as soon as it is possible
to distinguish the substance related symptoms from other independent
conditions.
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2.5
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OPIOID
TREATMENT PROGRAM (OTP)
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(a)
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As
defined by 32 CFR 199.2(b),
an OTP is a service setting for opioid treatment, either free standing
or hospital based, that adhere to the Department of Health and Human
Services’ (DHHS’) regulations at 42 CFR Part 8 and use medications
indicated and approved by the Food and Drug Administration (FDA).
Treatment in OTPs provides a comprehensive, individually tailored
program of medication therapy integrated with psychosocial and medical
treatment and support services that address factors affecting each
patient, as certified by the Center for Substance Abuse Treatment
(CSAT) of the Department of Health and Human Services’ Substance
Abuse and Mental Health Services Administration (SAMHSA). Treatment
in OTPs can include management of withdrawal symptoms (detoxification)
from opioids and medically supervised withdrawal from maintenance medications.
Patients receiving care for substance use and co-occurring disorders
care can be referred to, or otherwise concurrently enrolled in,
OTPs. Such programs must enter into a Participation Agreement with
the Director, DHA, or designee, and be accredited and in substantial
compliance with a SAMHSA recognized state-certified program (see: http://dpt2.samhsa.gov/treatment/directory.aspx for
the SAMHSA directory of OTPs). OTPs are differentiated from:
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(b)
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Acute
psychoactive substance use treatment and from treatment of acute
biomedical/mental health problems; which problems are either life-threatening
and/or severely incapacitating and often occur within the context
of a discrete episode of addiction-related biomedical or psychiatric
dysfunction;
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(c)
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A
Substance Use Disorder Rehabilitation Facility (SUDRF), as defined
in 32 CFR 199.2,
which serves patients with SUDs through an inpatient rehabilitation
program on a 24-hour, seven-day-per week basis (see the TRICARE
Policy Manual (TPM), Chapter 11, Addendum D for the SUDRF Participation
Agreement);
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(d)
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An
partial hospitalization program (PHP), as defined in 32 CFR 199.2, which serves patients who exhibit
emotional/ behavioral dysfunction but who can function in the community
for defined periods of time with support in one or more of the major
life areas (see TPM, Chapter 11, Addendum F for the PHP Participation
Agreement);
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(e)
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An
Intensive Outpatient Program (IOP), as defined in 32 CFR 199.2, which serves patients in a day
or evening program not requiring 24-hour care for mental health
or SUDs (see TPM, Chapter 11, Addendum G for the IOP Participation
Agreement);
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(f)
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A
group home, sober-living environment, halfway house, or three-quarter
way house;
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(g)
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Therapeutic
schools, which are educational programs supplemented by addiction-
focused services;
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(h)
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Facilities
that treat patients with primary psychotic diagnoses other than
psychoactive substance use or dependence;
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(i)
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Facilities
that care for patients with the primary diagnosis of mental retardation
or developmental disability.
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ARTICLE
3
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PERFORMANCE
PROVISIONS
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3.1
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GENERAL
AGREEMENT
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(a)
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The
OTP agrees to render opioid treatment services to eligible beneficiaries
in need of such services, in accordance with this Participation
Agreement and the 32 CFR 199. These services shall include patient
assessment, case management, and such other services as are required by
the 32 CFR 199.
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(b)
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The
OTP agrees that all certifications and information provided to the
Director, DHA, incident to the process of obtaining and retaining
authorized provider status is accurate and that it has no material
errors or omissions. In the case of any misrepresentations, whether
by inaccurate information being provided or material facts withheld,
authorized provider status will be denied or terminated, and the
OTP will be ineligible for consideration for authorized provider
status for a two-year period. Termination of authorized IOP status
will be pursuant to Article 12 of this agreement.
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(c)
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The
OTP shall not be considered an authorized provider nor may any benefits
be paid to the IOP for any services provided prior to the date the
IOP is approved by the Director, DHA, or a designee as evidenced
by signature on the Participation Agreement.
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3.2
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LIMIT
ON RATE BILLED
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(a)
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The
OTP agrees to limit charges for services to beneficiaries to the
rate set forth in this agreement.
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(b)
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The
OTP agrees to charge only for services to beneficiaries that qualify
within the limits of law, regulation, and this agreement.
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3.3
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ACCREDITATION
AND STANDARDS
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The
OTP hereby agrees to:
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(a)
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Be
licensed to provide OTP services within the applicable jurisdiction
in which it operates.
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(b)
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Be
specifically accredited by and remain in compliance with standards
issued by a SAMHSA recognized state-certified program (see: http://dpt2.samhsa.gov/treatment/directory.aspx for
the SAMHSA directory of OTPs).
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(c)
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Accept
the allowable OTP rate, as provided in 32 CFR 199.14(a)(2)(ix)(A)(3),
as payment in full for services provided.
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(d)
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Comply
with all requirements of 32 CFR 199.4 applicable
to institutional providers generally concerning concurrent care
review, claims processing, beneficiary liability, double coverage, utilization
and quality review, and other matters.
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(e)
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Ensure
that all mental health services are provided by qualified mental
health providers who meet the requirements for individual professional
providers. (Exception: OTPs that employ individuals with master’s
or doctoral level degrees in a mental health discipline who do not meet
the licensure, certification, and experience requirements for a
qualified mental health provider but are actively working toward
licensure or certification, may provide mental health services within
the per diem rate but the individual must work under the direct
clinical supervision of a fully qualified mental health provider
employed by the OTP.) All other program services will be provided
by trained, licensed staff.
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(f)
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Not
bill the beneficiary for services in excess of the cost-share or
services for which payment is disallowed for failure to comply with
requirements.
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(g)
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Not
bill the beneficiary for services excluded on the basis of 32 CFR 199.4(g)(1) (not medically or psychologically
necessary), (g)(3) (inappropriate
level of care), or (g)(7) (custodial
care), unless the beneficiary has agreed in writing to pay for the
care, knowing the specific care in question has been determined
as noncovered. (A general statement signed at admission as to financial
liability does not fill this requirement.)
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3.4
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QUALITY
OF CARE
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(a)
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The
OTP shall assure that any and all eligible beneficiaries receive
opioid treatment services which comply with standards in Article
3.3.
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(b)
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The
OTP shall provide opioid treatment services in the same manner to
beneficiaries as it provides to all patients to whom it renders
services.
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(c)
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The
OTP shall not discriminate against beneficiaries in any manner including
admission practices or provisions of special or limited treatment.
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3.5
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BILLING
FORM
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The
OTP shall use the Centers for Medicare and Medicaid Services (CMS)
1450 UB-04 billing form and the CMS 1500 Claim Form for outpatient
services (or subsequent editions). OTPs shall identify opioid treatment
care on the billing form in the remarks block by stating “OTP care.”
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3.6
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COMPLIANCE
WITH DHA UTILIZATION REVIEW ACTIVITIES UNDER THE TERMS OF THIS AGREEMENT,
THE OTP SHALL:
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(a)
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Appoint
a single individual within the facility to serve as the point of
contact for conducting utilization review activities with DHA or
its designee. The OTP will inform DHA in writing of the designated
individual.
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(b)
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Promptly
provide medical records and other documentation required in support
of the utilization review process upon request by DHA or its designee.
Confidentiality considerations are not valid reasons for refusal
to submit medical records on any beneficiary. Failure to comply
with documentation requirements will usually result in denial of authorization
of care.
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(c)
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Maintain
medical records, including the clinical formulation, progress notes,
and master treatment plan, to include documentation of standardized
assessment measures for Post- Traumatic Stress Disorder (PTSD),
Generalized Anxiety Disorder (GAD), and Major Depressive Disorder
(MDD) using the PTSD Checklist (PCL), GAD-7, and Patient Health
Questionnaire (PHQ)-8, respectively, at baseline, at 60-120 day
intervals, and at discharge (see Chapter 1, Section 5.1 for details);
in compliance with TRICARE standards and regulations.
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ARTICLE
4
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PAYMENT
PROVISIONS
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4.1
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RATE
STRUCTURE: DETERMINATION OF RATE
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The
TRICARE rate is the per diem rate that TRICARE will authorize for
all mental health and substance use disorder services rendered to
a patient and the patient’s family as part of the total treatment
plan submitted by an approved OTP, and approved by DHA or a designee.
The per diem rate will be as specified in 32 CFR 199.14(a)(2)(ix).
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4.2
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OTP
SERVICES INCLUDED IN PER DIEM PAYMENT
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(a)
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OTPs
will be reimbursed based on the variability in the dosage and frequency
of the drug being administered and in related supportive services.
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(b)
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Methadone
OTPs will be reimbursed the lower of the billed charge or the weekly
all-inclusive per diem rate (the weekly national all-inclusive rate
adjusted for locality), including the cost of the drug and related
services (i.e., the costs related to the initial intake/assessment,
drug dispensing and screening and integrated psychosocial and medical
treatment and support services). The bundled weekly per diem payments
will be accepted as payment in full, subject to the outpatient cost-sharing
provisions under 32 CFR 199.4(f).
The methadone per diem rate for OTPs will be updated annually by
the Medicare update factor used for their Inpatient Prospective
Payment System (IPPS).
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(c)
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When
providing other medications which are more likely to be prescribed
and administered in an office-based opioid treatment setting, but
which are still available for treatment of substance use disorders
in an outpatient treatment program setting, OTPs will be reimbursed on
a fee-for-service basis (i.e., separate payments will be allowed
for both the medication and accompanying support services), subject
to the outpatient cost-sharing provisions under 32 CFR 199.4(f). OTPs’ rates will be updated
annually by the Medicare update factor used for their IPPS.
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(d)
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The
Director, DHA, will have discretionary authority in establishing
the reimbursement methodologies for new drugs and biologicals that
may become available for the treatment of substance use disorders
in OTPs. The type of reimbursement (e.g., fee-for-service versus bundled
per diem payments) will be dependent on the variability of the dosage
and frequency of the medication being administered, as well as the
support services.
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(e)
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Psychotherapy
sessions and non-mental health related medical services not normally included
in the evaluation and assessment of PHP, IOP, or OTPs, provided
by authorized independent professional providers who are not employed
by, or under contract with, PHP, IOP, or OTPs for the purposes of
providing clinical patient care are not included in the per diem
rate and may be billed separately. This includes ambulance services
when medically necessary for emergency transport.
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4.3
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OTHER
PAYMENT REQUIREMENTS
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No
payment is due for leave days, for days in which treatment is not
provided, or for days on which the patient is absent from treatment
(whether excused or unexcused).
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4.4
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PREREQUISITES
FOR PAYMENT
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Provided
that there shall first have been a submission of claims in accordance
with procedures, the OTP shall be paid based upon the allowance
of the rate determined in accordance with the prevailing 32 CFR 199.14 (see Article 4.1), and contingent
upon certain conditions provided in the 32 CFR 199, and in particular
the following:
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(a)
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The
patient seeking admission is suffering from a mental disorder, to
include substance use disorder, which meets the diagnostic criteria
of the current edition of the DSM and meets the TRICARE definition
of a mental disorder.
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(b)
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The
patient meets the criteria for admission to an OTP issued by the
Director, DHA.
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(c)
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A
qualified mental health professional who meets requirements for
individual professional providers and who is permitted by law and
by the OTP recommends that the patient be admitted to the OTP.
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(d)
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A
qualified mental health professional with admitting privileges who
meets the requirements for individual professional providers will
be responsible for the development, supervision, implementation,
and assessment of a written, individualized, interdisciplinary clinical
formulation and plan of treatment.
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(e)
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All
services are provided by or under the supervision of an authorized
mental health provider (see Article 3.3(e)).
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(f)
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The
patient meets eligibility requirements for coverage.
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4.5
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DETERMINED
RATE AS PAYMENT IN FULL
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(a)
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The
OTP agrees to accept the rate determined pursuant to the 32 CFR 199.14 (see Article 4.1) as the total
charge for services furnished by the OTP to beneficiaries. The OTP
agrees to accept the rate even if it is less than the billed amount,
and also agrees to accept the amount paid, combined with the cost-share
amount and deductible, if any, paid by or on behalf of the beneficiary,
as full payment for the OTP services. The OTP agrees to make no
attempt to collect from the beneficiary or beneficiary’s family,
except as provided in Article 4.6(a), amounts for IOP services in
excess of the rate.
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(b)
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The
OTP agrees to submit all claims as a participating provider. DHA
agrees to make payment of the determined rate directly to the OTP
for any care authorized under this agreement.
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(c)
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The
OTP agrees to submit claims for services provided to beneficiaries
at least every 30 days (except to the extent delay is necessitated
by efforts to first collect from other health insurance). If claims
are not submitted at least every 30 days, the OTP agrees not to
bill the beneficiary or the beneficiary’s family for any amounts
disallowed.
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4.6
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TRICARE
AS SECONDARY PAYOR
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(a)
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The
OTP is subject to the provisions of 10 United States Code (USC)
Section 1079 (j)(1). The OTP must submit claims first to all other
insurance plans and/or medical service or health plans under which
the beneficiary has coverage prior to submitting a claim to TRICARE.
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(b)
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Failure
to collect first from primary health insurers and/or sponsoring
agencies is a violation of this agreement, may result in denial
or reduction of payment, and may result in a false claim against
the United States. It may also result in termination of this agreement
by DHA pursuant to Article 7.
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4.7
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COLLECTION
OF COST-SHARE
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(a)
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The
OTP agrees to collect from the beneficiary or the parents or guardian
of the beneficiary only those amounts applicable to the patient’s
cost-share (copayment) as defined in 32 CFR 199.4,
and services and supplies which are not a benefit.
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(b)
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The
OTP’s failure to collect or to make diligent effort to collect the
beneficiary’s cost-share (copayment) as determined by policy is
a violation of this agreement, may result in denial or reduction
of payment, and may result in a false claim against the United States.
It may also result in termination by DHA of this agreement pursuant
to Article 12.
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4.8
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BENEFICIARY
RIGHTS
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If
the OTP fails to abide by the terms of this Participation Agreement
and DHA or its designee either denies the claim or claims and/or
terminates the agreement as a result, the OTP agrees to forego its
rights, if any, to pursue the amounts not paid by TRICARE from the
beneficiary or the beneficiary’s family.
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ARTICLE
5
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RECORDS
AND AUDIT PROVISIONS
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5.1
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ON-SITE
AND OFF-SITE REVIEWS/AUDITS
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The
OTP grants the Director, DHA [or authorized representative(s)],
the right to conduct on-site or off-site reviews or accounting audits
with full access to patients and records. The audits may be conducted
on a scheduled or unscheduled (unannounced) basis. This right to
audit/review includes, but is not limited to, the right to:
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(a)
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Examine
fiscal and all other records of the OTP which would confirm compliance
with this agreement and designation as an authorized OTP provider.
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(b)
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Conduct
audits of OTP records including clinical, financial, and census
records to determine the nature of the services being provided,
and the basis for charges and claims against the United States for
services provided to beneficiaries. The Director, DHA, or a designee
shall have full access to records of both TRICARE and non-TRICARE
patients. Note: In most cases, only TRICARE patients’ records will
be audited. Examples of situations where non-TRICARE patient records
would be requested may be in situations of differential quality
of care assessments or to identify systemic quality or safety concerns.
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(c)
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Examine
reports of evaluations and inspections conducted by federal, state,
local government, and private agencies and organizations.
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(d)
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Conduct
on-site inspections of the facilities of the OTP and interview employees,
members of the staff, contractors, board members, volunteers, and
patients, as may be required.
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(e)
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Release
copies of final review reports (including reports of on-site reviews)
under the Freedom of Information Act (FOIA).
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5.2
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RIGHT
TO UNANNOUNCED INSPECTION OF RECORDS
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(a)
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DHA
and its authorized agents shall have the authority to visit and
inspect the OTP at all reasonable times on an unannounced basis.
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(b)
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The
OTP’s records shall be available and open for review by DHA during
normal working hours, from 8 a.m. to 5 p.m., Monday through Friday,
on an unannounced basis.
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5.3
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CERTIFIED
COST REPORTS
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Upon
request, the OTP shall furnish DHA or a designee the audited cost
reports certified by an independent auditing agency.
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5.4
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RECORDS
REQUESTED BY DHA
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Upon
request, the OTP shall furnish DHA or a designee such records, including
medical records and patient census records, that would allow DHA
or a designee to determine the quality and cost-effectiveness of
care rendered.
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5.5
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FAILURE
TO COMPLY
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Failure
to allow audits/reviews and/or to provide records constitutes a
material breach of this agreement. It may result in denial or reduction
of payment, termination of this agreement pursuant to Article 12,
and any other appropriate action by DHA.
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ARTICLE
6
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NONDISCRIMINATION
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6.1
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COMPLIANCE
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The
OTP agrees to comply with provisions of section 504 of the Rehabilitation
Act of 1973 (Public Law 93-112; as amended) regarding nondiscrimination
on basis of handicap, Title VI of the Civil Rights Act of 1964 (Public
Law 88-352), the Americans With Disabilities Act of 1990 (Public
Law 101-336), and section 1557 of the Patient Protection and Affordable
Care Act, as well as all regulations implementing these Acts.
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ARTICLE
7
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AMENDMENT
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7.1
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AMENDMENT
BY DHA
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(a)
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The
Director, DHA, or designee may amend the terms of this Participation
Agreement by giving 120 days’ notice in writing of the amendment(s)
except amendments to the 32 CFR 199, which shall be considered effective
as of the effective date of the regulation change and do not require
a formal amendment of this agreement to be effective. When changes
or modifications to this agreement result from amendments to the
32 CFR 199 through rulemaking procedures, the Director, DHA, or
designee, is not required to give 120 days’ written notice. Amendments
to this agreement resulting from amendments to the 32 CFR 199 shall
become effective on the date the regulation amendment is effective
or the date this agreement is amended, whichever date is earlier.
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(b)
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The
OTP, if it concludes it does not wish to accept the proposed amendment(s),
including any amendment resulting from amendment(s) to the 32 CFR
199 accomplished through rulemaking procedures, may terminate its
participation as provided for in Article 12.3. However, if the OTP’s
notice of intent to terminate its participation is not given at
least 60 days prior to the effective date of the proposed amendment(s),
then the proposed amendment(s) shall be incorporated into this agreement
for OTP care furnished between the effective date of the amendment(s)
and the effective date of termination of this agreement.
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ARTICLE
8
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TRANSFER
OF OWNERSHIP
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8.1
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ASSIGNMENT
BARRED
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This
agreement is nonassignable.
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8.2
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AGREEMENT
ENDS
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(a)
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Unless
otherwise extended as specified in Article 8.3(b), this agreement
ends as of 12:01 am on the date that transfer of ownership occurs.
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(b)
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Change
of ownership is defined as follows:
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(1)
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The change in
an owner(s) that has/have 50% or more ownership constitutes change
of ownership.
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(2)
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The merger of
the OTP corporation (for-profit or not-for-profit) into another
corporation, or the consolidation of two or more corporations, resulting
in the creation of a new corporation, constitutes change of ownership.
The transfer of corporate stock or the merger of another corporation
into the OTP corporation, however, does not constitute change of
ownership. The transfer of title to property of the OTP corporation
to another corporation(s), and the use of that property for the
rendering of partial hospital care by the corporation(s) receiving
it is essential for a change of ownership.
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(3)
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The lease of all
or part of an OTP or a change in the OTP’s lessee constitutes change
of ownership.
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8.3
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NEW
AGREEMENT REQUIRED
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(a)
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If
there is a change of ownership of an OTP as specified in Article
8.2(b), then the new owner, in order to be an authorized intensive
outpatient program, must enter into a new agreement with DHA. The
new owner is subject to any existing plan of correction, expiration
date, applicable health and safety standards, ownership and financial
interest disclosure requirements and any other provisions and requirements
of this agreement.
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(b)
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An
OTP contemplating or negotiating a change in ownership must notify
DHA in writing at least 30 days prior to the effective date of the
change. At the discretion of the Director, DHA, or a designee, this
agreement may remain in effect until a new Participation Agreement
can be signed to provide continuity of coverage for beneficiaries.
An IOP that has provided the required 30 days’ advance notification
of a change of ownership may seek an extension of this agreement’s
effect for a period not to exceed 180 days from the date of the
transfer of ownership. Failure to provide 30 days’ advance notification
of a change of ownership will result in a denial of a request for
an extension of this agreement and termination of this agreement
upon transfer of ownership as specified in Article 8.2(a).
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(c)
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Prior
to a transfer of ownership of an OTP, the new owners may petition
DHA in writing for a new Participation Agreement. The new owners
must document that all required licenses and accreditations have
been maintained, and must provide documentation regarding any program
changes. Before a new Participation Agreement is executed, the Director,
DHA, or a designee will review the OTP to ensure that it is in compliance
with 32 CFR 199.
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ARTICLE
9
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REPORTS
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9.1
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INCIDENT
REPORTS
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Any
serious occurrence involving a beneficiary, outside the normal routine
of the OTP (see TRICARE Operations Manual (TOM), Chapter 7, Section
4), shall be reported to the referring military providers and/or
Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM)
referral management office (on behalf of the military provider),
and DHA, and/or a designee, as follows:
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(a)
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An
incident of a life-threatening accident, patient death, patient
disappearance, suicide attempt, incident of cruel or abusive treatment,
or any equally dangerous situation involving a beneficiary, shall
be reported by telephone on the next business day with a full written report
within seven days.
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(b)
|
The
incident and the following report shall be documented in the patient’s
clinical record.
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(c)
|
Notification
shall be provided, if appropriate, to the parents, legal guardian,
or legal authorities.
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9.2
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DISASTER
OR EMERGENCY REPORTS
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Any
disaster or emergency situation, natural or man-made, such as fire
or severe weather, shall be reported telephonically within 72 hours,
followed by a comprehensive written report within seven days to
DHA.
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9.3
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REPORTS
OF OTP CHANGES
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The
governing body or the administrator of the OTP shall submit in writing
to DHA any proposed significant changes within the OTP no later
than 30 days prior to the actual date of change; failure to report
such changes may lead to termination of this agreement. A report
shall be made concerning the following items:
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|
(a)
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Any
change in administrator or primary professional staff.
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(b)
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Any
change in purpose, philosophy or any addition or deletion of services
or programs. This includes capacity or hours of operation.
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(c)
|
Any
licensure, certification, accreditation or approval status change
by a state agency or national organization.
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(d)
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Any
anticipated change in location or anticipated closure.
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(e)
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Any
suspension of operations for 24 hours or more.
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ARTICLE
10
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|
GENERAL
ACCOUNTING OFFICE
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|
10.1
|
RIGHT
TO CONDUCT AUDIT
|
|
The
OTP grants the United States General Accounting Office (GAO) the
right to conduct audits.
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ARTICLE
11
|
|
APPEALS
|
|
11.1
|
APPEAL
ACTIONS
|
|
Appeals
of DHA actions under this agreement, to the extent they are allowable,
will be pursuant to the 32 CFR 199.10 and 32 CFR 199.15.
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|
ARTICLE
12
|
|
TERMINATION
AND AMENDMENT
|
|
12.1
|
TERMINATION
OF AGREEMENT BY DHA
|
|
The
Director, DHA, or a designee, may terminate this agreement in accordance
with procedures for termination of institutional providers as specified
in 32 CFR 199.9.
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|
12.2
|
BASIS
FOR TERMINATION OF AGREEMENT BY DHA
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|
(a)
|
In
addition to any authority under the 32 CFR 199.9 to
terminate or exclude a provider, the Director, DHA, or a designee
may terminate this agreement upon 30 days’ written notice, for cause,
if the OTP:
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|
|
(1)
|
Is not in compliance
with the requirements of the Dependents Medical Care Act, as amended
(10 USC 1071 et seq.), the 32 CFR 199, the industry standards for
OTPs, or with performance provisions stated in Article 3 of this
Participation Agreement.
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|
|
(2)
|
Fails to comply
with payment provisions set forth in Article 4 of this Participation Agreement.
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|
|
(3)
|
Fails to allow
audits/reviews and/or to provide records as required by Article
5 of this Participation Agreement.
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|
|
(4)
|
Fails to comply
with nondiscrimination provisions of Article 6 of this Participation Agreement.
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|
|
(5)
|
Changes ownership
as set forth in Article 8 of this Participation Agreement.
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|
|
(6)
|
Fails to provide
incident reports, disaster or emergency reports, or reports of OTP changes
as set forth in Article 9 of this Participation Agreement.
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|
|
(7)
|
Initiates a program
change without written approval by DHA or a designee; program changes
include but are not limited to: changes in the physical location;
population served; number of beds; type of license; expansion of
program(s); or development of new program(s).
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|
|
(8)
|
Does not admit
a beneficiary during any period of 24 months.
|
|
|
(9)
|
Suspends operations
for a period of 120 days or more.
|
|
|
(10)
|
Is determined
to be involved in provider fraud or abuse, as established by 32 CFR 199.9. This includes the submission
of falsified or altered claims or medical records which misrepresent
the type, frequency, or duration of services or supplies.
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|
(b)
|
The
Director, DHA, or designee may terminate this agreement without
prior notice in the event that the OTP’s failure to comply with
the industry standards for OTPs presents an immediate danger to
life, health, or safety.
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|
12.3
|
TERMINATION
OF AGREEMENT BY THE OTP
|
|
The
OTP may terminate this agreement by giving the Director, DHA, or
designee, written notice of such intent to terminate. The effective
date of a voluntary termination under this article shall be 60 days
from the date of notification of intent to terminate or, upon written
request, as agreed between the OTP and DHA.
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|
ARTICLE
13
|
|
RECOUPMENT
|
|
13.1
|
RECOUPMENT
|
|
DHA
shall have the authority to suspend claims processing or seek recoupment
of claims previously paid as specified under the provisions of the
Federal Claims Collection Act (31 USC 3701 et seq.), the Federal
Medical Care Recovery Act (42 USC 2651-2653), and 32 CFR 199.14.
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|
ARTICLE
14
|
|
ORDER
OF PRECEDENCE
|
|
14.1
|
ORDER
OF PRECEDENCE
|
|
If
there is any conflict between this agreement and any Federal statute
or regulation including the 32 CFR 199, the statute or regulation
controls.
|
|
ARTICLE
15
|
|
DURATION
|
|
15.1
|
DURATION
|
|
This
agreement shall remain in effect until the expiration date specified
in Article 17.1 unless terminated earlier by DHA or the OTP under
Article 12. DHA may extend this agreement for 60 days beyond the
established date if necessary to facilitate a new agreement.
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|
15.2
|
REAPPLICATION
|
|
The
OTP must reapply to DHA at least 90 days prior to the expiration
date of this agreement if it wishes to continue as an authorized
OTP. Failure to reapply will result in the automatic termination
of this agreement on the date specified in Article 17.1.
|
|
ARTICLE
16
|
|
EFFECTIVE
DATE
|
|
16.1
|
EFFECTIVE
DATE
|
|
(a)
|
This
Participation Agreement will be effective on the date signed by
the Director, DHA, or a designee.
|
|
(b)
|
This
agreement must be signed by the President, Chief Executive Officer
(CEO), or designee of the OTP.
|
ARTICLE
17
|
|
AUTHORIZED
PROVIDER
|
|
17.1
|
PROVIDER
STATUS
|
|
On
the effective date of the agreement, DHA recognizes the OTP as an
authorized provider for the purpose of providing opioid treatment
to eligible beneficiaries within the framework of the program(s)
identified below.
|