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
(USA) through the Department of Defense (DoD), Defense Health Agency
(hereinafter DHA), an agency of the Office of the Secretary of Defense
(OSD), the administering activity for TRICARE/Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS) (hereinafter DHA) and
___________ __________________________________________, doing business
as ______________________ ____________________________________ (hereinafter
designated the hospice program).
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1.2
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AUTHORITY
FOR HOSPICE CARE
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The
implementing regulations for TRICARE, 32 Code of Federal Regulations
(CFR) Part 199, provides for TRICARE cost-sharing of hospice care
under certain conditions.
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1.3
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INTENT
OF PARTICIPATION AGREEMENT
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It
is the intent of this participation agreement to recognize the undersigned
hospice program as a TRICARE-authorized provider of hospice care,
subject to terms and conditions of this agreement, and applicable
federal law and regulation.
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1.4
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BILLING
NUMBER
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The
number used for billing of all hospice care is the hospice program’s
Employer Identification Number (EIN). This number must be used until
the provider is officially notified by DHA of a change. The hospice
program’s billing number is shown on the face sheet of this agreement.
It is the only billing number that will be accepted by DHA claims
processors after the effective date of this hospice program under
TRICARE.
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Article
2
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Performance
Provisions
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2.1
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GENERAL
AGREEMENT
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The
hospice program agrees to render palliative hospice care to eligible
TRICARE beneficiaries as required by this participation agreement
and the TRICARE regulation (32 CFR 199). The terms and conditions
of 32 CFR 199 applicable to the participation or treatment of TRICARE
beneficiaries by hospice programs are incorporated herein by reference.
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2.2
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COVERAGE/BENEFITS
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(a)
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The
hospice program agrees to provide the care and services set forth
in 32 CFR 199.4(e)(19)(i).
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(b)
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The
hospice program further agrees to provide for such care and services
in individuals’ homes, on an outpatient basis, and on a short-term
inpatient basis, directly or under arrangements made by the hospice
program, except that the agency must:
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(1)
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Routinely
supply a substantial amount of core-services (i.e., nursing services;
physician services; medical social services; and counseling) services
for the TRICARE beneficiary and his or her family ( 32 CFR 199.4(e)(19)(ii)).
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(2)
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Maintain
professional management responsibility of non-core services (i.e.,
home health aide services, medical appliances and supplies, physical
therapy, occupational therapy, speech-language pathology and short-term
inpatient care) which are not directly furnished to the patient,
regardless of the location or facility in which the services are rendered
( 32 CFR 199.4(e)(19)(iii)).
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(3)
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Make
nursing services, physician services, and drugs and biologicals
routinely available on a 24-hour basis. All other covered services
must be available on a 24-hour basis to the extent necessary to
meet the needs of individuals for care that is reasonable and necessary
for palliation and management of the terminal illness and related
condition ( 32 CFR 199.4(e)(19)(iv)).
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(4)
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Provide
assurances that the aggregate number of days of inpatient care provided
in any 12-month period does not exceed 20% of the aggregate number
of days of hospice care during the same period.
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(5)
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Have
an interdisciplinary group (i.e., one physician; one registered
nurse; one social worker; and one pastoral or other counselor) who
provides those services set forth in 32 CFR 199.4(e)(19)(i) and establishes the
policies governing the provision of such services/care.
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(6)
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Maintain
central clinical records on all patients.
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2.3
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CONDITIONS
FOR COVERAGE
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Under
the terms of this agreement, the hospice program shall:
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(a)
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Assure
that there is written certification in the medical records that
the TRICARE beneficiary is terminally ill with a life expectancy
of six months or less if the terminal illness runs its normal course.
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(1)
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For
the initial 90-day period, the hospice must obtain written certification
statements from the individual’s attending physician (if the individual
has an attending physician) and the medical director of the hospice
or the physician member of the hospice interdisciplinary team no
later than two days after the period begins. If written certification
cannot be obtained within two calendar days, then oral certification
must be obtained within two calendar days, followed by written certification
no later than eight calendar days after hospice care is initiated.
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(2)
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Recertification
is required for any subsequent periods (for periods two, three and
four) of hospice care for which the beneficiary is eligible. The
hospice medical director or staff physician will be responsible
for recertifying TRICARE beneficiaries for subsequent election periods.
A written certification must always be in the medical records not
later than two days after hospice care is initiated.
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(b)
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Design
and print its own election statements to include the following information:
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(1)
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identification
of the particular hospice that will provide care to the individual;
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(2)
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individual’s
or representative’s acknowledgment that he or she has been given
a full understanding of hospice care;
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(3)
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individual’s
or representative’s acknowledgment that he or she understands that
certain TRICARE services are waived by the election;
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(4)
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effective
date of election; and
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(5)
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signature
of the individual or representative.
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(c)
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Assure
that an election statement is in the clinical records prior to signing
the Notice of Admission. This includes the admission date, which
must be the same date as the effective date of the hospice election.
The hospice program must notify the contractor of the initiation, change
or revocation of any election.
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(d)
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Establish
a written plan of care on the same day that a member of the basic
interdisciplinary group assesses the patient’s needs. The attending
physician and medical director or physician designee must review
the initial plan of care and provide their input within two calendar
days following the day of the assessment.
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2.4
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CERTIFICATION
REQUIREMENTS
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The
hospice program certifies and attaches hereto documentation that:
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(a)
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it
is Medicare approved and meets all Medicare conditions of participation
(42 CFR 418); and
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(b)
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is
licensed pursuant to any applicable state or local law.
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2.5
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QUALITY
OF CARE
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(a)
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The
hospice program shall assure that any and all eligible beneficiaries
receive hospice services that are reasonable and necessary for the
palliation or management of a terminal illness and meet the conditions
for coverage as established in Article 2.3.
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(b)
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The
hospice program shall provide hospice services in the same manner
to TRICARE beneficiaries as it provides to all patients to whom
it renders services.
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(c)
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The
hospice shall not discriminate against TRICARE beneficiaries in
any manner, including admission practices or provisions of special
or limited treatment.
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2.6
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BILLING
FORM
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(a)
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The
hospice program shall use the Centers for Medicare and Medicaid
Services (CMS) 1450 UB-04 billing form (or subsequent editions.)
Hospice care shall be identified in item 4 of this form.
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(b)
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The
CMS 1450 UB-04 billing form (or subsequent editions) will also be
used as an admission notice. This notice will be used to notify
the contractor of the initiation, change or revocation of an election.
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2.7
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COMPLIANCE
WITH DHA MEDICAL REVIEW ACTIVITIES
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(a)
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Submit
all medical records and documentation to the contractor and, where
applicable, to the Peer Review Organization within 30 days of the
date of their request.
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(b)
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Failure
to submit the requested information will result in denial of the
claim.
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2.8
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STAFF
QUALIFICATIONS
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The
hospice shall comply with requirements for professional staff qualifications
as established in 32 CFR 199.4 and 32 CFR 199.6.
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Article
3
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Payment
Provisions
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3.1
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The
hospice program agrees to accept reimbursement at one of four predetermined
national TRICARE rates ( 32 CFR 199.14(g))
adjusted for regional wage differences using appropriate Medicare
wage indices as payment in full, except for physician-directed patient
services and applicable cost-shares. The hospice will be reimbursed
for an amount applicable to the type and intensity of the services
furnished (i.e., routine home care, continuous home care, inpatient respite
care and general inpatient care) to the TRICARE beneficiary on a
particular day.
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(a)
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One
rate will be paid for each level of care, except for continuous
home care where reimbursement is based on the number of hours of
continuous care furnished on a particular day. The following requirements
must be met in order to receive reimbursement for continuous home
care:
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(1)
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More
than half of the period of continuous care must be provided by either
a registered or licensed practical nurse.
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(2)
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A
minimum of eight hours must be provided during a 24-hour day which
begins and ends at midnight. If less than eight hours of care are
provided within a 24 hour period, the care will be paid at the lower
routine home care rate.
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(b)
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Payment
for inpatient respite care may be for a maximum of 5 days at a time,
including the date of admission but not counting the date of discharge.
Payment for the sixth and any subsequent days is to be made at the
routine home care rate.
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(c)
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The
hospice program agrees to submit all claims as a participating provider.
DHA agrees to make payment of the TRICARE-determined rate directly
to the hospice program for any care authorized under this agreement.
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(d)
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There
may be a reclassification of care from one rate category to another
as a result of medical review of the hospice claims. For example,
if continuous home care is provided to a TRICARE beneficiary whose
condition did not require the level of care described in 32 CFR 199.14 (or did not receive it), payment
is made for the services at the routine home care rate.
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3.2
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Physician
reimbursement is dependent on the physician’s relationship with
both the beneficiary and the hospice program.
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(a)
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Physicians
employed by, or contracted with, the hospice.
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(1)
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Administrative
and supervisory activities (i.e., establishment, review and updating
of plans of care, supervising care and services, and establishing
governing policies) are included in the adjusted national payment
rate.
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(2)
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Direct
patient care services are subject to the appropriate TRICARE allowable
charge methodology and are counted toward the cap limitation.
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(b)
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Independent
attending physician. Patient care services rendered by an independent attending
physician (a physician who is not considered employed by, or under
contract with, the hospice) are not part of the hospice benefit
and may be billed in his/her own right.
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(1)
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Services
are subject to the appropriate allowable charge methodology but
not counted toward the cap limitation.
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(2)
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Services
must be coordinated with any direct care services provided by hospice physicians.
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(3)
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The
hospice must notify the contractor of the name of the physician
whenever the attending physician is not a hospice employee.
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(c)
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No
payments are allowed for physician services furnished voluntarily
(both physicians employed by, and under contract with, the hospice
and independent attending physicians). Physicians may not discriminate
against TRICARE beneficiaries; e.g., designate all services rendered
to non-TRICARE patients as volunteer and at the same time bill for
TRICARE patients.
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3.3
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The
hospice program agrees to the cap and inpatient limitations as prescribed
in 32 CFR 199.14(g)(3).
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(a)
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The
hospice program further agrees to furnish such information as the
contractor deems necessary for calculation and application of the
cap amount and inpatient limitations within 30 days after the end
of the cap period.
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(b)
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Payments
in excess of the cap and/or inpatient limitations must be refunded
by the hospice.
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(c)
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A
hospice may request and obtain a contractor’s review of the calculation
and application of its cap amount and inpatient limitation if the
amount in controversy meets the administrative dollar level established
in 32 CFR 199.14(g)(3). These calculations are
not subject to the appeal procedures set forth in 32 CFR 199.10.
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3.4
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The
hospice program agrees to hold eligible TRICARE beneficiaries harmless
(not to charge the beneficiary) for the following services:
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(a)
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those
for which the provider is entitled to payment from TRICARE;
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(b)
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those
for which the beneficiary would be entitled to have TRICARE payment
made had the provider complied with certain procedural requirements
(e.g., election notification, care plan and submission of requested
records within 30 days);
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(c)
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those
which are not necessary for the palliation or management of the
terminal illness;
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Note: If the patient
is informed that the services are not covered under the TRICARE
hospice benefit and continues to insist that it be performed, he
or she will be liable for payment. The above item only applies to
those services and supplies prescribed by the hospice.
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(d)
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those
for which a beneficiary would be entitled to payment, but for a
reduction or denial in payment as a result of quality review;
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(e)
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those
rendered during a period in which the hospice was not in compliance
with one or more conditions for coverage.
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3.5
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TRICARE
AS SECONDARY PAYOR
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(a)
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The
hospice program is subject to the provisions of 10 USC Section 1079(j)(1).
The hospice program must submit claims first to all other insurance
plans and/or medical service or health plans under which the beneficiary
has coverage before 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 by DHA of this
agreement pursuant to Article 5.
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3.6
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COLLECTION
OF COST-SHARE
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(a)
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The
hospice program agrees to collect from the TRICARE beneficiary only
those amounts applicable to the patient’s cost-share as defined
in 32 CFR 199.14(g)(8).
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(b)
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The
collection of cost-shares by individual hospice programs is optional
under TRICARE. The waiver of cost-sharing will not be considered
fraudulent billing under 32 CFR 199.9.
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3.7
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BENEFICIARY’S
RIGHTS
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If
the hospice program 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 hospice program
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
4
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Records
And Audit Provisions
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4.1
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ON-SITE
AND OFF-SITE REVIEWS/AUDITS
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The
hospice program grants the Director, DHA, or his designee the right
to conduct quality assurance audits or accounting (record) audits
with full access to patients and records. The audits may be conducted
on a scheduled or unscheduled (unannounced) basis. The right to
audit/review includes, but is not limited to:
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(a)
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Examination
of fiscal and all other records of the hospice program which would
confirm compliance with this agreement and designation as an authorized
TRICARE hospice provider.
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(b)
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Audits
of hospice program 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 TRICARE beneficiaries. DHA or a designee shall have
full access to records of both TRICARE and non-TRICARE patients.
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(c)
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Examination
of reports of evaluations and inspections conducted by federal,
state, local government, and private agencies and organizations.
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4.2
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RIGHT
TO UNANNOUNCED INSPECTION OF RECORDS
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(a)
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DHA,
or its designee, shall have the authority to visit and inspect the
hospice program at all reasonable times on an unannounced basis.
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(b)
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The
hospice program’s records shall be available and open for review
by DHA during normal working hours (8am to 5pm, Monday through Friday)
on an unannounced basis.
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4.3
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CERTIFIED
COST REPORTS
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Upon
request, the hospice program shall furnish DHA or a designee audited
cost reports certified by an independent auditing agency.
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4.4
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RECORDS
REQUESTED BY DHA
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Upon
request, the hospice program 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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4.5
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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 6,
and any other appropriate action by DHA.
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Article
5
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General
Accounting Office
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5.1
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RIGHT
TO CONDUCT AUDIT
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The
hospice program grants the United States General Accounting Office
the right to conduct audits.
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Article
6
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Termination
And Amendment
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6.1
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TERMINATION
OF AGREEMENT BY DHA
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(a)
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The
Director, DHA, or designee, may terminate this agreement upon 30
days’ written notice, for cause, if the hospice program is not complying
substantially with the provisions of this agreement or with applicable
provisions set forth in 32 CFR 199. Causes for termination include
violation of patient charging and cost reporting procedures, refusal
to provide required program information or willfully providing false
information, failing to meet the Conditions of Participation, and
administrative remedies involving fraud, abuse, or conflict of interest
as set forth in 32 CFR 199.9.
Such written notice of termination shall be an initial determination
for purposes of the appeal procedures set forth in 32 CFR 199.10.
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Note: The notice provisions
in this article do not limit DHA’s authority to suspend claims processing
or seek recoupment of claims previously paid.
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(b)
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After
termination of the agreement, the hospice program may not file another
agreement to participate unless TRICARE finds that the reason for
termination of the prior agreement has been removed and that there
is reasonable assurance that it will not recur.
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6.2
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TERMINATION
OF AGREEMENT BY THE HOSPICE PROGRAM
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The
hospice program may terminate this agreement by giving the Director,
DHA, or designee, written notice of such intent to terminate at
least six months in advance of the effective date of termination.
If the hospice program permanently or temporarily ceases to furnish
services to the community, the agreement terminates effective with
the date the program goes out of business.
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6.3
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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 proposed amendment(s) except when
necessary to amend this agreement from time to time to incorporate
changes to the TRICARE regulation. When changes or modifications
to this agreement result from changes to the TRICARE regulation
through rulemaking procedures, the Director, DHA, or designee, is
not required to give 120 days written notice. Any such changes to
32 CFR 199 shall automatically be incorporated herein 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
hospice program, not wishing to accept the proposed amendment(s),
including any amendment resulting from changes to the TRICARE regulation
accomplished through rulemaking procedures, may terminate its participation
as provided in this Article. However, if the hospice program’s notice
of intent to terminate its participation is not given at least six months
prior to the effective day of the proposed amendment(s), then the
proposed amendment(s) shall be incorporated into this agreement
for services furnished by the hospice program between the effective
date of the amendment(s) and the effective date of termination of
this agreement.
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Article
7
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Change
Of Ownership
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7.1
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CHANGE
OF OWNERSHIP
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(a)
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When
an organization having a provider agreement undergoes a change of
ownership, the agreement is automatically assigned to the successor
provider.
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(b)
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A
change of ownership occurs whenever there is a transfer of ultimate
responsibility for operational decisions of the institution to a
different governing body; for example:
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(1)
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Where
a sole proprietor transfers title and property to another party;
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(2)
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Where,
in the case of a partnership, the addition, removal, or substitution
of a partner effects a termination of the partnership and creates
a successor partnership or other entity;
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(3)
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Where
an incorporated provider merges with another incorporated institution
not participating in the program, and the nonparticipating institution
is the surviving corporation;
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(4)
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Where
two or more corporate providers consolidate, and such consolidation
results in the creation of a new corporate entity;
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(5)
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Where
an unincorporated provider (a sole proprietorship or partnership)
becomes incorporated; or
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(6)
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The
contractor must be notified in advance of any expected changes in
ownership.
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Article
8
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Appeals
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8.1
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APPEAL
ACTIONS
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Appeal
of DHA actions under this agreement, to the extent they are allowable,
will be pursuant to 32 CFR 199.10.
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Article
9
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Recoupment
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9.1
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RECOUPMENT
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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. Payments
in excess of the cap and/or inpatient limitations are subject to
the provisions as set forth above.
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Article
10
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Nondiscrimination
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10.1
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NONDISCRIMINATION
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The
hospice program agrees to comply with provisions of section 504
of the Rehabilitation Act of 1973 (Public Law 93-112; as amended)
regarding nondiscrimination on the basis of handicap, Title VI of
the Civil Rights Act of 1964 (Public Law 88-352), and with the Americans
With Disabilities Act of 1990 (Public Law 101-336), as well as all
regulations implementing these Acts.
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Article
11
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Order
Of Precedence
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11.1
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ORDER
OF PRECEDENCE
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If
there is any conflict between this agreement and any Federal statute
or Federal regulation, including the TRICARE regulation, 32 CFR
199 and Medicare Conditions of Participation (42 CFR 418), the statute
or regulation controls.
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Article
12
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Duration
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12.1
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DURATION
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The
term of this agreement shall begin on the date this agreement is
signed and shall continue in effect until such time as there is
a voluntary or involuntary termination.
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Article
13
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Effective
Date
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13.1
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DATE
SIGNED
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(a)
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This
participation agreement will be effective on the date signed by
the Director, DHA, or designee.
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(b)
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This
agreement must be signed by the President or Chief Executive Officer
(CEO) of the corporation that owns the hospice program and must
be accompanied by a resolution of the hospice program’s Board of
Directors authorizing the signature.
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Article
14
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AUTHORIZED
PROVIDER
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14.1
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DATE
RECOGNIZED
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On
the effective date of the agreement, DHA recognizes the hospice
program as an authorized provider for purposes of providing hospice
care to TRICARE eligible beneficiaries.
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Hospice
Program
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By:
Signature
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Type
Name and Title
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Corporate
Name
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Executed
on _________________________, ______
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DHA
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By:
Signature
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Type
Name and Title
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Executed
on _________________________, ______
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