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In
order to receive payment under TRICARE, ______________________________________________ dba
______________________________________________, as the provider
of services agrees:
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1.
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Not
to charge a beneficiary for the following:
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a.
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Services
for which the provider is entitled to payment from TRICARE;
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b.
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Services
for which the beneficiary would be entitled to have TRICARE payment
made had the provider complied with certain procedural requirements;
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c.
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Services
not medically necessary and appropriate for the clinical management
of the presenting illness, injury, disorder or maternity;
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d.
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Services
for which a beneficiary would be entitled to payment but for a reduction
or denial in payment as a result of quality review; and
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e.
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Services
rendered during a period in which the provider was not in compliance
with one or more conditions of authorization:
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2.
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To
comply with applicable provisions of 32 CFR 199 and related TRICARE
policy;
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3.
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To
accept the TRICARE determined allowable payment combined with the
cost-share, deductible, and other health insurance amounts payable
by, or on behalf of, the beneficiary, as full payment for TRICARE
allowed services;
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4.
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To
collect from the TRICARE beneficiary those amounts that the beneficiary
has a liability to pay for the TRICARE deductible and cost-share/copayment
(this requirement does not apply to a State Vaccine Program or State
Vaccine Program entity (SVP) participation agreement);
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5.
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To
permit access by the Director, DHA, or designee, to the clinical
record of any TRICARE beneficiary, to the financial and organizational
records of the provider, and to reports of evaluations and inspections
conducted by state or private agencies or organizations (this requirement
does not apply to a SVP participation agreement);
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6.
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To
provide to the Director, DHA, or designee (e.g., Contractor), prompt
written notification of the provider’s employment of an individual
who, at any time during the twelve months preceding such employment,
was employed in a managerial, accounting, auditing, or similar capacity
by an agency or organization which is responsible, directly or indirectly,
for decisions regarding Department of Defense payments to the provider;
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7.
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To
cooperate fully with a designated utilization and clinical quality
management organization which has a contract with the Department
of Defense for the geographic area in which the provider renders
services;
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8.
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Comply
with all applicable TRICARE authorization requirements before rendering
designated services or items for which TRICARE cost-share/copayment
may be expected;
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9.
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To
maintain clinical and other records related to individuals for whom
TRICARE payment was made for services rendered by the provider,
or otherwise under arrangement, for a period of 60 months from the
date of service (this requirement does not apply to a SVP participation
agreement);
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10.
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To
maintain contemporaneous clinical records that substantiate the
clinical rationale for each course of treatment, the methods, modalities
or means of treatment, periodic evaluation of the efficacy of treatment,
and the outcome at completion or discontinuation of treatment (this requirement
does not apply to a SVP participation agreement);
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Clinical
records are required to document the outcomes of standardized assessment
measures for PTSD, GAD, and 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); |
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11.
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To
refer TRICARE beneficiaries only to providers with which the referring
provider does not have an economic interest, as defined in 32 CFR 199.2 (this requirement does not apply
to a SVP participation agreement); |
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12.
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To
limit services furnished under arrangement to those for which receipt
of payment by the TRICARE authorized provider discharges the payment
liability of the beneficiary; and
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13.
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Notify
the referring military provider or MTF/eMSM referral management
office (on behalf of the military provider) when a Service member
or beneficiary, in the provider’s clinical judgment, meets any of
the following criteria:
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Harm
to self – The provider believes there is a serious risk of self-harm
by the Service member either as a result of the condition itself
or medical treatment of the condition;
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Harm
to others – There is a serious risk of harm to others either as
a result of the condition itself or medical treatment of the condition.
This includes any disclosures concerning child abuse or domestic
violence;
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Harm
to mission – There is a serious risk of harm to a specific military
operational mission. Such a serious risk may include disorders that
significantly impact impulsivity, insight, reliability, and judgment;
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Inpatient
care – Admitted or discharged from any inpatient mental health or
substance use treatment facility as these are considered critical
points in treatment and support nationally recognized patient safety
standards;
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Acute
medical conditions interfering with duty – Experiencing an acute
mental health condition or is engaged in an acute medical treatment
regimen that impairs the beneficiary’s ability to perform assigned
duties;
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Substance
abuse treatment program – Entered into, or is being discharged from,
a formal outpatient or inpatient treatment program.
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14.
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Meet
such other requirements as the Secretary of Defense may find necessary
in the interest of health and safety of the individuals who are
provided care and services.
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Defense
Health Agency (DHA) agrees to:
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Pay
the above-named provider the full allowable amount less any applicable
double-coverage, cost-share/copayment, and deductible amounts.
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This
agreement shall be binding on the provider and DHA upon acceptance
by the Deputy Director, DHA, or designee.
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This
agreement shall be effective until terminated by either party. The
effective date shall be the date the agreement is signed by DHA
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This
agreement may be terminated by either party by giving the other
party written notice of termination. The provider shall also provide
written notice to the public. Such notice of termination is to be
received by the other party no later than 45 days prior to the date
of termination. In the event of transfer of ownership, this agreement
is assigned to the new owner, subject to the conditions specified
in this agreement and pertinent regulations.
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FOR
PROVIDER OF SERVICES BY:
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FOR
DHA BY:
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_______________________________________
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_______________________________________
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Name
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Name
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_______________________________________
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_______________________________________
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Title
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Date
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Title
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Date
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