3.3 In addition,
in order for a freestanding OTP to be authorized, the OTP shall
comply with the following requirements:
3.3.2 The OTP shall be licensed as an
OTP to provide OTP services within the applicable jurisdiction in
which it operates.
3.3.3 The OTP shall accept the allowable
OTP rate, as provided in
32 CFR 199.14(a)(2)(ix)(A)(2), for OTPs and
the TRICARE Reimbursement Manual (TRM),
Chapter 13, Section 2, paragraph 3.9, for payment
in full for services provided.
Note: Where different
certification, accreditation, or licensing standards exist, the
more exacting standard applies. Regulations take precedence over
standards, and standards take precedence over participation agreements.
3.3.4 The OTP
shall comply with all requirements of this section applicable to
institutional providers generally concerning accreditation requirements,
claims processing, beneficiary liability, double coverage, utilization
and quality review, and other matters.
3.3.5 The OTP shall not be considered
an authorized provider nor will any benefits be paid to the facility
for any services provided prior to the date the facility is approved
and the participation agreement is signed by the Director, DHA,
or designee. Retroactive approval is not given.
3.3.6 All services,
supplies, equipment, and space necessary to fulfill the requirements
of each patient’s individualized diagnosis and treatment plan are
included in the reimbursement approved for an authorized OTPs. All
mental health services must be provided by a TRICARE authorized
individual professional provider of mental health services. Assessments
will include documentation of the outcomes 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). [Exception: OTPs that
employ individuals with degrees in a mental health discipline who
do not meet the licensure, certification, and experience requirements for
a qualified mental health provider but work under the clinical supervision
of a fully qualified mental health provider employed by the facility.]
3.3.7 Case management
services required. Care, treatment, or services should be coordinated among
providers and between settings, independent of whether they are
provided directly by the organization or by an organization or by
an outside source, so that the individual’s needs are addressed in
a seamless, synchronized, and timely manner.
3.3.8 The OTP must
enter into a written participation agreement with the Director,
DHA, or designee. (See
Section 12.3 and
Addendum H.)
3.3.9 The OTP agrees to notify the referring
military provider or Military Treatment Facility (MTF)/Enhanced
Multi-Service Market (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:
• 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;
• 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;
• 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;
• 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;
• 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;
• Substance abuse treatment program - Entered
into, or is being discharged from, a formal outpatient or inpatient
treatment program.