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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 Comprehensive
Autism Care Demonstration Corporate Services Provider (ACSP)/Sole Provider Participation
Agreement (“Participation Agreement”) is between the United States
of America (USA) through the Defense Health Agency (DHA), an agency
of the Office of the Assistant Secretary of Defense (Health Affairs)
(OASD(HA)) and ____________________________________, doing business
as ________________________________________________ (hereinafter
ACSP/Sole Provider).
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1.2
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AUTHORITY FOR
ACSPs/SOLE PROVIDERS AS TRICARE-AUTHORIZED
PROVIDERS
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The authority
to designate ACSPs/Sole Providers as
authorized TRICARE providers resides with the Department of Defense
(DoD) Demonstration authority under 10 USC 1092. This authority ceases
upon termination of the Comprehensive Autism Care Demonstration
Project (“Demonstration”) as determined by the Director, DHA, or
designee.
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1.3
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PURPOSE OF PARTICIPATION
AGREEMENT
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The purpose
of this Participation Agreement is to:
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(a)
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Establish the
undersigned ACSP/Sole Provider as an
authorized provider of Applied Behavior Analysis (ABA) services;
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(b)
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Establish the
terms and conditions that the undersigned ACSP/Sole
Provider must meet to be an authorized provider under
the Demonstration.
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article 2
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References
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2.1
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REQUIREMENTS
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By reference,
the requirements set forth in the TRICARE Operations Manual (TOM), Chapter 18, Section 4, are incorporated into
this Participation Agreement and shall have the same force and effect
as if fully set out herein. In addition, the provider
must: |
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(a)
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Attend
an annual provider education provided by the TRICARE Managed Care
Support Contractors (MCSCs), Uniformed Services Family Health Plans
(USFHP) Designated Providers (DPs), or the TRICARE overseas contractor.
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(b)
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Incorporate
discharge summaries and planning into every treatment plan. The
provider cannot abruptly stop/terminate services for any reason
to a beneficiary. All discharges or cessation of services require
a minimum of a 30 calendar day transition/discharge plan.
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(c)
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If
the ACSP/Sole Provider terminates services with any beneficiary
for any reason, the ACSP/Sole Provider must notify the contractor
a minimum of 45 calendar days prior to termination.
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2.2
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GENERAL AGREEMENT
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(a)
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The undersigned
ACSP /Sole Provider agrees to render clinically appropriate
ABA services to eligible beneficiaries as specified in the TOM, Chapter 18, Section 4. |
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(b)
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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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(c)
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Signing
of this Participation Agreement attests that the ACSP/Sole Provider
has reviewed and agrees to comply with the requirements set forth
in TOM, Chapter 18, Section 4.
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article 3
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Reimbursement
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3.1
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Claims
for Demonstration services will be submitted electronically on
a Centers for Medicare and Medicaid Services (CMS) 1500 Claim Form
by the ACSP /Sole Provider in accordance
with the TOM, Chapter 18, Section 4. |
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3.2
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The ACSP/Sole
Provider shall:
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(a)
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Submit claims
to the appropriate TRICARE contractor, USFHP DP, or
TRICARE overseas contractor in accordance with the
TOM, Chapter 18, Section 4; and |
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(b)
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Collect the sponsor
cost-share in accordance with TOM, Chapter 18, Section 4; and |
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(c)
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Not bill the
sponsor/beneficiary for:
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(1)
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Services for
which the provider is entitled to TRICARE reimbursement; and
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(2)
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Services
not clinically necessary and appropriate for the clinical management
of the presenting illness, injury, or disorder;
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(3)
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Services
for which a provider would be entitled to payment but for a reduction
or denial in payment as a result of quality review; and
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(4)
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Services that
are denied or recouped due to provider
non-compliance with all applicable requirements in the TOM, Chapter 18, Section 4. |
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article 4
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Records
And Audit Provisions
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4.1
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The
ASCP/Sole Provider grants the Director, DHA [or authorized representative(s)],
the right to conduct on-site or off-site reviews or audits with
full access to patients and records. The audits will 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 ACSP/Sole Provider which would
confirm compliance with this agreement and designation as an authorized
ACSP/Sole Provider under the ACD.
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(b)
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Conduct
audits of ACSP/Sole Provider records including administrative and
clinical 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 TRICARE beneficiaries.
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4.2
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RECORDS
REQUESTED BY DHA
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Upon
request, the ACSP/Sole Provider shall furnish DHA or a designee
such records, including administrative and medical records, that
would allow DHA or a designee to determine the quality and cost-effectiveness
of care rendered.
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4.3
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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 5,
and any other appropriate action by DHA.
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Article 5
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Term, Termination,
And Amendment
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5.1
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TERM
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The term
of this agreement shall begin on the date this agreement is signed
and shall continue in effect until terminated or superseded as specified
herein.
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5.2
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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 written notice,
for cause, if the ACSP /Sole Provider is
found not to be in compliance with the provisions set forth in TOM, Chapter 18, Section 4, or is determined to
be subject to the 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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(b)
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In addition,
the Director, DHA, or designee, may terminate this agreement without
cause by giving the ACSP/Sole Provider written
notice not less than 45 calendar days
prior to the effective date of such termination.
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4.3
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TERMINATION
OF AGREEMENT BY THE ACSP/SOLE PROVIDER
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The ACSP/Sole
Provider may terminate this agreement by giving the
Director, DHA, or designee, written notice not less than 45 calendar days
prior to the effective date of such termination. Effective the date
of termination, the ACSP/Sole Provider will
cease being a TRICARE-authorized provider of Demonstration services.
Subsequent to termination, an ACSP/Sole Provider may
be reinstated as a TRICARE-authorized provider of Demonstration
services only by entering into a new Participation Agreement.
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5.4
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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 calendar 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 TOM, Chapter 18, Section 4 and 32
CFR 199. When changes or modifications to this agreement result
from changes to the 32 CFR 199 through rulemaking procedures, the
Director, DHA, or designee, is not required to give 120 calendar days
written notice. Any such changes to 32 CFR 199 shall automatically
be incorporated herein on the date the regulation amendment is effective. |
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(b)
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An ACSP /Sole
Provider who does not accept the proposed amendment(s),
including any amendment resulting from changes to TOM, Chapter 18, Section 4 and 32
CFR 199 accomplished through rulemaking procedures, may terminate
its participation as provided for in this Article. However, if the
ACSP /Sole Provider notice of intent
to terminate its participation is not given at least 30 calendar days
prior to the effective date of the proposed amendment(s), the proposed
amendment(s) shall be incorporated into this agreement for services
furnished by the ACSP /Sole Provider between
the effective date of the amendment(s) and the effective date of
termination of this agreement. |
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article 6
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Effective Date
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6.1
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DATE SIGNED
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This Participation
Agreement is effective on the date signed by the Director, DHA,
or designee.
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DHA
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ACSP/Sole
Provider
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By: Typed Name
and Title
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By: Typed Name
and Title
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Executed on
_____________________, ______
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