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TRICARE Policy Manual 6010.63-M, April 2021
Providers
Chapter 11
Section 2.7
Intensive Outpatient Program (IOP) Standards
Issue Date:  June 13, 2017
Revision:  
1.0  ISSUE
IOP Standards.
2.0  DESCRIPTION
IOP services consist of a comprehensive and complimentary schedule of recognized treatment approaches that may include day, evening, night, and weekend services consisting of individual and group counseling or therapy, and family counseling or therapy as clinically indicated for children and adolescents, or adults aged 18 and over, and may include case management to link patients and their families with community based support systems.
3.0  POLICY
3.1  IOPs must be either a distinct part of an otherwise authorized institutional provider or a freestanding psychiatric or Substance Use Disorder (SUD) IOP. Approval of a hospital by TRICARE is sufficient for its IOP to be an authorized TRICARE provider. Such hospital-based IOPs are not required to be separately authorized by TRICARE.
3.2  Authorization:
3.2.1  Hospital-Based IOPs. When a hospital is a TRICARE authorized provider, the hospital’s IOP also shall be considered a TRICARE authorized provider.
3.2.2  Freestanding IOPs must enter into a participation agreement with the Defense Health Agency (DHA), or designee.
3.3  In addition, in order for a freestanding IOP to be authorized, the IOP shall comply with the following requirements:
3.3.1  The IOP shall be currently accredited by the Joint Commission (TJC), the Commission on Accreditation of Rehabilitation Facilities (CARF), the Council on Accreditation (CoA), or an accrediting organization approved by the DHA. The contractor may submit additional accrediting organizations for TRICARE authorization, subject to approval by the Government Designated Authority (GDA).
3.3.2  The IOP shall be licensed as an IOP to provide IOP services within the applicable jurisdiction in which it operates.
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.
3.3.3  The IOP shall accept the allowable IOP rate, as provided in 32 CFR 199.14(a)(2)(ix)(A)(2), for IOPs and the TRICARE Reimbursement Manual (TRM), Chapter 7, Section 2 and Chapter 13, Section 2 for hospital-based IOPs as payment in full for services provided.
3.3.4  The IOP shall comply with all requirements applicable to institutional providers generally concerning accreditation requirements, concurrent care review, claims processing, beneficiary liability, double coverage, utilization and quality review, and other matters.
3.3.5  The IOP 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 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 IOP. All mental health services must be provided by a TRICARE authorized individual qualified mental health provider. Assessments will include documentation of the outcomes of standardized assessment measures for Post-Traumatic Stress Disorder (PTSD), anxiety disorders, and depressive disorders using the PTSD Checklist (PCL-5), Generalized Anxiety Disorder (GAD-7), and Patient Health Questionnaire (PHQ-9 or A), respectively, at baseline, at 60 calendar day intervals, and at discharge (see Chapter 1, Section 5.1 for details). [Exception: IOPs 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 services within the all-inclusive per diem rate but such individuals must work under the clinical supervision of a fully qualified mental health provider employed by the facility.]
3.3.7  Case management. When appropriate, and with the consent of the person served, the IOP should coordinate the care, treatment, or services, including providing coordinated treatment with other services.
3.3.8  The IOP must enter into a participation agreement with the DHA, or designee. (See Section 12.3 and Addendum G.)
3.3.9  The IOP agrees to notify the referring military provider or Market/Military Medical Treatment Facility (MTF) referral management office (on behalf of a 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.
4.0  EFFECTIVE DATE
October 3, 2016.
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