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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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