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 Participation
Agreement is between the United States of America through the Department of
Defense (DoD), Defense Health Agency (hereinafter DHA), the administering
activity for TRICARE and __________________________________________
Intensive Outpatient Program (hereinafter designated the IOP).
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1.2
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AUTHORITY FOR
PARTIAL HOSPITAL CARE
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The implementing
regulations for DHA, 32 Code of Federal Regulations (CFR), Part
199, provides for cost-sharing of IOP care under certain conditions.
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1.3
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PURPOSE OF PARTICIPATION
AGREEMENT
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It is the purpose
of this Participation Agreement to recognize the undersigned IOP
as an authorized provider of intensive outpatient care as part of
the IOP Pilot for Psychological Health Sequelae of Sexual Trauma,
subject to the terms and conditions of this agreement, and applicable
federal law and regulation.
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ARTICLE 2
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DEFINITIONS
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2.1
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AUTHORIZED DHA
REPRESENTATIVES
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The authorized
representative(s) of the Director, DHA, may include, but are not
limited to, DHA staff, DoD personnel, and contractors, such as private
sector accounting/audit firm(s) and/or utilization review and survey
firm(s). Authorized representatives will be specifically designated
as such.
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2.2
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BILLING NUMBER
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The billing
number for all IOP services is the IOP’s Employer’s Identification
Number (EIN). In most situations, each EIN must enter into a separate
Participation Agreement with the Director, DHA, or designee. This
number must be used until the provider is officially notified by
DHA or a designee of a change. The IOP’s billing number is shown
on the face sheet of this agreement.
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2.3
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ADMISSION AND
DISCHARGE
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(a)
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An admission
occurs upon the formal acceptance by the IOP of a beneficiary for
the purpose of participating in the therapeutic program with the
registration and assignment of a patient number or designation.
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(b)
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A discharge
occurs at the time that the IOP formally releases the patient from
intensive outpatient status; or when the patient is admitted to
another level of care.
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2.4
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MENTAL DISORDER
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As defined in
the 32 CFR 199.2:
For the purposes of the payment of benefits, a mental disorder is a
nervous or mental condition that involves a clinically significant
behavioral or psychological syndrome or pattern that is associated
with a painful symptom, such as distress, and that impairs a patient’s
ability to function in one or more major life activities. A Substance
Use Disorder (SUD) is a mental condition that involves a maladaptive
pattern of substance use leading to clinically significant impairment
or distress; impaired control over substance use; social impairment;
and risky use of a substance(s). Additionally, the mental disorder
must be one of those conditions listed in the current edition of
the Diagnostic and Statistical Manual of Mental Disorders (DSM).
“Conditions Not Attributable to a Mental Disorder,” or V codes
( Z codes in the International Classification of Diseases,
10th Revision, Clinical Modification (ICD-10-CM)), are not considered
diagnosable mental disorders. Co-occurring mental and substance
use disorders are common and assessment should proceed as soon as
it is possible to distinguish the substance related symptoms from
other independent conditions.
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2.5
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INTENSIVE OUTPATIENT
PROGRAM (IOP)
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As
defined by 32 CFR 199.2(b),
IOP is a treatment setting capable of providing an organized day or
evening program that includes assessment, treatment, case management
and rehabilitation for individuals not requiring 24-hour care for
mental health disorders, to include SUDs, as appropriate for the
individual patient. The program structure is regularly scheduled, individualized
and shares monitoring and support with the patient's family and
support system. Such programs must enter into a Participation Agreement
with TRICARE, and be accredited and in substantial compliance for
IOPs with the Joint Commission (TJC), the Commission on Accreditation
of Rehabilitation Facilities (CARF), the Council on Accreditation
(CoA), or by an accrediting organization approved by the Director,
DHA. The contractor may submit (via the TRICARE Regional Office
(TRO), the TRICARE Overseas Program Office (TOPO), or the Contracting Officer’s
Representative (COR) for the Uniformed Services Family Health Plan
(USFHP)) additional accrediting organizations for TRICARE authorization,
subject to approval by the Director, DHA. IOPs are differentiated
from:
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(a)
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Acute psychoactive
substance use treatment and from treatment of acute biomedical/mental
health problems; which problems are either life-threatening and/or
severely incapacitating and often occur within the context of a
discrete episode of addiction-related biomedical or psychiatric
dysfunction;
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(b)
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A inpatient/residential
Substance Use Disorder Rehabilitation Facility (SUDRF), as defined
in 32 CFR 199.2,
which serves patients with SUDs through an inpatient rehabilitation
program on a 24-hour, seven-day-per week basis (see the TRICARE
Policy Manual (TPM), Chapter 11, Addendum D for the SUDRF Participation
Agreement);
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(c)
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An Partial Hospitalization
Program (PHP), as defined in 32 CFR 199.2,
which serves patients who exhibit emotional/behavioral dysfunction
but who can function in the community for defined periods of time
with support in one or more of the major life areas (see TPM, Chapter 11, Addendum F for the PHP Participation
Agreement);
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(d)
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An Opioid Treatment
Program (OTP), as defined in 32 CFR 199.2,
which serves patients in a treatment setting for opioid treatment
(see TPM, Chapter 11, Addendum H for the OTP Participation
Agreement);
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(e)
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A group home,
sober-living environment, halfway house, or three-quarter way house;
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(f)
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Therapeutic
schools, which are educational programs supplemented by addiction-
focused services;
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(g)
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Facilities that
treat patients with primary psychotic diagnoses other than psychoactive substance
use or dependence;
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(h)
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Facilities that
care for patients with the primary diagnosis of mental retardation
or developmental disability.
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2.6
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SEXUAL TRAUMA
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For
the purposes of this pilot project, sexual trauma is sexual harassment
or sexual assault that has been documented in the member’s medical
record.
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ARTICLE 3
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PERFORMANCE
PROVISIONS
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3.1
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GENERAL AGREEMENT
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(a)
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The IOP
agrees to render IOP services to eligible beneficiaries in need
of such services, in accordance with this Participation Agreement
and the 32 CFR 199. These services shall include patient assessment,
treatment services, case management, and such other services as
are required by the 32 CFR 199.
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(b)
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The IOP
agrees that all certifications and information provided to the Director,
DHA, incident to the process of obtaining and retaining authorized
provider status is accurate and that it has no material errors or
omissions. In the case of any misrepresentations, whether by inaccurate
information being provided or material facts withheld, authorized
provider status will be denied or terminated, and the IOP will be
ineligible for consideration for authorized provider status for
a two-year period. Termination of authorized IOP status will be
pursuant to Article 12 of this agreement.
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(c)
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The IOP
shall not be considered an authorized provider nor will any benefits
be paid to the IOP for any services provided prior to the date the
IOP is approved by the Director, DHA, or a designee as evidenced
by signature on the Participation Agreement.
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3.2
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LIMIT ON RATE
BILLED
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(a)
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The IOP agrees
to limit charges for services to beneficiaries to the rate set forth
in this agreement.
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(b)
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The IOP agrees
to charge only for services to beneficiaries that qualify within
the limits of law, regulation, and this agreement.
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3.3
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ACCREDITATION
AND STANDARDS
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The IOP hereby
agrees to:
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(a)
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Be licensed
to provide IOP services within the applicable jurisdiction in which
it operates.
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(b)
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Be specifically
accredited by and remain in compliance with standards issued for
IOPs by TJC, CARF, CoA, or an accrediting organization approved
by the Director, DHA. The contractor may submit (via the TRO, the
TOPO, or the COR for the USFHP) additional accrediting organizations
for TRICARE authorization, subject to approval by the Director,
DHA.
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(c)
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Accept the allowable
IOP rate, as provided in 32 CFR 199.14(a)(2)(ix), as payment in full
for services provided.
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(d)
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Comply with
all requirements of 32 CFR 199.4 applicable
to institutional providers generally concerning concurrent care
review, claims processing, beneficiary liability, double coverage, utilization
and quality review, and other matters.
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(e)
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Ensure
that all mental health services are provided by qualified mental
health providers who meet the requirements for individual professional
providers. (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 mental health services within
the per diem rate but the individual must work under the direct
clinical supervision of a fully qualified mental health provider
employed by the IOP.) All other program services will be provided
by trained, licensed staff.
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(f)
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Not bill the
beneficiary for services in excess of the cost-share or services
for which payment is disallowed for failure to comply with requirements.
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(g)
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Not bill the
beneficiary for services excluded on the basis of 32 CFR 199.4(g)(1) (not medically or psychologically
necessary), (g)(3) (inappropriate
level of care), or (g)(7) (custodial
care), unless the beneficiary has agreed in writing to pay for the
care, knowing the specific care in question has been determined
as noncovered. (A general statement signed at admission as to financial
liability does not fill this requirement.)
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3.4
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QUALITY OF CARE
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(a)
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The IOP
shall assure that any and all eligible beneficiaries receive intensive
outpatient services which comply with standards in Article 3.3.
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(b)
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The IOP
shall provide intensive outpatient services in the same manner to
beneficiaries as it provides to all patients to whom it renders
services.
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(c)
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The IOP
shall not discriminate against beneficiaries in any manner including
admission practices or provisions of special or limited treatment.
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3.5
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BILLING FORM
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The IOP
shall use the Centers for Medicare and Medicaid Services (CMS) 1450
UB-04 billing form and the CMS 1500 Claim Form for outpatient services
(or subsequent editions). IOPs shall identify IOP care on the billing
form in the remarks block by stating “IOP care.”
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3.6
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COMPLIANCE WITH
DHA UTILIZATION REVIEW ACTIVITIES
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Under
the terms of this agreement, the OIP shall:
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(a)
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Appoint
a single individual within the facility to serve as the point of
contact for conducting utilization review activities with DHA or
its designee. The IOP will inform DHA in writing of the designated
individual.
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(b)
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Promptly
provide medical records and other documentation required in support
of the utilization review process upon request by DHA or its designee.
Confidentiality considerations are not valid reasons for refusal
to submit medical records on any beneficiary. Failure to comply
with documentation requirements will usually result in denial of authorization
of care.
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(c)
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Maintain medical
records, including the clinical formulation, progress notes, and
master treatment plan, to include documentation 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 the TPM, Chapter 1, Section 5.1 for details); in compliance
with TRICARE standards and regulation.
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3.7
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SPECIFIC CONDITIONS
FOR PARTICIPATION IN THE IOP PILOT FOR PSYCHOLOGICAL HEALTH SEQUELAE
OF SEXUAL TRAUMA
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(a)
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he IOP
shall report the following data on each beneficiary enrolled in
the pilot, after removing patient identifying information. These
outcomes shall be measured within seven days of treatment baseline,
within three days of discharge (i.e., post-treatment), three months post-treatment,
six months post-treatment and one year post-treatment. Data collected within
14 days of the scheduled follow-up is within allowance:
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(i)
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PTSD - PCL
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(ii)
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Depression -
PHQ-8
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(iii)
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Alcohol use
- Alcohol Use Disorder Identification Test (AUDIT) or AUDIT-C
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(iv)
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Functioning/Quality
of Life (QOL) - QOL or World Health Organization (WHO) Disability Assessment
Schedule or Veterans’ Rand-12
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(v)
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Brief narrative
of family support/involvement.
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(b)
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The IOP
shall conduct a patient assessment on admission which includes the
assessment of each ADSM accepted by the facility, and must, at a
minimum, consist of a physical examination; psychiatric evaluation
(to include medication evaluation); psychological assessment; assessment
of physiological, biological and cognitive processes; developmental assessment;
family history and assessment; social history and assessment; educational
or vocational history and assessment; environmental assessment;
screening or assessment and recreational/activities assessment.
Screening or assessment of sexual dysfunction shall also be performed.
Assessments conducted within seven days prior to admission to an
IOP may be used if approved by the facility Medical Director, and
deemed adequate to permit treatment planning by the IOP.
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(c)
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A written
treatment discharge summary shall be provided by the participating
IOP to the referring provider within three business days of discharge
or program exit. The treatment summary shall list treatment groups
attended, pre- and post-treatment outcome measures as defined above,
information regarding patient engagement in treatment, and documentation
of any suicidal or homicidal ideation during IOP treatment (along
with any interventions delivered targeting suicidal or homicidal
ideation).
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(d)
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The IOP
shall share clinical and community outreach best practices with
other organizations and institutions participating in the pilot
consistent with NDAA FY 2019, Section 702. Participation is specified
as staff representation at minimally 75% of scheduled meetings and/or
teleconferences related to the pilot (such meetings will occur no
more frequently than monthly), timely responses to requests for
information regarding best practices, and actively identifying and
providing best practice knowledge generated from the IOP to the other
participating partner IOPs.
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ARTICLE 4
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PAYMENT PROVISIONS
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4.1
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RATE STRUCTURE:
DETERMINATION OF RATE
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The TRICARE
rate is the per diem rate that TRICARE will authorize for all mental
health services rendered to a patient and the patient’s family as
part of the total treatment plan submitted by an approved IOP, and
approved by DHA or a designee. The per diem rate will be as specified
in 32 CFR 199.14(a)(2)(ix).
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4.2
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IOP SERVICES
INCLUDED IN PER DIEM PAYMENT
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The
per diem payment amount must be accepted as payment in full for
all institutional services provided, including patient assessment,
treatment services (with the exception of the psychotherapy sessions
which may be allowed separately for individual or family psychotherapy when
provided and billed by an authorized professional provider who is
not employed by or under contract with the IOP), routine nursing
services, psychological testing and assessments, case management
services, overhead and any other services for which the customary
practice among similar providers is included as part of institutional
charges. Non-mental-health-related medical services may be separately
allowed when provided and billed by an authorized independent professional
provider not employed by or under contract with the IOP. This includes ambulance
services when medically necessary for emergency transportation
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4.3
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OTHER PAYMENT
REQUIREMENTS
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No payment is
due for leave days, for days in which treatment is not provided,
or for days on which the patient is absent from treatment (whether
excused or unexcused).
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4.4
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PREREQUISITES
FOR PAYMENT
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Provided
that there shall first have been a submission of claims in accordance
with procedures, the IOP shall be paid based upon the allowance
of the rate determined in accordance with the prevailing 32 CFR 199.14 (see Article 4.1), and contingent
upon certain conditions provided in the 32 CFR 199, and in particular
the following:
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(a)
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The patient
seeking admission is an active duty service member suffering from
a mental disorder which is the sequelae of sexual trauma, which
meets the diagnostic criteria of the current edition of the DSM
and meets the TRICARE definition of a mental disorder.
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(b)
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The patient
meets the criteria for admission to an IOP issued by the Director,
DHA and specified in the TRICARE Operations Manual (TOM), Chapter 18, Section 8.
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(c)
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A qualified
mental health professional who meets requirements for individual
professional providers and who is permitted by law and by the IOP
recommends that the patient be admitted to the IOP.
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(d)
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A qualified
mental health professional with admitting privileges who meets the requirements
for individual professional providers will be responsible for the
development, supervision, implementation, and assessment of a written,
individualized, interdisciplinary clinical formulation and plan
of treatment.
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(e)
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All services
are provided by or under the supervision of an authorized mental
health provider (see Article 3.3(e)).
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(f)
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The patient
meets eligibility requirements for coverage.
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4.5
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DETERMINED RATE
AS PAYMENT IN FULL
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(a)
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The IOP agrees
to accept the rate determined pursuant to the 32 CFR 199.14 (see Article 4.1) as the total
charge for services furnished by the IOP to beneficiaries. The IOP
agrees to accept the rate even if it is less than the billed amount,
and also agrees to accept the amount paid, combined with the cost-share
amount and deductible, if any, paid by or on behalf of the beneficiary,
as full payment for the IOP services. The IOP agrees to make no
attempt to collect from the beneficiary or beneficiary’s family,
except as provided in Article 4.6(a), amounts for IOP services in
excess of the rate.
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(b)
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The IOP agrees
to submit all claims as a participating provider. DHA agrees to
make payment of the determined rate directly to the IOP for any
care authorized under this agreement.
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(c)
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The IOP agrees
to submit claims for services provided to beneficiaries at least
every 30 days (except to the extent delay is necessitated by efforts
to first collect from other health insurance). The IOP agrees not
to bill the active duty service member for any amounts disallowed.
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4.6
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BENEFICIARY
RIGHTS
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If the IOP fails
to abide by the terms of this Participation Agreement and DHA or
its designee either denies the claim or claims and/or terminates
the agreement as a result, the IOP agrees to forego its rights,
if any, to pursue the amounts not paid by TRICARE from the beneficiary
or the beneficiary’s family.
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ARTICLE 5
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RECORDS AND
AUDIT PROVISIONS
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5.1
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ON-SITE AND
OFF-SITE REVIEWS/AUDITS
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The IOP
grants the Director, DHA [or authorized representative(s)], the
right to conduct on-site or off-site reviews or accounting 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 IOP which would confirm compliance
with this agreement and designation as an authorized IOP provider.
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(b)
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Conduct
audits of IOP records including clinical, financial, and census
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 both TRICARE and non-TRICARE
patients. Note: In most cases, only TRICARE patients’ records will
be audited. Examples of situations where non-TRICARE patient records
would be requested may be in situations of differential quality
of care assessments or to identify systemic quality and safety concerns.
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(c)
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Examine reports
of evaluations and inspections conducted by federal, state, local government,
and private agencies and organizations.
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(d)
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Conduct on-site
inspections of the facilities of the IOP and interview employees,
members of the staff, contractors, board members, volunteers, and
patients, as required.
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(e)
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Release copies
of final review reports (including reports of on-site reviews) under
the Freedom of Information Act (FOIA).
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5.2
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RIGHT TO UNANNOUNCED
INSPECTION OF RECORDS
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(a)
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DHA and
its authorized agents shall have the authority to visit and inspect
the IOP at all reasonable times on an unannounced basis.
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(b)
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The IOP’s
records shall be available and open for review by DHA during normal
working hours, from 8 a.m. to 5 p.m., Monday through Friday, on
an unannounced basis.
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5.3
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CERTIFIED COST
REPORTS
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Upon
request, the IOP shall furnish DHA or a designee the audited cost
reports certified by an independent auditing agency.
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5.4
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RECORDS REQUESTED
BY DHA
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Upon
request, the IOP shall furnish DHA or a designee such records, including
medical records and patient census records, that would allow DHA
or a designee to determine the quality and cost-effectiveness of
care rendered.
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5.5
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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 12, and
any other appropriate action by DHA.
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ARTICLE 6
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NONDISCRIMINATION
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6.1
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COMPLIANCE
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The IOP agrees
to comply with provisions of section 504 of the Rehabilitation Act
of 1973 (Public Law 93-112; as amended) regarding nondiscrimination
on basis of handicap, Title VI of the Civil Rights Act of 1964 (Public
Law 88-352), the Americans With Disabilities Act of 1990 (Public
Law 101-336), and section 1557 of the Patient Protection and Affordable
Care Act as well as all regulations implementing these Acts.
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ARTICLE 7
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AMENDMENT
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7.1
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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 days’ notice in writing of the amendment(s) except
amendments to the 32 CFR 199, which shall be considered effective
as of the effective date of the regulation change and do not require
a formal amendment of this agreement to be effective. When changes
or modifications to this agreement result from amendments to the
32 CFR 199 through rulemaking procedures, the Director, DHA, or
designee, is not required to give 120 days’ written notice. Amendments
to this agreement resulting from amendments to the 32 CFR 199 shall
become effective on the date the regulation amendment is effective
or the date this agreement is amended, whichever date is earlier.
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(b)
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The IOP,
if it concludes it does not wish to accept the proposed amendment(s),
including any amendment resulting from amendment(s) to the 32 CFR
199 accomplished through rulemaking procedures, may terminate its
participation as provided for in Article 12.3. However, if the IOP’s
notice of intent to terminate its participation is not given at
least 60 days prior to the effective date of the proposed amendment(s),
then the proposed amendment(s) shall be incorporated into this agreement
for IOP care furnished between the effective date of the amendment(s)
and the effective date of termination of this agreement.
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ARTICLE 8
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TRANSFER OF
OWNERSHIP
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8.1
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ASSIGNMENT BARRED
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This agreement
is nonassignable.
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8.2
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AGREEMENT ENDS
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(a)
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Unless otherwise
extended as specified in Article 8.3(b) this agreement ends as of
12:01 am on the date that transfer of ownership occurs.
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(b)
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Change of ownership
is defined as follows:
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(1)
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The change in
an owner(s) that has/have 50% or more ownership constitutes change
of ownership.
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(2)
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The merger of
the IOP corporation (for-profit or not-for-profit) into another
corporation, or the consolidation of two or more corporations, resulting
in the creation of a new corporation, constitutes change of ownership.
The transfer of corporate stock or the merger of another corporation
into the IOP corporation, however, does not constitute change of
ownership. The transfer of title to property of the IOP corporation
to another corporation(s), and the use of that property for the
rendering of partial hospital care by the corporation(s) receiving
it is essential for a change of ownership.
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(3)
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The lease of
all or part of an IOP or a change in the IOP’s lessee constitutes
change of ownership.
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8.3
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NEW AGREEMENT
REQUIRED
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(a)
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If there is
a change of ownership of an IOP as specified in Article 8.2(b),
then the new owner, in order to be an authorized intensive outpatient
program, must enter into a new agreement with DHA. The new owner
is subject to any existing plan of correction, expiration date, applicable
health and safety standards, ownership and financial interest disclosure requirements
and any other provisions and requirements of this agreement.
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(b)
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An IOP
contemplating or negotiating a change in ownership must notify DHA
in writing at least 30 days prior to the effective date of the change.
At the discretion of the Director, DHA, or a designee, this agreement
may remain in effect until a new Participation Agreement can be
signed to provide continuity of coverage for beneficiaries. An IOP
that has provided the required 30 days’ advance notification of
a change of ownership may seek an extension of this agreement’s
effect for a period not to exceed 180 days from the date of the
transfer of ownership. Failure to provide 30 days’ advance notification
of a change of ownership will result in a denial of a request for
an extension of this agreement and termination of this agreement
upon transfer of ownership as specified in Article 8.2(a).
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(c)
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Prior to
a transfer of ownership of an IOP, the new owners may petition DHA
in writing for a new Participation Agreement. The new owners must
document that all required licenses and accreditations have been
maintained, and must provide documentation regarding any program
changes. Before a new Participation Agreement is executed, the Director,
DHA, or a designee will review the IOP to ensure that it is in compliance
with 32 CFR 199.
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ARTICLE 9
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REPORTS
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9.1
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INCIDENT REPORTS
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Any serious
occurrence involving an active duty service member, outside the
normal routine of the IOP (see the TOM, Chapter 7, Section 4),
shall be reported to the referring military providers and/or Military
Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) referral management
office (on behalf of the military provider), and DHA, and/or a designee,
as follows:
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(a)
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An incident
of a life-threatening accident, patient death, patient disappearance,
suicide attempt, incident of cruel or abusive treatment, or any
equally dangerous situation involving a beneficiary, shall be reported
by telephone on the next business day with a full written report
within seven days.
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(b)
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The incident
and the following report shall be documented in the patient’s clinical
record.
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(c)
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Notification
shall be provided, if appropriate, to the parents, legal guardian,
or legal authorities.
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9.2
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DISASTER OR
EMERGENCY REPORTS
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Any disaster
or emergency situation, natural or man-made, such as fire or severe
weather, shall be reported telephonically within 72 hours, followed
by a comprehensive written report within seven days to DHA.
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9.3
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REPORTS OF OTP
CHANGES
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The governing
body or the administrator of the IOP shall submit in writing to
DHA any proposed significant changes within the IOP no later than
30 days prior to the actual date of change; failure to report such
changes may lead to termination of this agreement. A report shall
be made concerning the following items:
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(a)
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Any change in
administrator or primary professional staff.
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(b)
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Any change in
purpose, philosophy or any addition or deletion of services or programs.
This includes capacity or hours of operation.
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(c)
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Any licensure,
certification, accreditation or approval status change by a state
agency or national organization.
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(d)
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Any anticipated
change in location or anticipated closure.
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(e)
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Any suspension
of operations for 24 hours or more.
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ARTICLE 10
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GENERAL ACCOUNTING
OFFICE
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10.1
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RIGHT TO CONDUCT
AUDIT
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The IOP grants
the United States General Accounting Office (GAO) the right to conduct
audits.
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ARTICLE 11
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APPEALS
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11.1
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APPEAL ACTIONS
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Appeals
of DHA actions under this agreement, to the extent they are allowable,
will be pursuant to the 32 CFR 199.10 and 32 CFR 199.15.
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ARTICLE 12
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TERMINATION
AND AMENDMENT
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12.1
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TERMINATION
OF AGREEMENT BY DHA
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The Director,
DHA, or a designee, may terminate this agreement in accordance with
procedures for termination of institutional providers as specified
in 32 CFR 199.9.
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12.2
|
BASIS FOR TERMINATION
OF AGREEMENT BY DHA
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(a)
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In addition
to any authority under the 32 CFR 199.9 to
terminate or exclude a provider, the Director, DHA, or a designee
may terminate this agreement upon 30 days’ written notice, for cause,
if the IOP:
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(1)
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Is not in compliance
with the requirements of the Dependents Medical Care Act, as amended
(10 USC 1071 et seq.), the 32 CFR 199, or with performance provisions
stated in Article 3 of this Participation Agreement.
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(2)
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Fails to comply
with payment provisions set forth in Article 4 of this Participation Agreement.
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(3)
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Fails to allow
audits/reviews and/or to provide records as required by Article
5 of this Participation Agreement.
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(4)
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Fails to comply
with nondiscrimination provisions of Article 6 of this Participation Agreement.
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(5)
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Changes ownership
as set forth in Article 8 of this Participation Agreement.
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(6)
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Fails to provide
incident reports, disaster or emergency reports, or reports of IOP
changes as set forth in Article 9 of this Participation Agreement.
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(7)
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Initiates a
program change without written approval by DHA or a designee; program changes
include but are not limited to: changes in the physical location;
population served; number of beds; type of license; expansion of
program(s); or development of new program(s).
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(8)
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Does not admit
a beneficiary during any period of 24 months.
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(9)
|
Suspends operations
for a period of 120 days or more.
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(10)
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Is determined
to be involved in provider fraud or abuse, as established by 32 CFR 199.9. This includes the submission
of falsified or altered claims or medical records which misrepresent
the type, frequency, or duration of services or supplies.
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(b)
|
The Director,
DHA, or designee may terminate this agreement without prior notice
in the event that the IOP’s failure to comply with the industry
standards for IOPs presents an immediate danger to life, health,
or safety.
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12.3
|
TERMINATION
OF AGREEMENT BY THE IOP
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|
The IOP
may terminate this agreement by giving the Director, DHA, or designee,
written notice of such intent to terminate. The effective date of
a voluntary termination under this article shall be 60 days from
the date of notification of intent to terminate or, upon written
request, as agreed between the IOP and DHA.
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ARTICLE 13
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|
RECOUPMENT
|
|
13.1
|
RECOUPMENT
|
|
DHA shall
have the authority to suspend claims processing or seek recoupment
of claims previously paid as specified under the provisions of the
Federal Claims Collection Act (31 USC 3701 et seq.), the Federal
Medical Care Recovery Act (42 USC 2651-2653), and 32 CFR 199.14.
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ARTICLE 14
|
|
ORDER OF PRECEDENCE
|
|
14.1
|
ORDER OF PRECEDENCE
|
|
If there is
any conflict between this agreement and any Federal statute or regulation
including the 32 CFR 199, the statute or regulation controls.
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ARTICLE 15
|
|
DURATION
|
|
15.1
|
DURATION
|
|
This
agreement shall remain in effect until August 1, 2021 or the expiration
date specified in Article 17.1 whichever is earlier unless terminated
earlier by DHA or the IOP under Article 12. DHA may extend this
agreement for 60 days beyond the established date if necessary to
facilitate a new agreement.
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15.2
|
REAPPLICATION
|
|
The IOP
must reapply to DHA at least 90 days prior to the expiration date
of this agreement if it wishes to continue as an authorized IOP.
Failure to reapply will result in the automatic termination of this
agreement on the date specified in Article 17.1.
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|
ARTICLE 16
|
|
EFFECTIVE DATE
|
|
16.1
|
EFFECTIVE DATE
|
|
(a)
|
This Participation
Agreement will be effective on the date signed by the Director,
DHA, or a designee.
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(b)
|
This agreement
must be signed by the President, Chief Executive Officer (CEO),
or designee of the IOP.
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ARTICLE 17
|
|
AUTHORIZED PROVIDER
|
|
17.1
|
PROVIDER STATUS
|
|
On the effective
date of the agreement, DHA recognizes the IOP as an authorized provider
for the purpose of providing intensive outpatient care to eligible
beneficiaries within the framework of the program(s) identified
below.
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