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 (DHA) (hereinafter DHA), an
agency of the Office of the Secretary of Defense (OASD), the administering
activity for the Defense Health Agency (hereinafter DHA) and ______________________________________________,
doing business as ______________________________________________
(hereinafter designated certified marriage and family therapist).
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1.2
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AUTHORITY FOR CERTIFIED MARRIAGE
AND FAMILY THERAPISTS AS AUTHORIZED PROVIDERS
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32 Code of Federal Regulations
(CFR) Part 199 provides for cost-sharing of services provided by certified
marriage and family therapists under certain conditions.
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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 certified
marriage and family therapist as an authorized provider of mental
health services;
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(b)
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Establish the terms and conditions
that the undersigned certified marriage and family therapist must
meet.
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1.4
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BILLING NUMBER
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The certified marriage and
family therapists’ billing number for all mental health services rendered
is the certified marriage and family therapist’s Social Security
Number (SSN) or Employer’s Identification Number (EIN) or National
Provider Identifier (NPI). This billing number must be used until
the provider is officially notified by TRICARE of a change. The
certified marriage and family therapist’s number is shown on the
face sheet of this agreement. It is the only billing number that
will be accepted by TRICARE claims processors after the effective
date of this agreement for becoming an authorized certified marriage
and family therapist.
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article 2
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Performance Provisions
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2.1
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GENERAL AGREEMENT
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The certified marriage and
family therapist agrees to render medically necessary and appropriate covered
mental health services within the scope of his/her practice and
licensure to eligible beneficiaries as required by this participation
agreement and the 32 CFR 199.6.
The terms and conditions of 32 CFR 199.6 applicable
to the participation or treatment of beneficiaries by the certified
marriage and family therapist are incorporated herein by reference.
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2.2
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LICENSURE AND CERTIFICATION
REQUIREMENTS
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The certified marriage and
family therapist certifies and attaches hereto documentation that:
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(a)
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He/she is now licensed or certified
to practice as a marriage and family therapist by the state in which
practicing; or
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(b)
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If practicing in a state which
does not provide specific licensure or certification, the certified marriage
and family therapist must be certified by or be eligible for full
clinical membership in the American Association for Marriage and
Family Therapy; and
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(c)
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He/she has a recognized graduate
professional education with a minimum of an earned master’s degree
from a accredited educational institution in an appropriate behavioral science
field, mental health discipline; and
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(d)
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He/she has the following experience:
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(1)
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Either 200 hours of approved
supervision in the practice of marriage and family counseling, ordinarily
to be completed in a two- to three-year period, of which at least 100
hours must be in individual supervision. This supervision will occur
preferably with more than one supervisor and should include a continuous
process of supervision with at least three cases; and
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(2)
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1,000 hours of clinical experience
in the practice of marriage and family counseling under approved
supervision, involving at least 50 different cases; or
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(3)
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150 hours of approved supervision
in the practice of psychotherapy, ordinarily to be completed in
a two- to three-year period, of which at least 50 hours must be
individual supervision; plus at least 50 hours of approved individual
supervision in the practice of marriage and family counseling, ordinarily
to be completed within a period of not less than one nor more that
two years; and
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(4)
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750 hours of clinical experience
in the practice of psychotherapy under approved supervision involving
at least 30 cases; plus at least 250 hours of clinical practice
in marriage and family counseling under approved supervision, involving
at least 20 cases.
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2.3
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The certified marriage and
family therapist agrees that, having an exclusive election to participate
as certified marriage and family therapist, he or she will not be
authorized in any other category of extramedical provider, either
during or subsequent to the period this agreement is in effect.
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article 3
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Payment Provisions
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3.1
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DETERMINED ALLOWABLE CHARGE
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The determined allowable charge
is the maximum amount that can be authorized for services rendered
by an authorized individual professional provider of care. The determined
allowable charge is determined following the provisions set forth
in 32 CFR 199.14.
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3.2
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DETERMINED ALLOWABLE CHARGE
AS PAYMENT IN FULL
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The certified marriage and
family therapist agrees to accept the determined allowable charge
as payment in full for services rendered to beneficiaries, except
for applicable deductible and cost-shares.
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3.3
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HOLD HARMLESS
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The certified marriage and
family therapist agrees to hold eligible beneficiaries harmless
for non-covered care (i.e., certified marriage and family therapist
may not bill a beneficiary for non-covered care and may not balance
bill the beneficiary for amounts above the determined allowable
charge).
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article 4
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Term, Termination, And Amendment
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4.1
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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 by either party.
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4.2
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TERMINATION OF AGREEMENT BY
DHA
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The Director, DHA, or designee,
may terminate this agreement upon written notice, for cause, if the
certified marriage and family therapist is found not to be in compliance
with the provisions set forth in 32 CFR 199.6,
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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4.3
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TERMINATION OF AGREEMENT BY
THE CERTIFIED MARRIAGE AND FAMILY THERAPIST
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The certified marriage and
family therapist may terminate this agreement by giving the Director, DHA,
or designee, written notice of such intent to terminate at least
60 days in advance of the effective date of termination. Effective
the date of termination, the certified marriage and family therapist
will no longer be recognized as an authorized provider, and reinstatement
shall be disallowed for any other category of extramedical individual
provider. Subsequent to termination, the certified marriage and
family therapist may only be reinstated as an authorized extramedical
provider by entering into a new participation agreement as a certified
marriage and family therapist.
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4.4
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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
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 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 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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The certified marriage and
family therapist, not wishing to accept the proposed amendment(s),
including any amendment resulting from changes to the 32 CFR 199 accomplished
through rulemaking procedures, may terminate his or her participation
as provided for in this Article. However, if the certified marriage
and family therapist notice of intent to terminate 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 services furnished by the certified marriage
and family therapist between the effective date of the amendment(s)
and the effective date of termination of this agreement.
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article 5
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EFFECTIVE DATE
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5.1
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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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Certified Marriage and Family
Therapist
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By: Typed Name and Title
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By: Typed Name and Title
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Name and Title
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Name and Title
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Executed on _____________________,
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