3.3 In
addition, in order for a freestanding OTP to be authorized, the
OTP shall comply with the following requirements:
3.3.2 The
OTP shall be licensed as an OTP to provide OTP services within the
applicable jurisdiction in which it operates.
3.3.3 The OTP shall accept the allowable
OTP rate, as provided in
32 CFR 199.14(a)(2)(ix)(A)(2), for OTPs and
the TRICARE Reimbursement Manual (TRM),
Chapter 13, Section 2, paragraph 3.9, for payment
in full for services provided.
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.
3.3.4 The OTP shall comply with all
requirements of this section applicable to institutional providers
generally concerning accreditation requirements, claims processing,
beneficiary liability, double coverage, utilization and quality
review, and other matters.
3.3.5 The
OTP 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 Director, 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
OTPs. All mental health services must be provided by a TRICARE authorized
individual professional provider of mental health services. Assessments
will include documentation of the outcomes 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 Chapter 1, Section 5.1 for details). [Exception: OTPs that
employ individuals with degrees in a mental health discipline who
do not meet the licensure, certification, and experience requirements for
a qualified mental health provider but work under the clinical supervision
of a fully qualified mental health provider employed by the facility.]
3.3.7 Case management services required.
Care, treatment, or services should be coordinated among providers
and between settings, independent of whether they are provided directly
by the organization or by an organization or by an outside source,
so that the individual’s needs are addressed in a seamless, synchronized,
and timely manner.
3.3.8 The OTP
must enter into a written participation agreement with the Director,
DHA, or designee. (See
Section 12.3 and
Addendum H.)
3.3.9 The OTP
agrees to notify the referring military provider or Military Treatment
Facility (MTF)/Enhanced Multi-Service Market (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:
• 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.