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
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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)
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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)
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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
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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
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13.1
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RECOUPMENT
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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
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ORDER OF PRECEDENCE
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14.1
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ORDER OF PRECEDENCE
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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
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DURATION
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15.1
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DURATION
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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
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REAPPLICATION
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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
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EFFECTIVE DATE
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16.1
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EFFECTIVE DATE
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(a)
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This Participation Agreement
will be effective on the date signed by the Director, DHA, or a designee.
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(b)
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This agreement must be signed
by the President, Chief Executive Officer (CEO), or designee of the
IOP.
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ARTICLE 17
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AUTHORIZED PROVIDER
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17.1
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PROVIDER STATUS
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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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