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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 Comprehensive Autism Care
Demonstration Corporate Services Provider (ACSP)/Sole Provider Participation
Agreement (“Participation Agreement”) is between the United States
of America (USA) through the Defense Health Agency (DHA), an agency
of the Office of the Assistant Secretary of Defense (Health Affairs)
(OASD(HA)) and ____________________________________, doing business
as ________________________________________________ (hereinafter
ACSP/Sole Provider).
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1.2
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AUTHORITY FOR ACSPs/SOLE
PROVIDERS AS TRICARE-AUTHORIZED PROVIDERS
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The authority to designate
ACSPs/Sole Providers as authorized
TRICARE providers resides with the Department of Defense (DoD) Demonstration
authority under 10 USC 1092. This authority ceases upon termination
of the Comprehensive Autism Care Demonstration Project (“Demonstration”)
as determined by the Director, DHA, or designee.
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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 ACSP/Sole
Provider as an authorized provider of Applied Behavior Analysis
(ABA) services;
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(b)
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Establish the terms and conditions
that the undersigned ACSP/Sole Provider must
meet to be an authorized provider under the Demonstration.
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article 2
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References
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2.1
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REQUIREMENTS
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By reference, the requirements
set forth in the TRICARE Operations Manual (TOM), Chapter 18, Section 4, are incorporated into
this Participation Agreement and shall have the same force and effect
as if fully set out herein. In addition, the provider
must: |
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(a)
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Attend an annual
provider education provided by the TRICARE Managed Care Support Contractors
(MCSCs), Uniformed Services Family Health Plans (USFHP) Designated
Providers (DPs), or the TRICARE overseas contractor.
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(b)
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Incorporate discharge
summaries and planning into every treatment plan. The provider cannot
abruptly stop/terminate services for any reason to a beneficiary.
All discharges or cessation of services require a minimum of a 30
calendar day transition/discharge plan.
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(c)
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If the ACSP/Sole
Provider terminates services with any beneficiary for any reason,
the ACSP/Sole Provider must notify the contractor a minimum of 45
calendar days prior to termination.
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2.2
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GENERAL AGREEMENT
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(a)
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The undersigned ACSP /Sole
Provider agrees to render clinically appropriate
ABA services to eligible beneficiaries as specified in the TOM, Chapter 18, Section 4. |
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(b)
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Comply with all
applicable TRICARE authorization requirements before rendering designated services
or items for which TRICARE cost-share/copayment may be expected.
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(c)
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Signing of this
Participation Agreement attests that the ACSP/Sole Provider has
reviewed and agrees to comply with the requirements set forth in
TOM, Chapter 18, Section 4.
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article 3
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Reimbursement
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3.1
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Claims for Demonstration services
will be submitted electronically on
a Centers for Medicare and Medicaid Services (CMS) 1500 Claim Form
by the ACSP /Sole Provider in accordance
with the TOM, Chapter 18, Section 4. |
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3.2
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The ACSP/Sole
Provider shall:
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(a)
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Submit claims to the appropriate
TRICARE contractor, USFHP DP, or TRICARE overseas contractor in
accordance with the TOM, Chapter 18, Section 4; and |
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(b)
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Collect the sponsor
cost-share in accordance with TOM, Chapter 18, Section 4; and |
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(c)
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Not bill the sponsor/beneficiary
for:
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(1)
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Services for which the provider
is entitled to TRICARE reimbursement; and
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(2)
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Services not
clinically necessary and appropriate for the clinical management
of the presenting illness, injury, or disorder;
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(3)
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Services for
which a provider would be entitled to payment but for a reduction
or denial in payment as a result of quality review; and
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(4)
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Services that are denied or
recouped due to provider non-compliance with all
applicable requirements in the TOM, Chapter 18, Section 4. |
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article 4
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Records And Audit
Provisions
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4.1
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The ASCP/Sole
Provider grants the Director, DHA [or authorized representative(s)],
the right to conduct on-site or off-site reviews or 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 ACSP/Sole Provider which would confirm compliance
with this agreement and designation as an authorized ACSP/Sole Provider
under the ACD.
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(b)
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Conduct audits
of ACSP/Sole Provider records including administrative and clinical
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 TRICARE beneficiaries.
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4.2
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RECORDS REQUESTED
BY DHA
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Upon request,
the ACSP/Sole Provider shall furnish DHA or a designee such records,
including administrative and medical records, that would allow DHA
or a designee to determine the quality and cost-effectiveness of
care rendered.
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4.3
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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 5, and
any other appropriate action by DHA.
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Article 5
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Term, Termination, And Amendment
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5.1
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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 or superseded as specified herein.
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5.2
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TERMINATION OF AGREEMENT BY
DHA
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(a)
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The Director, DHA, or designee,
may terminate this agreement upon written notice, for cause, if
the ACSP /Sole Provider is found not
to be in compliance with the provisions set forth in TOM, Chapter 18, Section 4, 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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(b)
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In addition, the Director,
DHA, or designee, may terminate this agreement without cause by giving
the ACSP/Sole Provider written notice
not less than 45 calendar days prior
to the effective date of such termination.
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4.3
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TERMINATION OF AGREEMENT BY
THE ACSP/SOLE PROVIDER
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The ACSP/Sole
Provider may terminate this agreement by giving the
Director, DHA, or designee, written notice not less than 45 calendar days
prior to the effective date of such termination. Effective the date
of termination, the ACSP/Sole Provider will
cease being a TRICARE-authorized provider of Demonstration services.
Subsequent to termination, an ACSP/Sole Provider may
be reinstated as a TRICARE-authorized provider of Demonstration
services only by entering into a new Participation Agreement.
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5.4
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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 calendar 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 TOM, Chapter 18, Section 4 and 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 calendar 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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An ACSP /Sole
Provider who does not accept the proposed amendment(s),
including any amendment resulting from changes to TOM, Chapter 18, Section 4 and 32
CFR 199 accomplished through rulemaking procedures, may terminate
its participation as provided for in this Article. However, if the
ACSP /Sole Provider notice of intent
to terminate its participation is not given at least 30 calendar days
prior to the effective date of the proposed amendment(s), the proposed
amendment(s) shall be incorporated into this agreement for services
furnished by the ACSP /Sole Provider between
the effective date of the amendment(s) and the effective date of
termination of this agreement. |
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article 6
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Effective Date
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6.1
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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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ACSP/Sole Provider
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By: Typed Name and Title
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By: Typed Name and Title
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Executed on _____________________,
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