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 (USA) through the Department
of Defense (DoD), Defense Health Agency (hereinafter DHA), the administering
activity for TRICARE and ______________________________ (hereinafter
designated the RTC).
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1.2
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AUTHORITY FOR RTC CARE
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The implementing regulations
for the TRICARE, DoD Regulation, 32 Code of Federal Regulations
(CFR), Part 199, provides for TRICARE cost-sharing of RTC 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 RTC as a TRICARE-authorized provider
of RTC care, 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, or designee, may include, but are not limited
to, DHA staff, DoD personnel, and DHA contractors, such as private
sector accounting/audit firm(s) and/or utilization review and survey
forms. 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
RTC services is the RTC’s Employer’s Identification Number (EIN).
In most situations, each EIN must enter into a separate Participation
Agreement with the DHA, or designee. This number must be used until
the provider is officially notified by DHA, or a designee, of a
change. The RTC’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 RTC of a TRICARE beneficiary for the purpose
of occupying a bed with the reasonable expectation that the patient
will remain at least 24 hours, and with the registration and assignment
of an inpatient number or designation.
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(b)
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A discharge occurs at the time
that the RTC formally releases the patient from inpatient status;
or when the patient is admitted to any other inpatient setting (e.g.,
an acute mental or medical hospital).
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(c)
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The day of admission is considered
a day of care for payment purposes; the day of discharge is not.
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2.4
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MENTAL DISORDER
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For this agreement, a mental
disorder shall be the definition in the TRICARE regulation ( 32
CFR 199.2): For the purposes of 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) and billed with the corresponding International
Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM), are not considered diagnosable mental disorders. “Conditions
Not Attributable to a Mental Disorder,” or V codes
( Z codes in the 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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RTC
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As defined in 32 CFR 199.6(b)(4)(vii)(A)(1), an RTC is a
facility or distinct part of a facility that provides to beneficiaries
under 21 years of age a medically supervised, interdisciplinary
program of mental health treatment. An RTC is appropriate for patients
whose predominant symptom presentation is essentially stabilized,
although not resolved, and who have persistent dysfunction in major
life areas. Residential treatment may be complemented by family
therapy and case management for community based resources. Discharge
planning should support transitional care for the patient and family,
to include resources available in the geographic area where the
patient will be residing. The extent and pervasiveness of the patient’s problems
require a protected and highly structured therapeutic environment.
Residential treatment is differentiated from:
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(a)
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Acute psychiatric care which
requires medical treatment and 24-hour availability of a full range
of diagnostic and therapeutic services to establish and implement
an effective plan of care which will reverse life-threatening and/or
severely incapacitating symptoms;
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(b)
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Partial hospitalization, as
defined in 32 CFR 199.2, which provides a less than 24-hour-per-day,
seven-day-per-week treatment program for patients who continue to
exhibit psychiatric problems but can function with support in some
of the major life areas (see TRICARE Policy Manual (TPM), Chapter 11, Addendum F for the Partial Hospitalization
Participation Agreement);
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(c)
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An Intensive Outpatient Program
(IOP), as defined in 32 CFR 199.2,
which serves patients in a day or evening program not requiring
24-hour care for mental health and SUDs (see TPM, Chapter 11, Addendum G for the IOP Participation
Agreement);
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(d)
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A group home, which is a professionally
directed living arrangement with the availability of psychiatric consultation
and treatment for patients with significant family dysfunction and/or
chronic but stable psychiatric disturbances;
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(e)
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Therapeutic school, which is
an educational program supplemented by psychological and psychiatric services;
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(f)
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Facilities that treat patients
with a primary diagnosis of chemical abuse or dependence;
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(g)
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Facilities providing care for
patients with a primary diagnosis of intellectual disability or
developmental disability.
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2.6
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THERAPEUTIC ABSENCE
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A therapeutic absence in the
treatment of a mental disorder involves a patient’s therapeutically
planned absence from the RTC. The patient is not discharged from
the facility and may be away for a period of from several hours
to several days. The purpose of therapeutic absence is to give the
patient an opportunity to test his or her ability to function outside
the inpatient setting before actual discharge. Therapeutic absences involving
overnight stays or longer must be included in the treatment plan
submitted to DHA, or a designee, for review of an inpatient mental
health admission.
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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 RTC agrees to render RTC
services to eligible TRICARE beneficiaries in need of such services,
in accordance with this Participation Agreement and the TRICARE
regulation (32 CFR 199). These services shall include room and board,
patient assessment, psychological testing, treatment services, social services,
educational services, family therapy, and such other services as
are required by the TRICARE regulation (32 CFR 199).
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(b)
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The RTC agrees that all certifications
and information provided to the DHA, or designee, 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 RTC will be ineligible for consideration
for authorized provider status for a two-year period. Termination
of RTC status will be pursuant to Article 13 of this agreement.
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(c)
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The RTC agrees that it shall
not be considered a TRICARE authorized provider nor will any TRICARE benefits
be paid to the facility for any services provided prior to the date
the facility is approved by the Director, DHA, or 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 RTC agrees to limit charges
for services to TRICARE beneficiaries to the rate set forth in this agreement.
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(b)
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The RTC agrees to charge only
for services to TRICARE 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 RTC hereby agrees to:
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(a)
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Be licensed to provide RTC
services within the applicable jurisdiction in which it operates,
if licensure is available.
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(b)
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Be specifically accredited
by and remain in compliance with standards issued by the Joint Commission (TJC),
the Commission on Accreditation of Rehabilitation Facilities (CARF),
the Council on Accreditation (CoA), or an accrediting organization
approved by the DHA. The contractor may submit (via the Government
Designated Authority (GDA)) additional accrediting organizations
for TRICARE authorization, subject to approval by the Director,
DHA).
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(c)
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Accept the TRICARE all-inclusive
per diem rate, as provided in 32 CFR 199.14(f) 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 preauthorization,
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 listed are provided by qualified mental health providers
who meet TRICARE requirements for individual professional providers.
(Exception: RTCs 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
all-inclusive per diem rate but the individual must work under the
documented direct clinical supervision of a fully qualified mental health
provider employed by the RTC). 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 for preauthorization.
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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
to be noncovered by TRICARE. (A general statement signed at admission
relative 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 RTC shall assure that any
and all eligible beneficiaries receive RTC services that comply
with the standards in Article 3.3.
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(b)
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The RTC shall provide RTC services
in the same manner to TRICARE beneficiaries as it provides to all patients
to whom it renders services.
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(c)
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The RTC shall not discriminate
against TRICARE beneficiaries in any manner including admission practices,
placement in special or separate wings or rooms, or provisions of
special or limited treatment.
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3.5
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BILLING FORM
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(a)
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The RTC shall use the Centers
for Medicare and Medicaid Services (CMS) 1450 UB-04 billing form
(or most current subsequent editions).
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(b)
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RTCs shall identify RTC care
on the billing form in the remarks block by stating “RTC care”.
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(c)
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RTCs shall identify on the
billing form those days that patient was absent from the facility.
This includes therapeutic absences as well as unplanned absences.
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(d)
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Charges for geographically
distant family therapy must be billed in the RTC patient’s name
and be authorized by DHA, or designee.
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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 RTC shall:
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(a)
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Appoint a single individual
within the RTC to serve as the point of contact for conducting utilization review
activities with DHA, or its designee. The RTC will inform DHA in
writing of the designated individual.
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(b)
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Obtain preauthorization for
all care to be rendered within the RTC. Failure to obtain preauthorization
will subject the facility to payment reductions according to 32 CFR 199.15(b)(4)(iii).
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(c)
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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
TRICARE beneficiary. Failure to comply with documentation requirements
will result in the denial of authorization of care and/or termination
of provider status.
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(d)
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Maintain and provide medical
records, including progress notes, clinical formulation, and the
master treatment plan, to include documentation of standardized
assessment measures for Post-Traumatic Stress Disorder (PTSD), anxiety
disorders, depressive disorders using the PTSD Checklist (PCL-5), Generalized
Anxiety Disorder (GAD-7), and Patient Health Questionnaire (PHQ-9
or A), respectively, at baseline, at 60 calendar day intervals,
and at discharge (see TPM, Chapter 1, Section 5.1 for details); in compliance
with TRICARE standards and regulations.
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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 a TRICARE-approved RTC, and approved
by the Director, DHA, or designee. The per diem rate will be calculated
according to 32 CFR 199.14(f).
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(a)
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Effective for care on or after
April 1, 1995, the per diem amount shall not exceed a cap of the
70th percentile of all established Federal Fiscal Year (FY) 1994
RTC rates nationally, weighted by total TRICARE days provided at
each rate during the first half of Federal FY 1994, and updated
to FY 1995. For Federal FYs 1996 and 1997, the cap shall remain
unchanged. For Federal fiscal years after FY 1997, the cap shall
be adjusted by the Medicare update factor for hospitals and units
exempt from the Medical Prospective Payment System (PPS).
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(b)
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Subject to the applicable RTC
cap, adjustments to the RTC rates may be made annually.
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(1)
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For Federal fiscal years through
1995, the adjustment shall be based on the Consumer Price Index-Urban
(CPI-U) for medical care as determined applicable by the Director,
DHA, or designee.
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(2)
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For purposes of rates for Federal
FYs 1996 and 1997:
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a
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For any RTC whose 1995 rate
was at or above the thirtieth percentile of all established Federal
FY 1995 RTC rates normally weighted by total TRICARE days provided
at each rate during the first half of Federal FY 1994, that rate
shall remain in effect with no additional update, throughout FYs 1996
and 1997.
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b
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For any RTC whose 1995 rate
was below the 30th percentile level, the rate shall be adjusted
by the lesser of the CPI-U for medical care, or the amount that
brings the rate up to the 30th percentile level.
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(3)
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For subsequent Federal fiscal
years after FY 1997, RTC rates shall be updated by the Medicare
update factor for hospitals and units exempt from the Medicare PPS.
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(c)
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The initial per diem rate under
this agreement is specified in Article 18.1.
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4.2
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RTC SERVICES INCLUDED IN PER
DIEM PAYMENT
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(a)
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DHA determined per diem rate
encompasses the RTC’s daily charge for RTC inpatient care and all
mental health treatment determined necessary and rendered as part
of the treatment plan established for the RTC patient, and accepted
by DHA, or a designee. This includes all individual and group psychotherapy rendered
to the RTC patient, family therapy rendered to the parents of the
RTC patient at or in close proximity to the facility, collateral
visits with individuals other than the RTC patient determined necessary in
order to gather information or implement treatment goals for the
patient, and all other ancillary services provided by the RTC.
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(b)
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The all-inclusive per diem
rate also includes charges for the routine medical management of
a beneficiary while residing in an RTC. Services provided by medical
professionals employed by or contracted with the RTC are part of
the all-inclusive per diem rate and cannot be billed separately.
These routine medical services are made available to all children
entering the facility and are designed to maintain the general health
and welfare of the patient population. Examples of this type of
care are: 1) routine health and physical examinations provided by
RTC medical staff; 2) in-house pharmaceutical services; and 3) other ancillary
medical services routine provided to the RTC population.
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(c)
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The only charges that will
be allowed outside the all-inclusive rate will be for:
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(1)
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Geographically Distant
Family Therapy. Family therapy may be billed individually
from the RTC all-inclusive rate if it is provided to one or both
of the parents residing a minimum of 250 miles from the RTC. Family
therapy must be authorized by DHA, or a designee, at the time the
treatment plan is submitted and approved in order for the cost-sharing
to occur. The RTC may elect to provide family therapy via telemedicine
in accordance with existing TRICARE Telemedicine requirements (see
TPM, Chapter 7, Section 22.1 and the TRICARE Operations
Manual (TOM), Chapter 27).
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(2)
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RTC Education Services. Educational
services will be covered if the sponsor and/or RTC can demonstrate
that the school district in which the TRICARE beneficiary was last
enrolled refuses to pay for the educational component of the child’s
RTC care.
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(3)
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Nonmental Health Services.
Otherwise covered medical services related to a nonmental health condition
(e.g., treatment of broken leg) and rendered by an independent provider
outside the RTC are payable in addition to the all-inclusive per
diem rate.
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4.3
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OTHER PAYMENT REQUIREMENTS
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For care provided on or after
July 1, 1995, TRICARE will not pay for days in which the patient
is absent on leave from the RTC. The RTC must identify these days
when claiming reimbursement.
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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 TRICARE procedures,
the RTC shall be paid on the basis of the allowance of the rate
determined in accordance with the controlling TRICARE regulation
(see Article 4.1) contingent upon certain conditions provided in
the TRICARE regulation, and in particular the following:
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(a)
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The patient seeking admission
is suffering from a mental disorder that meets both the diagnostic
criteria of the current edition of the DSM and the TRICARE definition
of a mental disorder.
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(b)
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The patient seeking admission
does not have a primary diagnosis of SUD including management of withdrawal
symptoms (detoxification).
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(c)
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The patient seeking admission
does not have a primary diagnosis of intellectual disability or developmental
disability.
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(d)
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The patient meets the criteria
for admission to an RTC issued by the Director, DHA, or designee.
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(e)
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The medical and/or psychological
necessity of the patient’s admission is determined by a qualified mental
health professional who meets TRICARE requirements for individual
professional providers, and who is permitted by law and by the facility
to refer patients for admission.
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(f)
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A qualified mental health professional
who meets TRICARE 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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(g)
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All services in 32 CFR 199.4(c)(3)(ix) are provided by or
under the supervision of a TRICARE-authorized mental health provider
(see Article 3.3(e)).
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(h)
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DHA, or a designee, has preauthorized
all care rendered to the patient.
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(i)
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The patient meets eligibility
requirements for TRICARE coverage.
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4.5
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TRICARE-DETERMINED RATE AS
PAYMENT IN FULL
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(a)
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The RTC agrees to accept the
TRICARE rate determined pursuant to the TRICARE regulation (see
Article 4.1) as the total charge for services furnished by the RTC
to TRICARE beneficiaries. The RTC agrees to accept the amount paid
by TRICARE, combined with the cost-share amount and deductible,
if any, paid by or on behalf of the beneficiary, as full payment
for the RTC services. The RTC agrees to make no attempt to collect
from the beneficiary or beneficiary’s family, except as provided
in Article 4.6(a) amounts for RTC services in excess of the TRICARE
rate.
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(b)
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The RTC agrees to submit all
claims as a participating provider. DHA agrees to make payment of
the TRICARE-determined rate directly to the RTC for any care authorized
under this agreement.
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(c)
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The RTC agrees to submit claims
for services provided to TRICARE beneficiaries at least every 30
calendar days (except to the extent a delay is necessitated by efforts
to first collect from other health insurance). If claims are not
submitted at least every 30 calendar days, the RTC agrees not to
bill the beneficiary or the beneficiary’s family for any amounts
disallowed by TRICARE.
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(d)
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The RTC agrees to bill only
the TRICARE-determined rate.
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4.6
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TRICARE AS SECONDARY PAYOR
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(a)
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The RTC is subject to the provisions
of 10 USC, Section 1079(j)(1). The RTC must submit claims first
to all other insurance plans and/or medical service or health plans
under which the beneficiary has coverage before to submitting a
claim to TRICARE.
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(b)
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Failure to collect first from
primary health insurers and/or sponsoring agencies is a violation
of this agreement, may result in the denial or reduction of payment,
and may result in a false claim against the United States (US).
It may also result in termination by DHA of this agreement pursuant
to Article 13.
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4.7
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COLLECTION OF COST-SHARE
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(a)
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The RTC agrees to collect from
the TRICARE beneficiary or the parents or guardian of the TRICARE beneficiary
only those amounts applicable to the patient’s cost-share/copayment,
as defined in 32 CFR 199.4,
and services and supplies that are not a benefit of TRICARE.
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(b)
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The RTC’s failure to collect
or to make diligent effort to collect the beneficiary’s cost-share
as determined by TRICARE policy is a violation of this agreement,
may result in the denial or reduction of payment, and may result
in a false claim against the US. It may also result in termination
by DHA of this agreement pursuant to Article 13 of this agreement.
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4.8
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BENEFICIARY’S RIGHTS
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If the RTC 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 RTC 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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Educational Costs
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5.1
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REIMBURSEMENT OF EDUCATIONAL
SERVICES
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(a)
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All educational costs, whether
they include routine education or special education costs, are excluded from
reimbursement.
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(b)
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In accordance with the TRICARE
regulation 32 CFR 199.14(f)(4)(iii) the only exception
to Article 5.1(a) is when appropriate education is not available
from or not payable by the cognizant public entity. Each case must
be referred to the Director, DHA, or designee, for review and a
determination of the applicability of TRICARE benefits. If the coverage
of educational services meets the exception, payment will be allowed
outside the all-inclusive facility rate. The amount paid shall not
exceed the RTC’s most-favorable rate to any other patient, agency,
or organization for special or general educational services whichever
is appropriate.
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5.2
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EXCLUSION FROM PER DIEM RATE
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The RTC shall exclude costs
for education from its daily rate.
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5.3
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ACCOUNTING REQUIREMENTS
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The RTC’s accounting system
must be adequate to assure TRICARE is not billed for educational
costs.
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Article 6
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Records And Audit Provisions
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6.1
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ON-SITE AND OFF-SITE REVIEWS/AUDITS
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The RTC grants the Director,
DHA, or designee, the right to conduct on-site or off-site reviews
or accounting audits with full access to patients and records. The
reviews or 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 RTC that would confirm compliance with this agreement
and designation as a TRICARE-authorized RTC provider.
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(b)
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Conduct audits of RTC 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 US for services provided to TRICARE beneficiaries.
The Director, DHA, or a designee, will 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 RTC 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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6.2
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RIGHT TO UNANNOUNCED INSPECTION
OF RECORDS
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(a)
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DHA and its authorized agents
will have the authority to visit and inspect the RTC at all reasonable
times on an unannounced basis.
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(b)
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The RTC’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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6.3
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CERTIFIED COST REPORTS
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Upon request, the RTC shall
furnish the Director, DHA, or a designee, with audited cost reports
certified by an independent auditing agency.
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6.4
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RECORDS REQUESTED BY DHA
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Upon request, the RTC shall
furnish the Director, DHA, or a designee, with 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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6.5
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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 the denial or reduction of payment,
termination of this agreement pursuant to Article 13 of this agreement,
and any other appropriate action by DHA.
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Article 7
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Nondiscrimination
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7.1
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NONDISCRIMINATION
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The RTC agrees to comply with
the provisions of section 504 of the Rehabilitation Act of 1973
(Public Law 93-112; as amended) regarding nondiscrimination on the
basis of handicap, and 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 (PPACA) as well as all regulations implementing
these Acts.
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Article 8
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Amendment
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8.1
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AMENDMENT BY DHA
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(a)
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The DHA, or designee, may amend
the terms of this Participation Agreement by giving 120 calendar
days’ notice in writing of the amendment(s) except amendments
to the TRICARE regulation, 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
TRICARE regulation through rulemaking procedures, the Director,
DHA, or designee, is not required to give 120 calendar days written
notice. Amendments to this agreement resulting from amendments to
the TRICARE regulation 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 RTC, if it concludes it
does not wish to accept the proposed amendment(s), including any amendment
resulting from amendment(s) to the TRICARE regulation accomplished
through rulemaking procedures, may terminate its participation as
provided for in Article 13.3. However, if the RTC’s notice of intent
to terminate its participation is not given at least 60 calendar
days before the effective date of the proposed amendment(s), then
the proposed amendment(s) shall be incorporated into this agreement
for RTC care furnished between the effective date of the amendment(s)
and the effective date of termination of this agreement.
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Article 9
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Change Of Ownership
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9.1
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ASSIGNMENT BARRED
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This agreement is nonassignable.
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9.2
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AGREEMENT ENDS
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(a)
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Unless otherwise extended as
specified in Article 9.3(b), this agreement ends as of 12:01 a.m.
on the date following 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 a change of ownership.
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(2)
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The merger of the RTC 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 a change of ownership. The transfer of
corporate stock or the merger of another corporation into the RTC
corporation, however, does not constitute change of ownership. The
transfer of title to property of the RTC corporation to another
corporation(s), and the use of that property for the rendering of RTC
care by the corporation(s) receiving it is a change of ownership.
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(3)
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The lease of all or part of
an RTC or a change in the RTC’s lessee constitutes change of ownership.
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9.3
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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 RTC as specified in Article 9.3(b), then the new owner, in
order to be a TRICARE-authorized RTC, must enter into a new agreement
with DHA. The new owner is immediately 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 RTC contemplating or negotiating
a change of ownership must notify DHA in writing at least 30 calendar
days before the effective date of the change. At the discretion
of the Director, DHA, or designee, this agreement may remain in
effect until a new Participation Agreement can be signed to provide continuity
of coverage for beneficiaries. An RTC that has provided the required
30 calendar days advance written notification of a change of ownership
may seek an extension of this agreement’s effect for a period not
to exceed 180 calendar days from the date of the transfer of ownership.
Failure to provide 30 calendar days’ advance written notification
of a change of ownership will result in a denial of a request for an
extension of this agreement and the termination of this agreement
upon transfer of ownership as specified in Article 9.3(a).
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(c)
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Prior to a transfer of ownership
of an RTC, 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 designee, will review the RTC
to ensure that it is in compliance with TRICARE requirements.
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Article 10
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Reports
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10.1
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INCIDENT REPORTS
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Any serious occurrence involving
a TRICARE beneficiary, outside the normal routine of the RTC (see
the TRICARE Operations Manual (TOM), Chapter 7, Section 6), must be reported to
the referring military providers and/or Market/Military Medical
Treatment Facility (MTF) 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, a patient death, patient disappearances, suicide attempt, incident
of cruel or abusive treatment, physical or sexual abuse, or any
equally dangerous situation involving a TRICARE beneficiary, shall
be reported by telephone on the next business day with a full written
report within seven calendar 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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(d)
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When a TRICARE beneficiary
is absent without leave and is not located within 24 hours, the
incident is reported by telephone to DHA on the next business day.
If the patient is not located within three calendar days, a written
report of the incident is made to DHA within seven calendar days.
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10.2
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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 calendar days to DHA.
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10.3
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REPORTS OF RTC CHANGES
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The governing body or the administrator
of the RTC shall submit a written report to DHA any significant proposed
changes within the RTC no later than 30 calendar days prior to the
actual date of change; failure to report such changes may result
in 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 11
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General Accounting Office (GAO)
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11.1
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RIGHT TO CONDUCT AUDIT
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The RTC grants the US GAO the
right to conduct audits.
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Article 12
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Appeals
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12.1
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APPEAL ACTIONS
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Appeals of DHA actions under
this agreement, to the extent they present an appealable issue and
are allowed under the TRICARE regulation, will be pursuant to 32
CFR 199.10, and 32 CFR 199.15.
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Article 13
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Termination
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13.1
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PROCEDURE FOR TERMINATION OF
THE AGREEMENT BY DHA
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The Director, DHA, or 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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13.2
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BASIS FOR TERMINATION OF THE
AGREEMENT BY DHA
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(a)
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In addition to any authority
under the TRICARE regulation to terminate or exclude a provider,
the Director, DHA, or designee, may terminate this agreement upon
30 calendar days’ written notice, for cause, if the RTC:
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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 TRICARE regulation (32 CFR 199), or with
performance provisions stated in Article 3 of this agreement.
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(2)
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Fails to comply with payment
provisions set forth in Article 4 of this agreement.
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(3)
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Fails to allow audits/reviews
and/or to provide records as required by Article 6 of this agreement.
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(4)
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Fails to comply with nondiscrimination
provisions of Article 7 of this agreement.
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(5)
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Changes ownership as set forth
in Article 9 of this agreement.
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(6)
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Fails to provide incident reports,
disaster or emergency reports, or reports of RTC changes, as set
forth in Article 10 of this agreement.
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(7)
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Initiates a change as specified
in Article 10.3 of this agreement, without written approval by the Director,
DHA, or designee.
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(8)
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Does not admit a TRICARE beneficiary
during any consecutive 24-month period.
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(9)
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Suspends operations for a period
of 120 calendar 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 TRICARE regulation
( 32 CFR 199.9).
This includes the submission of falsified or altered TRICARE 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 RTC’s failure to comply with the industry standards for RTCs
presents an immediate danger to life, health, or safety.
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13.3
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TERMINATION OF AGREEMENT BY
THE RTC
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The RTC 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 calendar days from the date of notification
of intent to terminate, or upon written request, as agreed between
the RTC and DHA.
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Article 14
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Recoupment
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14.1
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RECOUPMENT
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DHA will 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.
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Article 15
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Order Of Precedence
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15.1
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ORDER OF PRECEDENCE
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If there is any conflict between
this agreement and any Federal statute or Federal regulation, including
the TRICARE regulation, 32 CFR 199, the statute or regulation controls.
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Article 16
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Duration
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16.1
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DURATION
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This agreement will remain
in effect until the expiration date specified in Article 18.1 unless
terminated earlier by Director, DHA, or the RTC under Article 13.
DHA may extend this agreement for 60 calendar days beyond the established
date if it is necessary to facilitate a new agreement.
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16.2
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REAPPLICATION
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The RTC must reapply to DHA
at least 90 calendar days prior to the expiration date of this agreement
if it wishes to continue as a TRICARE-authorized RTC. Failure to
reapply will result in automatic expiration of this agreement on
the date specified in Article 18.1.
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Article 17
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|
Effective Date
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17.1
|
EFFECTIVE DATE
|
|
(a)
|
This Participation Agreement
will be effective on the date signed by the Director, DHA, or designee.
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(b)
|
This agreement must be signed
by the Chief Executive Officer (CEO) or designee, of the RTC.
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Article 18
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Authorized Provider
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18.1
|
TRICARE-PROVIDER STATUS
|
|
On the effective date of the
agreement, DHA recognizes the RTC as an authorized provider for
the purpose of providing RTC care to TRICARE-eligible beneficiaries
within the framework of the program(s) identified below.
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