3.2 Authorization:
3.2.1 Hospital-Based PHPs. When a
hospital is a TRICARE authorized provider, the hospital’s PHP shall
be considered a TRICARE authorized provider. Separate TRICARE certification
of a hospital-based PHP is no longer required.
3.2.2 Freestanding PHPs must enter
into a participation agreement with the Director, Defense Health
Agency (DHA), or designee.
3.3 In addition,
in order for a freestanding PHP to be authorized, the PHP shall
comply with the following requirements:
3.3.1 The PHP shall be currently
accredited by the Joint Commission (TJC) under the Commission on Accreditation
of Rehabilitation Facilities (CARF), the Council on Accreditation
(CoA), or a DHA-approved accrediting organization. The contractor
may submit additional accrediting organizations for TRICARE authorization,
subject to approval by the Government Designated Authority (GDA).
3.3.2 The PHP shall be licensed as
a PHP to provide PHP services within the applicable jurisdiction
in which it operates.
3.3.3 The PHP shall accept the allowable
PHP rate, as provided in
32 CFR 199.14(a)(2)(ix), for freestanding PHPs
and the TRICARE Reimbursement Manual (TRM),
Chapter 13, Section 2 for hospital-based PHPs
as payment in full for services provided.
3.3.4 The PHP shall comply with all
requirements applicable to institutional providers generally concerning accreditation
requirements, concurrent care review, claims processing, beneficiary
liability, double coverage, utilization and quality review, and
other matters.
3.3.5 The PHP
shall not be considered an authorized provider nor will any benefits
be paid to the facility for any services provided prior to the date
the facility is approved by the DHA, or designee.
3.3.6 All diagnostic and therapeutic
mental health and SUD services must be provided by an authorized mental
health provider. This includes all psychotherapy (individual, group,
family or conjoint, psychoanalysis, collateral), psychological testing
and assessment to include documentation of the outcomes of standardized assessment
measures for Post-Traumatic Stress Disorder (PTSD), anxiety disorders,
and 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
Chapter 1, Section 5.1 for details). [Exception:
PHPs 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 services within the all-inclusive per diem rate but the
individual must work under the clinical supervision of a fully qualified
mental health provider employed by the PHP.] All other program services
shall be provided by trained, licensed staff.
3.3.7 Family Therapy
3.3.7.1 Family therapy is an integral
part of the treatment of children and adolescents and must be included in
their mental health treatment plans. If the family is not in the
area, the child or adolescent patient is probably not a candidate
for partial care as individuals in this program return to their
home setting daily, and effective family interaction is essential.
If the family or patient is not cooperative in participating in
family therapy, they may not be viable candidates for a partial
program. By accepting a child or adolescent under the age of 21
for admission, a partial program is acknowledging that it can provide
the specific treatment appropriate to that individual’s needs and
is responsible for taking only those individuals whom it feels it
can help through the development of an appropriate treatment program
designed to encompass family therapy and maximize the patient’s
ability to function in one or more major life activities. The requirement
for family therapy is not considered met by telephonic therapy or
multifamily group therapy. (See
Chapter 7, Section 3.11.)
3.3.7.2 The contractor may, if family
therapy is clinically contraindicated, grant an exception to this requirement
on a case-by-case basis.
3.3.8 Case Management Services Required
3.3.8.1 The facility must provide case
management services that help assure the patient appropriate living arrangements
after treatment hours, transportation to and from the facility,
arrangement of community based support services, referral of suspected
child abuse to the appropriate state agencies, and effective after
care arrangements, at a minimum.
3.3.8.2 The program case manager must
consult with the primary case manager assigned to the child by either
the contractor or Market/Military Medical Treatment Facility (MTF),
if applicable.
3.3.9 Educational services required.
Programs treating children and adolescents must ensure the provision
of a state certified educational component which assures that patients
do not fall behind in educational placement while receiving partial
hospital treatment. The cost of educational services will not be
funded separately from the per diem rate. The hours devoted to education
do not count toward the therapeutic program.
3.3.10 The PHP shall enter into a
written participation agreement with the DHA, or designee. (See
Section 12.3 and
Addendum F.)
3.3.11 The PHP agrees to notify the
referring provider or Market/MTF referral management office (on
behalf of a military provider) when a Service member or beneficiary,
in the provider’s clinical judgment, meets any of the following
criteria:
• Harm to self - The provider
believes there is a serious risk of self-harm by the Service member
either as a result of the condition itself or medical treatment
of the condition;
• Harm to others - There is a
serious risk of harm to others either as a result of the condition
itself or medical treatment of the condition. This includes any
disclosures concerning child abuse or domestic violence;
• Harm to mission - There is
a serious risk of harm to a specific military operational mission.
Such a serious risk may include disorders that significantly impact
impulsivity, insight, reliability, and judgment;
• Inpatient care - Admitted or
discharged from any inpatient mental health or substance use treatment
facility as these are considered critical points in treatment and
support nationally recognized patient safety standards;
• Acute medical conditions interfering
with duty - Experiencing an acute mental health condition or is
engaged in an acute medical treatment regimen that impairs the beneficiary’s
ability to perform assigned duties;
• Substance abuse treatment program
- Entered into, or is being discharged from, a formal outpatient
or inpatient treatment program.