3.2 Authorization:
3.2.1 Hospital-Based
OTPs. When a hospital is a TRICARE authorized provider, the hospital’s
OTP also shall be considered a TRICARE authorized provider.
3.2.2 Freestanding OTPs must enter
into a participation agreement with the Defense Health Agency (DHA), or
designee.
3.3 In addition,
in order for a freestanding OTP to be authorized, the OTP shall
comply with the following requirements:
3.3.2 The OTP
shall be licensed as an OTP to provide OTP services within the applicable
jurisdiction in which it operates.
3.3.3 The OTP
shall accept the allowable OTP rate, as provided in
32 CFR 199.14(a)(2)(ix)(A)(2), for OTPs and the
TRICARE Reimbursement Manual (TRM),
Chapter 13, Section 2, for payment in full
for services provided.
Note: Where different certification,
accreditation, or licensing standards exist, the more exacting standard applies.
Regulations take precedence over standards, and standards take precedence
over participation agreements.
3.3.4 The OTP
shall comply with all requirements of this section applicable to
institutional providers generally concerning accreditation requirements,
claims processing, beneficiary liability, double coverage, utilization
and quality review, and other matters.
3.3.5 The OTP
shall not be considered an authorized provider nor will any benefits
be paid to the facility for any services provided prior to the date
the facility is approved and the participation agreement is signed
by the Director, DHA, or designee. Retroactive approval is not given.
3.3.6 All services, supplies, equipment,
and space necessary to fulfill the requirements of each patient’s individualized
diagnosis and treatment plan are included in the reimbursement approved
for an authorized OTPs. All mental health services must be provided
by a TRICARE authorized individual professional provider of mental health
services. Assessments will include documentation of the outcomes
of standardized assessment measures for Post-Traumatic Stress Disorder
(PTSD), 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:
OTPs that employ individuals with degrees in a mental health discipline
who do not meet the licensure, certification, and experience requirements
for a qualified mental health provider but work under the clinical
supervision of a fully qualified mental health provider employed
by the facility.]
3.3.7 Case management
services required. Care, treatment, or services should be coordinated
among providers and between settings, independent of whether they
are provided directly by the organization or by an organization
or by an outside source, so that the individual’s needs are addressed
in a seamless, synchronized, and timely manner.
3.3.8 The OTP must enter into a written
participation agreement with the DHA, or designee. (See
Section 12.3 and
Addendum H.)
3.3.9 The OTP agrees to notify the
referring military provider or Market/Military Medical Treatment
Facility (MTF) referral management office (on behalf of the military
provider) when a Service member or beneficiary, in the provider’s
clinical judgment, meets any of the following criteria:
• Harm to self - The provider
believes there is a serious risk of self-harm by the Service member
either as a result of the condition itself or medical treatment
of the condition;
• Harm to others - There is a
serious risk of harm to others either as a result of the condition
itself or medical treatment of the condition. This includes any
disclosures concerning child abuse or domestic violence;
• Harm to mission - There is
a serious risk of harm to a specific military operational mission.
Such a serious risk may include disorders that significantly impact
impulsivity, insight, reliability, and judgment;
• Inpatient care - Admitted or
discharged from any inpatient mental health or substance use treatment
facility as these are considered critical points in treatment and
support nationally recognized patient safety standards;
• Acute medical conditions interfering
with duty - Experiencing an acute mental health condition or is
engaged in an acute medical treatment regimen that impairs the beneficiary’s
ability to perform assigned duties;
• Substance abuse treatment program
- Entered into, or is being discharged from, a formal outpatient
or inpatient treatment program.