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TRICARE Policy Manual 6010.63-M, April 2021
Providers
Chapter 11
Section 2.8
Opioid Treatment Program (OTP) Standards
Issue Date:  June 13, 2017
Revision:  
1.0  Issue
OTP Standards.
2.0  DESCRIPTION
OTPs are service settings for opioid treatment, either free standing or hospital based, that adhere to the Department of Health and Human Services’ (DHHS’) regulations at 42 CFR Part 8 and use medications indicated and approved by the Food and Drug Administration (FDA). Treatment in OTPs provides a comprehensive, individually tailored program of medication therapy integrated with psychosocial and medical treatment and support services that address factors affecting each patient, as certified by the Center for Substance Abuse Treatment (CSAT) of the DHHS’ Substance Abuse and Mental Health Services Administration (SAMHSA). Treatment in OTPs can include management of withdrawal symptoms (detoxification) from opioids and medically supervised withdrawal from maintenance medications. Patients receiving care for substance use and co-occurring disorders care can be referred to, or otherwise concurrently enrolled in, OTPs.
3.0  POLICY
3.1  OTPs must be either a distinct part of an otherwise authorized institutional provider or a free-standing program. Approval of hospitals by TRICARE is sufficient for their OTPs to be authorized TRICARE providers. Such hospital-based OTPs, if certified under 42 CFR Part 8, are not required to be separately authorized by TRICARE.
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:
3.3.1  The OTP shall be currently accredited by a SAMHSA recognized state-certified program. (See: http://dpt2.samhsa.gov/treatment/directory.aspx for the SAMHSA directory of OTPs.)
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.
4.0  EFFECTIVE DATE
October 3, 2016.
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