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 the TRICARE and ______________________________ (hereinafter
designated the SUDRF).
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1.2
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AUTHORITY FOR INPATIENT/RESIDENTIAL
SUDRF CARE
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The implementing regulation
for the TRICARE, 32 Code of Federal Regulations (CFR), Part 199,
provides for TRICARE cost-sharing of care in inpatient/residential
SUDRFs 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 SUDRF as a TRICARE-authorized
provider of inpatient/residential SUDRFs 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
firm(s). 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
substance use treatment is the SUDRF’s Employer’s Identification
Number (EIN). In most situations, each EIN must enter into a separate
Participation Agreement with the Director, DHA, or designee. This
number must be used until the provider is officially notified by
Director, DHA, or a designee, of a change. The SUDRF’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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For inpatient services, an
admission occurs upon the formal acceptance by the SUDRF 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. A discharge
occurs at the time that the SUDRF 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. For
inpatient services, 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 purpose 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). “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 SUDs 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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SUDRF
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As defined in 32
CFR 199.6, SUDRFs are defined as free-standing facilities
or hospital-based units that provide treatment of SUDs. SUDRFs can
provide substance use treatment through inpatient rehabilitation
programs on a 24-hour, seven-day-per week basis; through partial
hospitalization in day, evening, or weekend programs. SUDRFs are
differentiated from:
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(a)
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Acute psychoactive substance
use treatment and from treatment of acute biomedical/mental health problems;
which problems are either life-threatening and/or severely incapacitating
and often occur within the context of a discrete episode of addiction-related
biomedical or psychiatric dysfunction;
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(b)
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A Partial Hospitalization Program
(PHP), as defined in 32 CFR 199.2,
which serves patients who exhibit emotional/behavioral dysfunction
but who can function in the community for defined periods of time with
support in one or more of the major life areas (see the TRICARE
Policy Manual (TPM), Chapter 11, Addendum F for the PHP 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 or SUD (see TPM, Chapter 11, Addendum G for the IOP Participation
Agreement);
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(d)
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An Opioid Treatment Program
(OTP), as defined in 32 CFR 199.2,
which serves patients in a treatment setting for opioid treatment
(see TPM, Chapter 11, Addendum H for the OTP Participation
Agreement);
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(e)
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A group home, sober-living
environment, halfway house, or three-quarter way house;
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(f)
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Therapeutic schools, which
are educational programs supplemented by addiction-focused services;
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(g)
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Facilities that treat patients
with primary psychotic diagnoses other than psychoactive substance
use or dependence;
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(h)
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Facilities that care for patients
with the primary diagnosis of intellectual disability or developmental disability.
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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 SUDRF agrees to render
treatment of SUDs 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 board,
routine nursing services, ancillary services, patient assessment,
psychological testing, case management, and all mental health treatment
determined necessary and consistent with the treatment plan established
for the SUDRF patient, and accepted by Director, DHA, or designee.
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(b)
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The SUDRF agrees that all certifications
and information provided to the Director, 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 SUDRF will be ineligible for
consideration for authorized provider status for a two year period. Termination
of SUDRF status will be pursuant to Article 12 of this agreement.
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(c)
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On October 1, 1995, the SUDRF
will not be considered to be a TRICARE-authorized provider nor will
any TRICARE benefits be paid to the facility for any services until
the date the Participation Agreement is signed by the Director,
DHA, or designee.
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3.2
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LIMIT ON RATE BILLED
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(a)
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The SUDRF agrees to limit charges
to the rates set forth in this agreement.
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(b)
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The SUDRF agrees to charge
only for services to TRICARE beneficiaries that qualify within the
limits of law and regulation, including but not limited to the requirements
that the care be medically or psychologically necessary as defined
by DHA, and all terms of this agreement.
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3.3
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ACCREDITATION AND STANDARDS
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The SUDRF hereby agrees to:
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(a)
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Be licensed to provide substance
use treatment 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),
Commission on Accreditation of Rehabilitation Facilities (CARF),
the Council on Accreditation (CoA), or an accrediting organization
approved by the Director, DHA. The contractor may submit (via the Government
Designated Authority (GDA)) additional organizations for TRICARE
authorization.
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(c)
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Accept the TRICARE-determined
rate, as provided in 32 CFR 199.14(a)(1)(ii)(F) for inpatient services,
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 any individual,
group, or family psychotherapy, or psychological testing and assessment,
is provided by a qualified mental health provider who meets TRICARE
requirements for individual professional providers. (Exception:
SUDRFs 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 direct clinical supervision
of a fully qualified mental health provider employed by the SUDRF).
All other program services will be provided by trained, licensed
staff.
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(f)
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Ensure the provision of individual,
group, and family psychotherapy and addiction counseling services that
are consistent with each patient’s treatment plan.
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(g)
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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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(h)
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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 had 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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(i)
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Prior to initiation of this
agreement, and annually thereafter, conduct a self-assessment of
its compliance with the TRICARE/CHAMPUS Standards for Inpatient
Rehabilitation and Partial Hospitalization for the Treatment of
SUDs as issued by the Director, DHA, or designee, and notify the
Director, DHA, or designee, of any matter in which the facility
is not in compliance with such standards.
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3.4
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QUALITY OF CARE
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(a)
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The SUDRF shall assure that
any and all eligible beneficiaries receive substance use treatment
that complies with the standards in Article 3.3.
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(b)
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The SUDRF shall provide substance
use treatment 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 SUDRF 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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The SUDRF shall use the Centers
for Medicare and Medicaid Services (CMS) 1450 UB-04 billing form
(or subsequent editions) for inpatient services, and the CMS 1500
Claim Form for outpatient services. The SUDRF shall identify SUDRF
care on the billing form in the remarks block by stating “SUDRF
care”.
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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 SUDRF shall:
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(a)
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Appoint a single individual
within the facility to serve as the point of contact for conducting
utilization review activities with Director, DHA, or its designee.
The SUDRF will inform DHA in writing of the designated individual.
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(b)
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Obtain preauthorization for
all inpatient services to be rendered to TRICARE beneficiaries within
the facility.
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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 Director, 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 usually result in the denial of authorization
of care.
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(d)
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Maintain and provide medical
records, including the clinical formulation, progress notes, and
master treatment plan, to include documentation 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 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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As specified in 32 CFR 199.14(a)(1)(ii)(F), effective for
admissions on or after July 1, 1995, SUDRFs are subject to the Diagnosis-Related-Group-based
(DRG-based) payment system for inpatient rehabilitation services.
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4.2
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INPATIENT SUDRF SERVICES INCLUDED
IN DRG PAYMENT
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All normally covered inpatient
services furnished to TRICARE beneficiaries by hospitals are subject
to the TRICARE DRG-based payment system. For inpatient rehabilitation
care, professional services are reimbursed separately according
to 32 CFR 199.14(a)(4).
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4.3
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OTHER PAYMENT REQUIREMENTS
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No payment is due for leave
days, for days on which treatment is not provided, or for days on
which the patient is absent from treatment (whether excused or unexcused).
The SUDRF must identify those 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 SUDRF 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, to include SUD 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 meets the criteria
for admission to an SUDRF issued by the Director, DHA, or designee.
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(c)
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The medical and/or psychological
necessity of the patient’s admission is determined by a qualified mental
health provider who meets TRICARE requirements as an individual
professional provider, and who is permitted by law and by the facility
to refer patients for admission.
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(d)
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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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(e)
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All individual, group, or family
psychotherapy, and psychological testing and assessment are provided
by or under the supervision of a qualified mental health provider
who meets TRICARE requirements as an individual professional provider
(see Article 3.3(h) above).
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(f)
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Director, DHA, or a designee,
has preauthorized all inpatient or residential care rendered to
the patient.
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(g)
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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 SUDRF 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 SUDRF
to TRICARE beneficiaries. The SUDRF agrees to accept the TRICARE
rate even if it is less than the billed amount, and also 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 SUDRF services. The SUDRF agrees to make
no attempt to collect from the beneficiary or beneficiary’s family,
except as provided in Article 4.5(a), amounts for SUDRF services
in excess of the TRICARE rate.
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(b)
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The SUDRF agrees to submit
all claims as a participating provider. DHA agrees to make payment
of the TRICARE-determined rate directly to the SUDRF for any care
authorized under this agreement.
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(c)
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The SUDRF 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 (OHI)). If
claims are not submitted at least every 30 calendar days, the SUDRF
agrees not to bill the beneficiary or the beneficiary’s family for
any amounts disallowed by TRICARE.
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4.6
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TRICARE AS SECONDARY PAYOR
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(a)
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The SUDRF is subject to the
provisions of 10 United States Code (USC), Section 1079(j)(1). The
SUDRF 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 12.
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4.7
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COLLECTION OF COST-SHARE
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(a)
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The SUDRF agrees to collect
from the TRICARE beneficiary or the parents or guardian of the TRICARE beneficiary
only those amounts applicable to the patient’s deductible and/or
cost-share, 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 SUDRF’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 12 of this agreement.
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4.8
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BENEFICIARY’S RIGHTS
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If the SUDRF fails to abide
by the terms of this Participation Agreement and Director, DHA,
or its designee, either denies the claim or claims and/or terminates
the agreement as a result, the SUDRF 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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Records And Audit Provisions
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5.1
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ON-SITE AND OFF-SITE REVIEWS/AUDITS
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The SUDRF 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
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 SUDRF that would confirm compliance with this agreement and
designation as a TRICARE-authorized provider.
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(b)
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Conduct audits of SUDRF 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.
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 or 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 SUDRF and interviewing 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 if requested under the Freedom of Information Act.
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5.2
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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 SUDRF at all reasonable times
on an unannounced basis.
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(b)
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The SUDRF’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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5.3
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CERTIFIED COST REPORTS
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Upon request, the SUDRF shall
furnish Director, DHA, or a designee, the audited cost reports certified
by an independent auditing agency.
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5.4
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RECORDS REQUESTED BY DHA
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Upon request, the SUDRF shall
furnish Director, DHA, or a designee, with such records, including
medical records and patient census records, that would allow Director,
DHA, or a designee, to determine the quality and cost-effectiveness
of care rendered.
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5.5
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FORMS
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Upon the provider’s completion
of this participation agreement and the DHA Form 771, the contractor
shall submit the information to the TRICARE Quality Monitoring Contractor
(TQMC).
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5.6
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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 12, and any other
appropriate action by DHA.
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Article 6
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Nondiscrimination
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6.1
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NONDISCRIMINATION
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The SUDRF 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 7
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Amendment
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7.1
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AMENDMENT BY DHA
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(a)
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The Director, DHA, or designee,
or may amend the terms of this Participation Agreement by giving
120 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 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 SUDRF, 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 12.3. However, if the SUDRF’s notice of
intent to terminate its participation is not given at least 60 days
before the effective date of the proposed amendment(s), then the
proposed amendment(s) shall be incorporated into this agreement
for SUDRF care furnished between the effective date of the amendment(s)
and the effective date of termination of this agreement.
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Article 8
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Change Of Ownership
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8.1
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ASSIGNMENT BARRED
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This agreement is nonassignable.
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8.2
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AGREEMENT ENDS
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(a)
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Unless otherwise extended as
specified in Article 8.3(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 SUDRF 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 SUDRF
corporation, however, does not constitute change of ownership. The
transfer of title to property of the SUDRF corporation to another
corporation(s), and the use of that property for the rendering of
substance use treatment 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
a SUDRF or a change in the SUDRF’s lessee constitutes change of
ownership.
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8.3
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NEW AGREEMENT REQUIRED
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(a)
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If there is a change of ownership
of a SUDRF as specified in Article 8.2(b), then the new owner, in
order to be a TRICARE-authorized SUDRF 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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A SUDRF contemplating or negotiating
a change of ownership must notify the Director, DHA, or designee,
in writing at least 30 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. A SUDRF
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 days from the date of the
transfer of ownership. Failure to provide 30 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
8.2(a).
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Prior to a transfer of ownership
of a SUDRF, the new owners may petition the Director, 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, or will review the SUDRF to ensure that it is in compliance
with TRICARE requirements.
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Article 9
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Reports
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9.1
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INCIDENT REPORTS
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Any serious occurrence involving
a TRICARE beneficiary, outside the normal routine of the SUDRF (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) referral 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 patient death,
life-threatening accident, suicide attempt, patient disappearance,
incident of cruel or abusive treatment, or any equally dangerous
situation involving a TRICARE beneficiary, shall be reported by
telephone on the next business day with a written report within
seven 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)
|
Notification shall be provided,
if appropriate, to the parents, legal guardian, or legal authorities.
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(d)
|
When a TRICARE beneficiary
is absent without leave and is not located within 24 hours, the
incident shall be reported by telephone on the next business day.
If the patient is not located within three calendar days, a written
report shall be made to DHA within seven calendar days.
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9.2
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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 days to DHA.
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9.3
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REPORTS OF SUDRF CHANGES
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The governing body or the administrator
of the facility shall submit in writing to DHA, any significant proposed
changes within the SUDRF no later than 30 days prior to the actual
date of change. A report shall be made concerning the following
items:
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|
(a)
|
Any change in administrator
or primary professional staff.
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(b)
|
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)
|
Any licensure, certification,
accreditation, or approval status change by a state agency or national organization.
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(d)
|
Any anticipated change in location
or anticipated closure.
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(e)
|
Any suspension of operations
for 24 hours or more.
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Article 10
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|
General Accounting Office (GAO)
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|
10.1
|
RIGHT TO CONDUCT AUDIT
|
|
The SUDRF grants the US GAO
the right to conduct audits.
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Article 11
|
|
Appeals
|
|
11.1
|
APPEAL ACTIONS
|
|
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 12
|
|
Termination
|
|
12.1
|
PROCEDURE FOR TERMINATION OF
AGREEMENT BY DHA
|
|
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.
|
|
12.2
|
BASIS FOR TERMINATION OF AGREEMENT
BY DHA
|
|
(a)
|
In addition to any authority
under the TRICARE regulation to terminate or exclude a provider,
the Director, DHA, or designee, may terminate this agreement for
cause, upon 30 days’ written notice, if the SUDRF:
|
|
|
(1)
|
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 Participation Agreement.
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|
|
(2)
|
Fails to comply with payment
provisions set forth in Article 4 of this agreement.
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|
|
(3)
|
Fails to allow audits/reviews
and/or to provide records as required by Article 5 of this agreement.
|
|
|
(4)
|
Fails to comply with nondiscrimination
provisions of Article 6 of this agreement.
|
|
|
(5)
|
Changes ownership as set forth
in Article 8 of this agreement.
|
|
|
(6)
|
Fails to provide incident reports,
disaster or emergency reports, or reports of SUDRF changes, as set forth
in Article 9 of this agreement.
|
|
|
(7)
|
Initiates a program change
without written approval by Director, DHA, or a designee; program changes
include but are not limited to: changes in the physical location,
population served, capacity, type of license, expansion of program(s),
or development of new program(s).
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|
|
(8)
|
Does not admit a TRICARE beneficiary
during any consecutive 24-month period.
|
|
|
(9)
|
Suspends operations for a period
of 120 days or more.
|
|
|
(10)
|
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)
|
The Director, DHA, or designee,
may terminate this agreement without prior notice in the event that
the SUDRF’s failure to comply with the industry standards for inpatient/residential
SUDRFs presents an immediate danger to life, health, or safety.
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|
12.3
|
TERMINATION OF AGREEMENT BY
THE SUDRF
|
|
The SUDRF 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 SUDRF and DHA.
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|
Article 13
|
|
Recoupment
|
|
13.1
|
RECOUPMENT
|
|
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.
|
|
Article 14
|
|
Order Of Precedence
|
|
14.1
|
ORDER OF PRECEDENCE
|
|
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.
|
|
Article 15
|
|
Duration
|
|
15.1
|
DURATION
|
|
This agreement will remain
in effect up to five years from the effective date (see Article
16) unless terminated earlier by DHA or the SUDRF under Article
12. DHA may extend this agreement for 60 days beyond the established
date if necessary to facilitate a new agreement.
|
|
15.2
|
REAPPLICATION
|
|
The SUDRF must reapply after
the automatic expiration of this agreement if it wishes to continue
as a TRICARE-authorized SUDRF. Failure to reapply will result in
the automatic expiration of this agreement on the date specified
in Article 17.
|
|
Article 16
|
|
Effective Date
|
|
16.1
|
EFFECTIVE DATE
|
|
(a)
|
This Participation Agreement
will be effective on the date signed by the Director, DHA, or designee.
|
|
(b)
|
This agreement must be signed
by the Chief Executive Officer (CEO) or designee of the SUDRF.
|
|
Article 17
|
|
Authorized Provider
|
|
17.1
|
TRICARE-PROVIDER STATUS
|
|
On the effective date of the
agreement, DHA recognizes the SUDRF as an authorized provider for
the purpose of providing substance use treatment to TRICARE-eligible
beneficiaries within the framework of the program(s) identified
below.
|