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In order to receive payment
under TRICARE, ______________________________________________ dba
______________________________________________, as the provider
of services agrees:
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1.
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Not to charge a beneficiary
for the following:
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a.
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Services for which the provider
is entitled to payment from TRICARE;
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b.
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Services for which the beneficiary
would be entitled to have TRICARE payment made had the provider
complied with certain procedural requirements;
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c.
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Services not medically necessary
and appropriate for the clinical management of the presenting illness,
injury, disorder or maternity;
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d.
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Services for which a beneficiary
would be entitled to payment but for a reduction or denial in payment
as a result of quality review; and
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e.
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Services rendered during a
period in which the provider was not in compliance with one or more
conditions of authorization:
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2.
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To comply with applicable provisions
of 32 CFR 199 and related TRICARE policy;
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3.
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To accept the TRICARE determined
allowable payment combined with the cost-share, deductible, and
other health insurance amounts payable by, or on behalf of, the
beneficiary, as full payment for TRICARE allowed services;
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4.
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To collect from the TRICARE
beneficiary those amounts that the beneficiary has a liability to
pay for the TRICARE deductible and cost-share/copayment (this requirement
does not apply to a State Vaccine Program or State Vaccine Program
entity (SVP) participation agreement);
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5.
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To permit access by the Director,
DHA, or designee, to the clinical record of any TRICARE beneficiary, to
the financial and organizational records of the provider, and to
reports of evaluations and inspections conducted by state or private
agencies or organizations (this requirement does not apply to a
SVP participation agreement);
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6.
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To provide to the Director,
DHA, or designee (e.g., Contractor), prompt written notification
of the provider’s employment of an individual who, at any time during
the twelve months preceding such employment, was employed in a managerial,
accounting, auditing, or similar capacity by an agency or organization
which is responsible, directly or indirectly, for decisions regarding
Department of Defense payments to the provider;
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7.
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To cooperate fully with a designated
utilization and clinical quality management organization which has
a contract with the Department of Defense for the geographic area
in which the provider renders services;
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8.
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Comply with all applicable
TRICARE authorization requirements before rendering designated services
or items for which TRICARE cost-share/copayment may be expected;
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9.
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To maintain clinical and other
records related to individuals for whom TRICARE payment was made for
services rendered by the provider, or otherwise under arrangement,
for a period of 60 months from the date of service (this requirement
does not apply to a SVP participation agreement);
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10.
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To maintain contemporaneous
clinical records that substantiate the clinical rationale for each course
of treatment, the methods, modalities or means of treatment, periodic
evaluation of the efficacy of treatment, and the outcome at completion
or discontinuation of treatment (this requirement does not apply
to a SVP participation agreement);
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Clinical records are required
to document the outcomes of standardized assessment measures for PTSD,
GAD, and MDD using the PTSD Checklist (PCL), GAD-7, and Patient
Health Questionnaire (PHQ)-8, respectively, at baseline, at 60-120
day intervals, and at discharge (See Chapter 1, Section 5.1 for details); |
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11.
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To refer TRICARE beneficiaries
only to providers with which the referring provider does not have
an economic interest, as defined in 32
CFR 199.2 (this requirement does not apply to a SVP participation
agreement); |
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12.
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To limit services furnished
under arrangement to those for which receipt of payment by the TRICARE
authorized provider discharges the payment liability of the beneficiary;
and
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13.
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Notify the referring military
provider or MTF/eMSM 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:
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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;
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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;
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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;
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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;
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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;
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Substance abuse treatment program
– Entered into, or is being discharged from, a formal outpatient
or inpatient treatment program.
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14.
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Meet such other requirements
as the Secretary of Defense may find necessary in the interest of health
and safety of the individuals who are provided care and services.
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Defense Health Agency (DHA)
agrees to:
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Pay the above-named provider
the full allowable amount less any applicable double-coverage, cost-share/copayment,
and deductible amounts.
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This agreement shall be binding
on the provider and DHA upon acceptance by the Deputy Director, DHA,
or designee.
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This agreement shall be effective
until terminated by either party. The effective date shall be the date
the agreement is signed by DHA
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This agreement may be terminated
by either party by giving the other party written notice of termination.
The provider shall also provide written notice to the public. Such
notice of termination is to be received by the other party no later
than 45 days prior to the date of termination. In the event of transfer
of ownership, this agreement is assigned to the new owner, subject
to the conditions specified in this agreement and pertinent regulations.
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FOR PROVIDER OF SERVICES BY:
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FOR DHA BY:
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_______________________________________
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_______________________________________
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Name
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Name
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_______________________________________
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_______________________________________
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Title
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Date
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Title
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Date
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