The
following are charges for services allowed outside the all-inclusive
RTC rate:
3.2.2.2 RTC Educational Services. The
RTC may request approval for payment of educational costs on an
individual case basis from the contractor when appropriate education
is not available from, or not payable by, a cognizant public entity.
3.2.2.2.1 As part of its admission procedures,
the RTC must counsel and assist the beneficiary and the beneficiary’s
family in the necessary procedures for assuring their rights to
a free and appropriate public education. There must be documentation
in the beneficiary’s record to substantiate this intake procedure.
3.2.2.2.2 The RTC must document any reasons
why an individual beneficiary cannot attend public educational facilities
and, in such case, why alternative educational arrangements have
not been provided by the cognizant public entity. Upon request,
the RTC should be able to produce a copy of all pertinent correspondence
with state or local educational agencies.
3.2.2.2.3 If reimbursement of educational
costs is approved for an individual beneficiary, such educational
costs shall be shown separately from the RTC’s daily costs on the
claim form.
3.2.2.2.4 Reimbursement of educational
costs shall not exceed the RTC’s most-favorable rate to any other
patient, agency, or organization for special or general education
services, whichever is appropriate.
3.2.2.2.5 When a local school district
reimburses authorized educational costs, but its payment does not
completely cover the RTC’s most-favorable rate, TRICARE shall cover
the remaining amount.
3.2.2.2.6 Approval for educational services
will be valid during the entire residential treatment center stay;
i.e., from admission through discharge or denial of continued stay,
whichever occurs first.
3.2.2.2.7 If the RTC fails to request
approval of educational costs on an individual case, the RTC may
not bill the beneficiary nor the beneficiary’s family for amounts
disallowed by contractor.
3.2.2.4 The all-inclusive rate includes
charges for the routine medical management of a beneficiary while
residing in an RTC. Services provided by medical professionals employed
by or contracted with the RTC are part of the all-inclusive per
diem rate and cannot be billed separately. These routine medical
services are made available to all children entering the facility
and are designed to maintain the general health and welfare of the
patient population. Examples of this type of care are:
• Routine health and physical
examinations provided by RTC medical staff;
• In-house pharmaceutical services;
and
• Other ancillary medical services
routinely provided to the RTC population.
3.2.2.5 Claims submitted by the RTC
for residential treatment care will be paid based upon the rate established
by the
Participation
Agreement.
All other mental health claims submitted by other providers for
services rendered to an RTC patient (except for those services allowed
outside the all-inclusive rate in
paragraph 3.2.2) will be denied. Other mental
health providers may continue to render services to RTC patients
under this payment system; however, such providers must look to
the RTC for their payment. Noncovered charges for personal items
(toiletries and clothing) are excluded.