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, paragraph 3.9, 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), Generalized Anxiety Disorder (GAD), and
Major Depressive Disorder (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). [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 Director,
DHA, or designee. (See
Section 12.3 and
Addendum H.)
3.3.9 The OTP
agrees to notify the referring military provider or Military Treatment
Facility (MTF)/Enhanced Multi-Service Market (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:
• 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.