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 Comprehensive Autism Care
Demonstration (ACD) Corporate Services Provider (ACSP)/Sole Provider Participation
Agreement (“Participation Agreement”) is between the United States
of America (USA) through the Defense Health Agency (DHA), an agency
of the Office of the Assistant Secretary of Defense (Health Affairs)
(OASD(HA)) and ___________________________________________________,
doing business as ________________________________________________
(hereinafter ACSP/Sole Provider).
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1.2
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AUTHORITY FOR ACSPS/SOLE
PROVIDERS AS TRICARE-AUTHORIZED PROVIDERS
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The authority to designate
ACSPs/Sole Providers as authorized TRICARE providers resides with
the Department of Defense (DoD) Demonstration authority under 10
USC 1092. This authority ceases upon termination of the Comprehensive
Autism Care Demonstration Project (“Demonstration”) as determined
by the Director, DHA, or designee.
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1.3
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PURPOSE OF PARTICIPATION AGREEMENT
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The purpose of this Participation
Agreement is to:
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(a)
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Establish the undersigned ACSP/Sole
Provider as an authorized provider of Applied Behavior Analysis (ABA)
services;
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(b)
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Establish the terms and conditions
that the undersigned ACSP/Sole Provider must meet to be an authorized
provider under the Demonstration.
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article 2
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References
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2.1
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REQUIREMENTS
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By reference, the requirements
set forth in the TRICARE Operations Manual (TOM), Chapter 18, Section 3, are incorporated into
this Participation Agreement and shall have the same force and effect
as if fully set out herein. In addition, the provider must:
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(a)
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Attend an annual provider education
provided by the TRICARE Managed Care Support Contractors (MCSCs),
Uniformed Services Family Health Plans (USFHP) Designated Providers
(DPs), or the TRICARE overseas contractor. |
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(b)
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Incorporate discharge summaries
and planning into every Treatment Plan (TP). The provider cannot abruptly
stop/terminate services for any reason to a beneficiary. All discharges
or cessation of services require a minimum of a 30 calendar day
transition/discharge plan.
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(c)
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If the ACSP/Sole Provider
terminates services with any beneficiary for any reason, the ACSP/Sole
Provider must notify the contractor a minimum of 45 calendar days
prior to termination.
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2.2
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GENERAL AGREEMENT
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(a)
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The undersigned ACSP/Sole Provider
agrees to render clinically appropriate ABA services to eligible beneficiaries
as specified in the TOM, Chapter 18, Section 3.
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(b)
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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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(c)
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Signing of this Participation
Agreement attests that the ACSP/Sole Provider has reviewed and agrees
to comply with the requirements set forth in the TOM, Chapter 18, Section 3.
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article 3
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Reimbursement
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3.1
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Claims for Demonstration services
will be submitted electronically on a Centers for Medicare and Medicaid Services
(CMS) 1500 Claim Form by the ACSP/Sole Provider in accordance with
the TOM, Chapter 18, Section 3.
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3.2
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The ACSP/Sole Provider shall:
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(a)
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Submit claims to the appropriate
TRICARE contractor, USFHP DP, or TRICARE overseas contractor in accordance
with the TOM, Chapter 18, Section 3; and
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(b)
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Collect the sponsor cost-share
in accordance with TOM, Chapter 18, Section 3;
and
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(c)
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Not bill the sponsor/beneficiary
for:
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(1)
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Services for which the provider
is entitled to TRICARE reimbursement;
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(2)
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Services not clinically necessary
and appropriate for the clinical management of the presenting illness,
injury, or disorder;
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(3)
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Services for which a beneficiary provider would
be entitled to payment but for a reduction or denial in payment
as a result of quality review; and
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(4)
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Services that are denied or
recouped due to provider non-compliance with all applicable requirements
in the TOM, Chapter 18, Section 3.
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article 4
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RECORDS AND AUDIT PROVISION
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4.1
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The ASCP/Sole Provider grants
the Director, DHA [or authorized representative(s)], the right to
conduct on-site or off-site reviews or 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 ACSP/Sole Provider which would confirm compliance
with this agreement and designation as an authorized ACSP/Sole Provider
under the ACD.
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(b)
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Conduct audits of ACSP/Sole Provider
records including administrative and clinical records to determine the
nature of the services being provided, and the basis for charges
and claims against the United States (US) for
services provided to beneficiaries. The Director, DHA, or a designee
shall have full access to records of TRICARE beneficiaries.
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4.2
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RECORDS REQUESTED BY DHA
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Upon request, the ACSP/Sole
Provider shall furnish DHA or a designee such records, including
administrative and medical records, that would allow DHA or a designee
to determine the quality and cost-effectiveness of care rendered.
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4.3
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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 denial or reduction of payment, termination
of this agreement pursuant to Article 5, and any other appropriate
action by DHA.
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article 5
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Term, Termination, And Amendment
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5.1
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TERM
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The term of this agreement
shall begin on the date this agreement is signed and shall continue
in effect until terminated or superseded as specified herein.
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5.2
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TERMINATION OF AGREEMENT BY
DHA
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(a)
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The Director, DHA, or designee,
may terminate this agreement upon written notice, for cause, if
the ACSP/Sole Provider is found not to be in compliance with the
provisions set forth in the TOM, Chapter 18, Section 3,
or is determined to be subject to the administrative remedies involving
fraud, abuse, or conflict of interest as set forth in 32
CFR 199.9. Such written notice of termination shall be
an initial determination for purposes of the appeal procedures set
forth in 32 CFR 199.10.
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(b)
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In addition, the Director,
DHA, or designee, may terminate this agreement without cause by
giving the ACSP/Sole Provider written notice not less than 45 calendar
days prior to the effective date of such termination.
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5.3
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TERMINATION OF AGREEMENT BY
THE ACSP/SOLE PROVIDER
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The ACSP/Sole Provider may
terminate this agreement by giving the Director, DHA, or designee,
written notice not less than 45 calendar days prior to the effective
date of such termination. Effective the date of termination, the
ACSP/Sole Provider will cease being a TRICARE-authorized provider
of Demonstration services. Subsequent to termination, an ACSP/Sole
Provider may be reinstated as a TRICARE-authorized provider of Demonstration
services only by entering into a new Participation Agreement.
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5.4
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AMENDMENT BY DHA
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(a)
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The Director, DHA, or designee,
may amend the terms of this Participation Agreement by giving 120 calendar
days notice in writing of the proposed amendment(s) except when
necessary to amend this agreement from time to time to incorporate
changes to the TOM, Chapter 18, Section 3 and
32 CFR 199. When changes or modifications to this agreement result
from changes to the 32 CFR 199 through rulemaking procedures, the
Director, DHA, or designee, is not required to give 120 calendar
days written notice. Any such changes to 32 CFR 199 shall automatically
be incorporated herein on the date the regulation amendment is effective.
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(b)
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An ACSP/Sole Provider who does
not accept the proposed amendment(s), including any amendment resulting
from changes to the TOM, Chapter 18, Section 3 and
32 CFR 199 accomplished through rulemaking procedures, may terminate
its participation as provided for in this Article. However, if the ACSP/Sole
Provider notice of intent to terminate its participation is not
given at least 30 calendar days prior to the effective date of the
proposed amendment(s), the proposed amendment(s) shall be incorporated
into this agreement for services furnished by the ACSP/Sole Provider
between the effective date of the amendment(s) and the effective
date of termination of this agreement.
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article 6
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Effective Date
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6.1
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DATE SIGNED
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This Participation Agreement
is effective on the date signed by the Director, DHA, or designee.
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DHA
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ACSP/Sole Provider
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By: Typed Name and Title
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By: Typed Name and Title
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Executed on ________________________,
________
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