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TRICARE Policy Manual 6010.60-M, April 1, 2015
Providers
Chapter 11
Section 8.1
Inpatient/Residential Substance Use Disorder Rehabilitation Facilities (SUDRFs) Standards
Issue Date:  March 13, 1992
Revision:  C-13, November 15, 2017
1.0  ISSUE
SUDRFs Standards.
2.0  DESCRIPTION
SUDRFs shall operate primarily for the purpose of providing treatment of Substance Use Disorders (SUDs). An SUDRF is a residential or rehabilitation facility, or distinct part of a facility, that provides medically monitored, interdisciplinary addiction-focused treatment to beneficiaries who have psychoactive SUDs. Qualified health care professionals provide 24-hour, seven-days-per-week, assessment, treatment, and evaluation. An SUDRF is appropriate for patients whose addiction-related symptoms, or concomitant physical and emotional/behavioral problems reflect persistent dysfunction in several major life areas. Such programs shall be accredited by and shall remain in substantial compliance with standards issued by either the Joint Commission (TJC), the Commission on Accreditation Rehabilitation Facilities (CARF), the Council on Accreditation (CoA), or an accrediting organization approved by the Director, Defense Health Agency (DHA). The regional contractor may submit, via the TRICARE Regional Office (TRO), additional accrediting organizations for TRICARE authorization, subject to approval by the Director, DHA.
3.0  POLICY
3.1  The contractor is the certifying authority for new applicants for status as an approved institutional provider for inpatient/residential SUDRFs. Separate certification is not required for authorized hospital units which are a distinct part of an authorized facility. Effective October 1, 1995, the SUDRF is not considered an authorized provider, and benefits are not paid for services provided until the date upon which a written participation agreement is signed.
3.2  Inpatient/residential SUD rehabilitation programs, except SUD rehabilitation programs provided in units which are a distinct part of an authorized hospital, must fully comply, and enter into a Participation Agreement with the Director, DHA, or designee.
3.3  In addition, in order for a freestanding inpatient/residential SUDRF to be authorized, the SUDRF shall comply with the following requirements:
3.3.1  An SUDRF shall be currently accredited by TJC, CARF, CoA, or an accrediting organization approved by the Director, DHA. The regional contractor may submit, via the TRO, additional accrediting organizations for TRICARE authorization, subject to approval by the Director, DHA.
3.3.2  The SUDRF shall be licensed as an SUDRF to provide SUD services within the applicable jurisdiction in which it operates.
3.3.3  The SUDRF shall accept the allowable SUDRF rate, as provided in 32 CFR 199.14(a)(1)(ii)(E) and (a)(2)(ix), and the TRICARE Reimbursement Manual (TRM), Chapter 7, Section 3.
3.3.4  The SUDRF shall comply with all requirements applicable to institutional providers generally concerning accreditation requirements, preauthorization, concurrent care review, claims processing, beneficiary liability, double coverage, utilization and quality review, and other matters.
3.3.5  The SUDRF shall not be considered an authorized provider, nor may any benefits be paid to, the facility for any services provided prior to the date the facility is approved by the Director, DHA, or designee.
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 SUDRFs. All mental health services must be provided by the 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: Residential treatment programs 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 services within the all-inclusive per diem rate, but such individuals must work under the clinical supervision of a fully qualified mental health provider employed by the facility.]
3.3.7  Case management services required. The facility must provide case management services that help assure the patient’s appropriate living arrangements after treatment hours, transportation to and from the facility, arrangement of community based support services, referral of suspected child abuse to the appropriate state agencies, and effective care arrangements, at a minimum.
3.3.8  The SUDRF shall enter into a written participation agreement with the Director, DHA, or designee. (See Section 12.3 and Addendum D.)
3.3.9  The SUDRF 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.
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