17_Attachment_J-7_Behavioral_Health_Facility_Certification.pdf

INITIAL CERTIFICATION

1. A facility requesting certification as a TRICARE-authorized RTC, PHP, or SUDRF must complete an application and submit it to the contractor.

2. Upon request of a facility, the contractor shall mail an application package consisting of the "Application for TRICARE-Provider Status," applicable TRICARE Standards, TRICARE Form 771 Reimbursement Information (RTC applicants only), a sample participation agreement, and pertinent provisions of the TRICARE regulation.

3. Within 7 calendar days of receipt of an application the contractor shall either return an application or issue a letter to the facility acknowledging receipt. The letter of acknowledgment shall advise the facility that the application has been received and that the facility will be advised of the outcome of the review. Applications shall be returned when:

A. The application does not contain documentation that the following eligibility requirements have been meet.

(1) The RTC, PHP or SUDRF must be licensed and fully operational (as defined in 32 CFR 199.6) for a period of at least six months and operate in substantial compliance with state and federal regulations; and

(2) The RTC or PHP must be accredited by the Joint Commission on Mental Health, Chemical Dependency, and Mental Retardation/Developmental Disabilities Services (MHM). The SUDRF must be accredited by the Joint Commission under the MHM or by the Commission on Accreditation of Rehabilitation Facilities (CARF) as an alcoholism or other drug dependency rehabilitation program under the Standards Manual for Organizations Serving People with Disabilities.

B. The application is not signed by an official authorized to act on behalf of the facility.

C. A SUDRF application is received from a facility which is certified by Medicare as a hospital. The TRICARE MCS contractors are responsible for TRICARE certification for Medicare certified hospitals providing substance use detoxification and rehabilitation care.

4. Unless otherwise directed by the DHA, the contractor shall process applications in the order of receipt. The contractor shall notify the facility in writing of the results of the application review with an Initial Determination within 40 days after receipt of an application and within 55 days for an RTC application that requires a rate calculation. For each application, 1 Initial Determination shall be issued. The contractor shall document the facility file with results of the application review.

A. The Initial Determination shall certify the facility as an approved provider of RTC, PHP or SUDRF care when the application review finds that the facility meets the requirements as specified in 32 CFR 199.6.

B. The Initial Determination shall deny certification as an approved provider of RTC, PHP, or SUDRF care when the application reviews finds that the facility is not in compliance with applicable 32 CFR 199.6 requirements.

C. When the application review finds that some programs included in the application meet the TRICARE requirements and some programs do not, then the Initial Determination shall certify the facility to provide RTC, PHP or SUDRF care in the specific programs that meet the TRICARE requirements. The Initial Determination shall also identify the programs that do not meet the

Attachment J-7 Behavioral Health Facility Certification

TQMC HT9402-15-R-0005, Section J, Attachment J-7 1 of 7 requirements and offer appeal rights for the determination on those specific programs. The Initial Determination shall include an explanation of the specific requirements that are not met and shall advise the facility that if it disagrees with the findings of the application review, it may request a reconsideration within 90 days from the contractor.

(5) Along with the Initial Determination which provides notice that the application was approved, the contractor shall forward to the facility 2 copies of the participation agreement.

A. For RTCs, the participation agreement shall include the per diem rate calculated by the contractor according to the methodology established by 32 CFR 199.14 and the TRICARE Policy Manual. The contractor also shall request that the facility conduct a self-assessment in accordance with Article 3.3 of the participation agreement, submit written documentation of the assessment , sign the participation agreement (by an official having authority to act for the facility) and return the agreement to the contractor within 7 calendar days from the date of the contractor's notification. The contractor shall advise the facility that the effective date of certification will be the date the participation agreement is signed on behalf of the Executive Director, DHA.

B. Within 10 calendar days after receipt of a participation agreement signed by an appropriate official of the facility, the contractor's responsible designee will sign the agreement on behalf of the Executive Director, DHA.

The effective date of the facility's certification is the date on which the participation agreement is signed by an official of the contractor to whom DHA has delegated authority for signature of such agreements. Under no circumstances will a retroactive effective date be permitted.

C. The expiration date of the Participation Agreement shall generally be for five years from the date of signature.

D. The contractor shall send the facility a copy of the signed participation agreement for its records, maintain 1 copy in the contractor’s facility file and shall provide instructions to the facility to contact the appropriate MCS contractor for billing instructions. The facility will be informed that cost-sharing and preauthorization/certification of covered services provided to TRICARE patients may begin as of 12:01 a.m. of the effective date of the Participation Agreement. The instructions shall also include the following:

(1) Although the facility has been certified as an authorized TRICARE provider; before payment can be made, the MCS contractor must determine if the patient is an eligible beneficiary and that the services billed are authorized, regardless of the standing of the provider;

(2) The facility must bill for and collect that portion of the total charges which is the responsibility of the Uniformed Service sponsor, and that TRICARE cost shares cannot be waived or absorbed;

(3) Payment cannot be made under TRICARE for any care (except in certain emergency or life-threatening situations) from a provider who practices discrimination against any individual. This pertains to both patients' access to care as well as employment practices;

(4) As specified in its participation agreement articles 9 and 10, the facility must notify the CQSS in writing of any significant changes, to include changes in professional staffing, program services, licensure, ownership/control, certification under Title VXIII or Title XIX of the Social Security Act, or other significant changes.

TQMC HT9402-15-R-0005, Section J, Attachment J-7 2 of 7

RECERTIFICATION

1. TRICARE-authorized RTCs, PHPs and SUDRFs are subject to reviews. The contractor shall perform a recertification review once every three years.

Any revisions to the recertification schedule require approval from the Contracting Officer's Representative. The purpose of the recertification review is to evaluate whether the facility remains in compliance with TRICARE requirements.

A. The contractor shall mail an application for recertification to the facility. The contractor shall notify the facility in a cover letter that the completed and signed application form along with the facility's annual self-assessment must be received by the contractor within 30 calendar days from the date of the contractor's letter.

B. If the application is not received within 30 days, the contractor will issue a notice to the facility that their agreement will be terminated in accordance with Article 13.2 for failure to provide records and allow the facility an additional 30 days to respond. If no response is received, proceed with termination as found in the TERMINATION section.

C. Within 7 calendar days of receipt of a recertification application, the contractor shall:

(1) Issue a written notice to the facility acknowledging receipt of the complete application: or

(2) Issue a written notice to the facility with notification that the required information to complete the application or the self-assessment was not submitted. The contractor will advise the facility that the information must be received by the contractor within 15 calendar days from the date of the request. If the information is not received by the contractor within 15 calendar days, the contractor shall complete the review based upon the information submitted.

(3) Return the application if is not signed by an official authorized to act on behalf of the facility.

D. The contractor shall complete its review of the application for recertification within 40 calendar days from the date of receipt of the complete application or 55 days from the date of the letter requesting additional information. Based on the results of its review, the contractor shall issue an Initial Determination to recertify the facility or shall recommend termination in accordance with Section 4 of these procedures. The contractor shall document the facility file with results of the recertification review.

(1) The Initial Determination shall recertify the facility as an approved provider of RTC, PHP or SUDRF care when the application review finds that the facility meets the requirements as specified in 32 CFR 199.6.

(2) When the application review finds that some programs included in the application meet the TRICARE requirements and some programs do not, then the Initial Determination shall certify the facility to provide RTC, PHP or SUDRF care in the specific programs that meet the TRICARE requirements. The Initial Determination shall also identify the programs that do not meet the requirements and offer appeal rights for the determination on those specific programs. The Initial Determination shall include an explanation of the specific requirements which are not met and shall advise the facility that if

TQMC HT9402-15-R-0005, Section J, Attachment J-7 3 of 7 it disagrees with the findings of the application review, it may request a reconsideration within 90 days from the contractor.

(3) Along with the Initial Determination which provides notice that the application was approved, the contractor shall forward to the facility two

(2) copies of the new participation agreement. The contractor shall request that the facility sign both of the participation agreements (by an official having authority to act for the facility) and return the agreements to the contractor within 7 calendar days from the date of contractor’s notification.

The contractor shall advise the facility that this agreement shall supersede the previous agreement.

(4) Within 10 calendar days after receipt of a participation agreement signed by an appropriate official of the facility, the contractor's responsible designee will sign the agreement on behalf of the Executive, DHA.

(5) The expiration date of the Participation Agreement shall generally be five years from the date of signature.

(6) The contractor shall send the facility a copy of the signed participation agreement for its records and maintain one copy for the contractor’s file.

(7) When the recertification review finds that the facility does not meet TRICARE requirements, the contractor shall follow the procedures in the TERMINATION section.

TERMINATION

1. If the contractor concludes that a TRICARE-authorized RTC, PHP or SUDRF is not in compliance with one or more of the standards applicable to its specific provider category, then the contractor shall proceed with steps to bring about compliance or terminate the status of the provider should be terminated according to the requirements in 32 CFR 199.9 . The contractor shall forward to DHA the following material:

A. A letter recommending termination of the facility as a TRICARE-authorized provider. The letter must contain a summary of the major reasons for termination.

B. A draft Notice of Proposed Termination. In the draft notice, the contractor shall cite the basis for the proposed termination to include the information that was considered, the specific areas in which the facility is not in compliance with applicable TRICARE standards and the specific standard(s) upon which the contractor relied for its finding(s).

2. As directed by DHA the contractor shall participate in meetings requested in writing by facility representatives under 32 CFR 199.9. These meetings shall be conducted at DHA in Aurora, Colorado. Appropriate staff from DHA will be in attendance.

3. Based on the written documentation submitted by the facility in response to a Notice of Proposed Termination, the contractor shall evaluate whether the facility is in compliance with applicable TRICARE requirements. Within 10 calendar days of receipt of all written material or from the date of a meeting with the facility, whichever is later, the contractor shall complete this evaluation and forward to DHA a recertification or termination recommendation.

TQMC HT9402-15-R-0005, Section J, Attachment J-7 4 of 7

4. If, based on a review of the written material, the contractor determines that the facility is in compliance with TRICARE requirements, the contractor shall submit to DHA a recommendation for recertification along with a draft recertification letter.

5. If the facility is not in compliance with TRICARE requirements, the contractor will submit to DHA a recommendation to terminate the provider.

The contractor will follow the requirements in 1.A. above for recommending termination, with the exception that the contractor shall prepare a draft Initial Determination in accordance with 32 CFR 199.9 rather than a draft Notice of Proposed Termination.

6. If the contractor determines that an RTC, PHP or SUDRF is in violation of standards detrimental to life, safety, or health, or substantially in violation of approved treatment programs, action shall be taken to terminate the facility as an authorized provider. In these cases, the contractor shall forward to the COR the following:

A. Draft letter to the facility which provides notice of the termination under 32 CFR 199.9 a brief statement of the nature of the violation(s) and that an initial determination will be issued.

B. A draft initial determination which includes all of the provisions in 32

CFR 199.9.

VOLUNTARY WITHDRAWAL

1. A facility may voluntarily withdraw an application to become a TRICARE-authorized RTC or may voluntarily terminate its participation agreement.

These same procedures apply when a facility closes.

A. At any time prior to the signing of a participation agreement by the Executive Executive Director, DHA or his designee, a facility may request the withdrawal of its application. The request must be submitted in writing to the contractor. Within 10 calendar days of receipt of such a written request, the contractor shall acknowledge the withdrawal in writing, shall terminate the participation agreement, shall notify appropriate MSC contractors and shall close the file on the facility. As a voluntary withdrawal is not an adverse action, the facility will not be afforded any appeal rights.

B. A TRICARE-authorized RTC, PHP or SUDRF may terminate its participation agreement by submitting a written request 60 calendar days prior to the date that the facility wishes its participation agreement to be terminated, or at any time after issuance of a notice of proposed termination upon which final action (i.e., termination or rectification) has not been taken. Because the facility's decision to terminate the participation agreement is voluntary, no appeal rights will be given and it is the responsibility of the facility to notify TRICARE patients and families and to arrange for timely discharge or transfer. Within 10 calendar days of receipt of such a written request, the contractor shall acknowledge the withdrawal in writing, shall terminate the participation agreement, shall notify appropriate MSC contractors and shall close the file on the facility effective with the date of termination.

MONITORING AND EVALUATIONS

1. TRICARE-authorized RTCs, PHPs and SUDRFs are required to notify DHA or a designee of a variety of serious occurrences outside the normal routine, material changes in the facility's structure, staffing or operations and any

TQMC HT9402-15-R-0005, Section J, Attachment J-7 5 of 7 matter regarding which the facility is not in compliance with standards as a result of the annual self-assessment. Failure to report may constitute a material breach of the participation agreement and may result in denial of claims or termination of the participation agreement. DHA will forward a copy of the notifications that it receives to the contractor for review and appropriate action.

2. When the contractor receives an occurrence report of illness, injury, death, prolonged elopement, an abuse situation, etc. or a self-assessment that shows noncompliance with standards, the contractor shall make an assessment of how adequately the facility addressed the problem. The contractor shall identify any pattern of occurrences that could suggest a violation of TRICARE standards, or a problem with the facility's staffing or programs that permit serious incidents to occur. The contractor shall document the facility file with the results of the assessment, and when appropriate, provide DHA with a written report.

3. If the contractor receives notice that the facility intends to change or expand its program in location, size, patient population, treatment philosophy, key staffing, or in any other significant manner, the contractor will obtain such information from the facility as is necessary to determine whether the change affects the facility's compliance with TRICARE standards.

These reviews shall be completed with 10 calendar days of receipt of complete information. If the contractor determines that the facility remains in compliance with TRICARE standards requirements, the contractor shall issue a letter approving the changes and an addendum to the agreement when necessary.

If the changes are not in compliance with the standards, the contractor shall deny approval for the program changes and shall include the specific TRICARE regulatory requirement, policy or standard with which the facility is not in compliance.

4. The participation agreement requires facilities to provide 30 calendar days advance notice of a change in ownership. The new owners are required to execute a new participation agreement with TRICARE. When the required advance notice is provided, the contractor shall extend the agreement for a period not to exceed 180 days from the date of the transfer of ownership. If the required advance notice is not provided, the contractor shall issue a letter which states that the participation agreement ended in accordance with Article 9.2. Before a participation agreement may be executed with the new owners, the contractor must review any program or clinical changes the new owners propose and must assure that all required licenses, certifications and accreditations have been transferred to the new owners. At a minimum, the first 5 pages of the application will be required. Approval of a change in ownership is discretionary. Within 20 calendar days after receipt of complete information regarding a change in ownership, the contractor shall either approve or deny a new participation agreement resulting from a change in ownership. If a new agreement is not specifically approved, the participation agreement ends as of 12:01 a.m. of the day following the date of the change in ownership. An Initial Determination approving or denying a new participation agreement shall be issued following the procedures in the section of this attachment on INITIAL CERTIFICATION.

BILLING PROCEDURES

A facility certification review is complete for billing purposes when:

TQMC HT9402-15-R-0005, Section J, Attachment J-7 6 of 7

1) An Initial Determination is issued based upon a review of a new facility application, a recertification application, or a change of ownership review;

or

2) A draft notice of termination is issued to DHA for noncompliance with TRICARE standards.

Attachment J-7 Behavioral Health Facility Certification

TQMC HT9402-15-R-0005, Section J, Attachment J-7 7 of 7 jblomquist Typewritten Text jblomquist Typewritten Text