Common use of PREREQUISITES FOR PAYMENT Clause in Contracts

PREREQUISITES FOR PAYMENT. Provided that there shall first have been a submission of claims in accordance with TRICARE procedures, the RTC shall be paid on the basis of the allowance of the rate determined in accordance with the controlling TRICARE regulation (see Article 4.1) contingent upon certain conditions provided in the TRICARE regulation, and in particular the following: (a) The patient seeking admission is suffering from a mental disorder that meets both the diagnostic criteria of the current edition of the DSM and the TRICARE definition of a mental disorder. (b) The patient seeking admission does not have a primary diagnosis of SUD including management of withdrawal symptoms (detoxification). (c) The patient seeking admission does not have a primary diagnosis of mental retardation or developmental disability. (d) The patient meets the criteria for admission to an RTC issued by the Director, DHA or designee. (e) The medical and/or psychological necessity of the patient’s admission is determined by a qualified mental health professional who meets TRICARE requirements for individual professional providers, and who is permitted by law and by the facility to refer patients for admission. (f ) A qualified mental health professional who meets TRICARE requirements for individual professional providers will be responsible for the development, supervision, implementation, and assessment of a written, individualized, interdisciplinary clinical formulation and plan of treatment. (g) All services in 32 CFR 199.4(c)(3)(ix) are provided by or under the supervision of a TRICARE- authorized mental health provider (see Article 3.3(e)). (h) DHA or a designee has preauthorized all care rendered to the patient. (i) The patient meets eligibility requirements for TRICARE coverage.

PREREQUISITES FOR PAYMENT. Provided that there shall first have been a submission of claims in accordance with TRICARE procedures, the RTC SUDRF shall be paid on the basis of the allowance of the rate determined in accordance with the controlling TRICARE regulation (see Article 4.1) contingent upon certain conditions provided in the TRICARE regulation, the TRICARE/CHAMPUS Standards for Inpatient Rehabilitation and Partial Hospitalization for the Treatment of Substance Use Disorders, and in particular the following: (a) The patient seeking admission is suffering from a mental disorder that meets both the diagnostic criteria of the current edition of the DSM Diagnostic and Statistical Manual of the American Psychiatric Association and the TRICARE definition of a mental disorder. (b) The patient seeking admission does not have a primary diagnosis of SUD including management of withdrawal symptoms (detoxification). (c) The patient seeking admission does not have a primary diagnosis of mental retardation or developmental disability. (d) The patient meets the criteria for admission to an RTC SUDRF issued by the Director, DHA or designee. (ec) The medical and/or psychological necessity of the patient’s admission is determined by a qualified mental health professional provider who meets TRICARE requirements for as an individual professional providersprovider, and who is permitted by law and by the facility to refer patients for admission. (f d) A qualified mental health professional who meets TRICARE requirements for individual professional providers will be responsible for the development, supervision, implementation, and assessment of a written, individualized, interdisciplinary clinical formulation and plan of treatment. (ge) All services in 32 CFR 199.4(c)(3)(ix) individual, group, or family psychotherapy, and psychological testing and assessment are provided by or under the supervision of a TRICARE- authorized qualified mental health provider who meets TRICARE requirements as an individual professional provider (see Article 3.3(e)3.3(h) above). (hf ) DHA or a designee has preauthorized precertified all inpatient or partial hospitalization care rendered to the patient. (ig) The patient meets eligibility requirements for TRICARE coverage.