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Provider certification application

General statement

For ACSP providers


Are you an autism school or a clinic affiliated with an autism school? *



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ACSP information


Yes
If Solo Provider does not have Type 2 NPI, please enter Solo Provider Type 1 NPI in field below.



Yes

Correspondence/point of contact information
Identify the person available to answer questions about this TRICARE certification application and the address where you would like to receive correspondence related to your application.

Is the correspondence address the same as physical address?
Is the correspondence address the same as billing address?
Professional liability information
Per TRICARE Operations Manual Chapter 18, Section 4, paragraph 8.3.1 Submit evidence to the contractor that professional liability insurance in the amounts of one million dollars per claim and three million dollars in aggregate, is maintained in the ACSP’s/Sole Provider’s name, unless state requirements specify greater amounts

Name of insured on policy needs to match the legal or DBA name & list address as covered location


ACSP claim amount and aggregate amount need to give money format in digits only, no commas, words or decimals.

$
$

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    ACSP agreement:
    ACSP participation agreement:
    TRICARE Policy Manual, Chapter 11, Addendum D
    Autism Care Demonstration-Corporate Services Providers (ACSPs)
    8.3.1  Submit evidence to the contractor that professional liability insurance in the amounts of one million dollars per claim and three million dollars in aggregate, is maintained in the ACSP’s/Sole Provider’s name, unless state requirements specify greater amounts;

    8.3.2  Submit to the contractor all documents necessary to support an application for designation as a TRICARE ACSP/Sole Provider;

    8.3.3  Enter into a Participation Agreement, Addendum A, approved by the Director, DHA or designee (i.e., the contractor).

    8.3.4  Employ directly or contract with qualified authorized ABA supervisors, assistant behavior analysts, and/or BTs, if applicable;

    8.3.5  Certify that all authorized ABA supervisors, assistant behavior analysts, and BTs employed by or contracted with the ACSP meet the education, training, experience, competency, supervision, and ACD requirements specified in the TRICARE Operations Manual Chapter 18, Section 4.;

    8.3.6  Comply with all applicable organizational and individual licensing or certification requirements that are extant in the State, county, municipality, or other political jurisdiction in which ABA services are provided under the ACD;

    8.3.7  Maintain all applicable business licenses and employment or contractual documentation in accordance with Federal, State, and local requirements and the authorized ABA supervisor’s business policies regarding assistant behavior analysts and BTs.

    8.3.8  Report to the contractor within 30 calendar days of notification of a state sanction or BACB sanction issued to the BCBA or BCBA-Doctoral level (BCBA-D) for violation of BACB Professional and Ethical Compliance Code for Behavior Analysts (http://www.bacb.com/ethics-code) or notification of loss of BACB certification. Loss of state licensure or certification, or loss of BACB certification shall result in termination of the Participation Agreement with the authorized ABA supervisor with an effective date of such notification. Termination of the Participation Agreement by the contractor may be appealed to DHA in accordance with the requirements of Chapter 12. While the Participation Agreement is with the ACSP/Sole provider, failure to remove the sanctioned provider will result in the termination of the entire ACSP or Sole provider group from the ACD.
    8.3.9  Familiarize themselves with, and comply with program requirements as stated in 32 CFR 199.6 and 32 CFR 199.9. This information is available online and is accessible to the public. TRICARE Manuals and CFRs can be found online at https://manuals.health.mil/.
    8.3.10  Attend a contractor-hosted “provider education” training, no less than annually, beginning no later than October 1, 2021.
    8.3.11  Comply with all applicable requirements of the Government designated utilization and clinical quality management organization.

    Participation Agreement For Comprehensive Autism Care Demonstration Corporate Services Provider (ACSP)/Sole Provider Practices
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    Article 1: Recitals
    1.1 Identification of parties This Autism Care Demonstration Corporate Services Provider (ACSP) 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).
    1.2 Authority for ACSPs as TRICARE-authorized providers The authority to designate ACSPs as authorized TRICARE providers resides with the Department of Defense (DoD) demonstration authority under 10 USC 1092. This authority ceases upon termination of the Autism Care Demonstration Project (“Demonstration”) as determined by the director, DHA or designee.
    1.3 Purpose of participation agreement The purpose of this participation agreement is to:
    a. Establish the undersigned ACSP as an authorized provider of Applied Behavior Analysis (ABA) services.
    b. Establish the terms and conditions that the undersigned ACSP must meet to be an authorized provider under the demonstration.

    Article 2: References
    2.1 Requirements By reference, the requirements set forth in the TRICARE Operations Manual (TOM), Chapter 18, Section 4, are incorporated into this participation agreement and shall have the same force and effect as if fully set out herein.
    2.2 General agreement The undersigned ACSP agrees to render appropriate ABA services to eligible beneficiaries as specified in the TOM, Chapter 18, Section 4.
    Article 3: Reimbursement
    3.1 Claims for demonstration services will be submitted on a Centers for Medicare and Medicaid Services (CMS) 1500 claim form by the ACSP in accordance with TOM, Chapter 18, Section 4, paragraph 11.0.
    3.2 The ACSP shall:
    a. Submit claims to the appropriate TRICARE regional contractor in accordance with the TOM, Chapter 18, Section 4, paragraph 11.0.
    b. Collect the monthly sponsor cost-share in accordance with TOM, Chapter 18, Section 4, paragraph 14.0
    c. Not bill the sponsor/beneficiary for:
    1. Services for which the provider is entitled to TRICARE reimbursement.
    2. Services that are denied due to provider non-compliance with all applicable requirements in the TOM, Chapter 18, Section 4.

    Article 4: Term, termination and amendment
    4.1 Term The term of this participation agreement shall begin on the date this participation agreement is signed and shall continue in effect until terminated or superseded as specified herein.
    4.2 Termination of agreement by DHA
    a. The director, DHA, or designee, may terminate this participation agreement upon written notice, for cause, if the ACSP is found not to be in compliance with the provisions set forth in 32 CFR 199.6, 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.
    b. In addition, the director, DHA or designee may terminate this agreement without cause by giving the ACSP written notice not less than 45 days prior to the effective date of such termination.
    4.3 Termination of agreement by the ACSP
    The ACSP may terminate this agreement by giving the director, DHA or designee written notice not less than 45 days prior to the effective date of such termination. Effective the date of termination, the ACSP will cease being a TRICARE-authorized provider of demonstration services. Subsequent to termination, an ACSP may be reinstated as a TRICARE-authorized provider of demonstration services only by entering into a new participation agreement.
    4.4 Amendment by DHA
    a. The director, DHA or designee may amend the terms of this participation agreement by giving 120 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 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 days written notice. Any such changes to 32 CFR 199 shall automatically be incorporated herein on the date the regulation amendment is effective.
    b. An ACSP who does not accept the proposed amendment(s), including any amendment resulting from changes to 32 CFR 199 accomplished through rulemaking procedures, may terminate its participation as provided for in this article. However, if the ACSP notice of intent to terminate its participation is not given at least 30 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 between the effective date of the amendment(s) and the effective date of termination of this agreement.
    Article 5: Effective date
    Date signed:

    This participation agreement is effective on the date signed by the director, DHA or designee.



    By Checking this checkbox, I acknowledge and agree to above participation agreement.*

    Executed on (date):*

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    Attestation:
    I confirm that the above information is true and complete to the best of my knowledge by typing my name in the box below.



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