Provider Certification Application

Organization information

For TRICARE providers

Federal Law (5 U.S.C. 5536) prohibits medical personnel, who are Active Duty Service Members (ADSM) or civilian employees of the government, compensation above their normal pay and allowances for medical care rendered. This prohibition applies to TRICARE benefits whether the claim for reimbursement is filed by the individual who provided the care, the facility in which the care was rendered, or by the sponsor/beneficiary. Claims for TRICARE benefits will be denied in any situation where either a uniform member or civilian employee of the uniform services has the opportunity to exert, directly or indirectly, any influence on the referral of TRICARE beneficiaries to one or more providers on a selective basis.

Organization information

Missing or invalid information will delay the processing of the certification application, or result in rejection of the application.

Organization name (DBA):* Organization tax ID:* Organization National Provider Identifier (NPI):*
Organization physical street address (PO box not allowed):* Organization physical apt/suite/other: Organization physical address city:* Organization physical address ZIP Code:* Organization phone # (No dashes):* I do not have a fax number Organization fax #(No dashes):* Is billing address same as physical address?: Yes
Organization billing street address:* Organization billing apt/suite/other: Organization billing address city:* Organization billing address ZIP Code:*

Organization billing phone # (No dashes):* Corporate ownership name:*

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.

Certification Point of Contact(POC) name:* Certification Point of Contact(POC) street address:* Certification Point of Contact(POC) apt/suite/other: Certification Point of Contact(POC) city:* Certification Point of Contact(POC) ZIP Code:* Certification Point of Contact(POC) phone #(No dashes):* Certification Point of Contact(POC) email:* Certification Point of Contact(POC) email:*

Back Continue

State license/certificate Information:

State license/certificate information

State license classification: State license/certificate number: Effective date (MM-DD-YYYY): Expiration date (MM-DD-YYYY): Note: If License does not expire use 12-31-9999.
Upload license

Any disciplinary action: Yes: No:
The state in which this organization is located does not offer a state license or certificate:(checkbox):

Back Continue

Other license information:

Medicare certification number

Medicare number: * Effective date (MM-DD-YYYY): * Upload medicare certificate

Back Continue

Participation agreement:

Hospital psych unit or freestanding psychiatric hospital participation agreement

In order to receive payment under TRICARE, DBA , as the provider of services agrees:
1.Not to charge a beneficiary for the following:
a.Services for which the provider is entitled to payment from TRICARE;
b.Services for which the beneficiary would be entitled to have TRICARE payment made had the provider complied withcertain procedural requirements;
c.Services not medically necessary and appropriate for the clinical management of the presenting illness, injury, disorderor maternity;
d.Services for which a beneficiary would be entitled to payment but for a reduction or denial in payment as a result ofquality review; and
e.Services rendered during a period in which the provider was not in compliance with one or more conditions of authorization:
2.To comply with applicable provisions of 32 CFR 199 and related TRICARE policy;
3.To accept the TRICARE determined allowable payment combined with the cost-share, deductible, and other healthinsurance amounts payable by, or on behalf of, the beneficiary, as full payment for TRICARE allowed services;
4.To collect from the TRICARE beneficiary those amounts that the beneficiary has a liability to pay for the TRICARE deductibleand cost-share/co-payment;
5.To permit access by the Executive Director, DHA, or designee, to the clinical record of any TRICARE beneficiary, to the financialand organizational records of the provider, and to reports of evaluations and inspections conducted by state or private agenciesor organizations;
6.To provide to the Executive Director, DHA, or designee, prompt written notification of the provider’s employment of an individualwho, at any time during the twelve months preceding such employment, was employed in a managerial, accounting, auditing, orsimilar capacity by an agency or organization which is responsible, directly or indirectly, for decisions regarding Department ofDefense payments to the provider;
7.To cooperate fully with a designated utilization and clinical quality management organization, which has a contract withthe Department of Defense for the geographic area, in which the provider renders services;
8.Comply with all applicable TRICARE authorization requirements before rendering designated services or items for whichTRICARE cost-share/co-payment may be expected;
9.To maintain clinical and other records related to individuals for whom TRICARE payment was made for services rendered bythe provider, or otherwise under arrangement, for a period of 60 months from the date of service.
10.To maintain contemporaneous clinical records that substantiate the clinical rationale for each course of treatment, themethods, modalities or means of treatment, periodic evaluation of the efficacy of treatment, and the outcome at completion ordiscontinuation of treatment;
11.To refer TRICARE beneficiaries only to providers with which the referring provider does not have an economic interest, asdefined in 32 CFR 199.2;
12.To limit services furnished under arrangement to those for which receipt of payment by the TRICARE-authorized provider discharges the payment liability of the beneficiary; and
13.Notify the referring military provider or MTF/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.

14.Meet such other requirements as the Secretary of Defense may find necessary in the interest of health and safety of the individuals who are provided care and services.
DHA agrees to pay the above- named provider the full allowable amount less any applicable double coverage, cost-share/copayment, and deductible amounts
This agreement shall be binding on the provider and DHA upon acceptance by the Executive Director, DHA, or designee.
This agreement shall be effective until terminated by either party. The effective date shall be the date the agreement is signed by DHA
This agreement may be terminated by either party by giving the other party written notice of termination. The provider shall also provide written notice to the public. Such notice of termination is to be received by the other party no later than 45 days prior to the date of termination. In the event of transfer of ownership, this agreement is assigned to the new owner, subject to the conditions specified in this agreement and pertinent regulations.

FOR PROVIDER OF SERVICES BY:

Name:*

Title:*

Date*

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

Back Continue

Associated provider type:

Do you offer any of the following services onsite? Intensive outpatient program
Opiod treatment program
Partial hospitalization program

Back Continue

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.

Electronic signature (Do not include middle initial):* Attested date:*

Back Submit