TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 APPENDIX A-4 Following are the rate adjustments for those RTCs whose 1995 per diems were below the 30th percentile of all established fiscal year 1995 rates. The rates were adjusted by the lesser of the Consumer Price Index - Urban Wage Earners (CPI-U) for medical care for the annual reporting period of July 1, 1995, to July 1, 1996 (3.6 percent) or the amount that brought the rate up to the 30th percentile level ($429). These rates are for payment of services provided on or after October 1, 1996. NOTE: This listing is for residential treatment center per diem rates only. It does not reflect a facility s status as a TRICARE-authorized residential treatment center. Information regarding a facility s current status as an authorized provider can be obtained from the appropriate contractor. ALABAMA Charter BHS of Mobile, Inc. 5800 Southland Center Mobile, AL 36693 Facility No. 01-00260 EIN: 58-1569921 Hillcrest Hospital BHS-AL 6869 Fifth Avenue South Birmingham, AL 35212 Facility No. 01-00234 EIN: 63-0862148 ARIZONA Wendy Paine O Brien Treatment CTR 5055 North 34th St. Phoenix, AZ 85018 Facility No. 03-00205 EIN: 86-0096778 (B) Desert Hills Ctr for Youth & Family 2797 N. Introspect Drive Tucson, AZ 85745 Facility No. 03-00148 EIN: 86-0276013 415.00 444.00 A4-1
APPENDIX A-4 TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 Westbridge RTC-Children & Adolescent 1830 E. Roosevelt Phoenix, AZ 85006 Facility No. 03-00209 EIN: 73-1195649 ARKANSAS CPC Pinnacle Pointe Hospital RTC 11501 Financial Center Parkway Little Rock, AR 72211 EIN: 94-3131886 CALIFORNIA Broad Horizons P.O. Box 1920 1236 H Street Ramona, CA 92065 Facility No. 04-09177 EIN: 62-1451701 CPC San Luis Rey Hospital 345 Saxony Road Encinitas, CA 92024 Facility No. 04-09225 EIN: 95-1907817 San Diego Center for Children 3002 Armstrong Street P.O. Box 11024 San Diego, CA 92111 Facility No. 04-00256 EIN: 95-1661089 Vista San Diego Center 3003 Armstrong Street San Diego, CA 92111 Facility No. 04-09223 EIN: 95-1944230 512.00 443.00 383.00 A4-2
TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 APPENDIX A-4 COLORADO Brockhurst Extended Care Program P.O. Box 7021 825 E. Pikes Peak Colorado Springs, CO 80903 Facility No. 05-04573 EIN: 84-0405257 Cheyenne Mesa 1301 South 8th Street Colorado Springs, CO 80906 Facility No. 05-00183 EIN: 84-1043265 Cedar Springs Hospital, Inc. 2135 Southgate Road Colorado Springs, CO 80906 Facility No. 05-04572 EIN: 84-1209539 FLORIDA Charter BHS at Medfield 12891 Seminole Boulevard Largo, FL 34648 Facility No. 09-09199 EIN: 58-1860493 CPC Palm Bay Hospital 4400 Dixie Hwy NE Palm Bay, FL 32905 EIN: 33-0176946 La Amistad RTC 201 Alpine Drive Maitland, FL 32751 Facility No. 09-09195 EIN: 58-1791069 406.00 426.00 448.00 422.00 490.00 A4-3
APPENDIX A-4 TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 Valuemark Laurel Oaks BHS, Inc 6601 Central Florida Parkway Orlando, FL 32821 Facility No. 09-09198 EIN: 58-2156425 Charter BHS at Manatee Palms 4480 51st Street Bradenton, FL 34201 Facility No. EIN: 58-1527678 Rivendell of Fort Walton Beach 1015 Mar Walt Drive FT. Walton Beach, FL 32547 Facility No. 09-09163 EIN: 59-3156031 Tampa Bay Academy 12012 Boyette Road Riverview, FL 33569 Facility No. 09-09192 EIN: 52-1955335 CPC St. Johns River Hospital CRC 6300 Beach Blvd. Jacksonville, FL 32216 EIN: 59-1482073 University Behavioral Center 2500 Discovery Drive Orlando, FL 32826 EIN: 59-2754032 GEORGIA Charter BHS of Atlanta at Laurel Heights 934 Briarcliff Road, N.E. Atlanta, GA 30306 Facility No. 10-00303 EIN: 58-1558212 459.00 405.00 413.00 494.00 A4-4
TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 APPENDIX A-4 Charter Augusta BHS 3100 Perimeter Parkway Augusta, GA 30909 EIN: 58-1615676 HAWAII Sutten Health Pacific DBA Kahi Mohala 912301 Fort Weaver Road Ewa Beach, HI 96706 Facility No. 51-00082 EIN: 99-0298651 IDAHO CPC Intermountain Hospital of Boise 303 N. Allumbaugh Street Boise, ID 83704 Facility No. 11-00048 EIN: 82-0358058 INDIANA Charter BHS of Indiana at Jefferson 2700 River City Park Jeffersonville, IN 47130 EIN: 35-1916342 KANSAS CPC College Meadows Hospital RTC 14425 College Boulevard Lenexa, KS 66215 Facility No. EIN: 48-1022176 The Menninger Clinic RTC 5800 S.W. Sixth Topeka, KS 66606-0829 EIN: 48-1036688 340.00 349.00 511.00 A4-5
APPENDIX A-4 TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 St. Francis at Salina, Inc. 5097 West Cloud Street Salina, KS 67401 EIN: 48-1030087 LOUISIANA DePaul Hospital 1040 Calhoun Street New Orleans, LA 70118 Facility No. 17-00157 EIN: 62-1410320 MISSISSIPPI CPC Sand Hill Hospital RTC Program 11149 Highway 49 North Gulfport, MS 39503 EIN: 95-3764550 MISSOURI Heartland Behavioral Health Svcs 1500 W. Ashland Nevada, MO 64772 Facility No. 24-00238 EIN: 43-1328523 Piney Ridge Center, Inc. 1000 Hospital Road P.O. Box 4067 Waynesville, MO 65583 Facility No. 24-00261 EIN: 43-1521295 NEVADA BHC Willow Springs Center 690 Edison Way Reno, NV 89502 Facility No. 49-00061 EIN: 88-0300031 279.00 426.00 491.00 A4-6
TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 APPENDIX A-4 NEW MEXICO Desert Hills Ctr for Youth & Family 5310 Sequoia, N.W. Albuquerque, NM 87120 Facility No. EIN: 74-2753620 NORTH CAROLINA Cumberland Hospital 3425 Melrose Road P.O. Box 42308 (28309) Fayetteville, NC 28304 Facility No. 31-00243 EIN: 56-0845796 OKLAHOMA Shadow Mountain Hospital 6262 South Sheridan Road Tulsa, OK 74133 Facility No. 34-00055 EIN: 73-1449306 SOUTH CAROLINA Charter of Charleston BHS 2777 Speissegger Drive Charleston, SC 29405 EIN: 58-1761157 TENNESSEE Charter Lakeside BHS 2911 Brunswick Road P.O. Box 341308 Memphis, TN 38133-4199 Facility No. 39-00174 EIN: 62-0892645 Pine Point Center 49 Old Hickory Blvd. Jackson, TN 38305 EIN: 62-1502599 441.00 320.00 291.00 476.00 445.00 A4-7
APPENDIX A-4 TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 TEXAS BHC Cedar Crest 3500 South IH 35 Belton, TX 76513 Facility No. 40-00774 EIN: 74-2669474 CRC of San Antonio 17720 Corporate Woods Drive San Antonio, TX 78259-3509 EIN: 74-2720152 CPC Millwood Hospital & CRC 1011 North Cooper Arlington, TX 76012 Facility No. 50-31490 EIN: 75-1757825 Healthcare Rehabilitation Center of Austin Box 43148 1106 West Dittmar Austin, TX 78745 Facility No. 40-00016 EIN: 74-2461514 Laurel Ridge Hospital 17720 Corporate Woods Drive P.O. Box 700590 San Antonio, TX 78259-3500 Facility No. 40-00765 EIN: 74-2388827 (D) Meridell Achievement Center 12550 Highway 29 West P.O. Box 87 Liberty Hill, TX 78642 Facility No. 40-00015 EIN 74-1655289 476.00 445.00 424.00 A4-8
TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 APPENDIX A-4 San Marcos Treatment Center Bert Brown Road P.O. Box 768 San Marcos, TX 78667-0768 Facility No. 40-00763 EIN: 74-2467014 (B) Southwest Mental Health Center 8538 Tom Slick Drive San Antonio, TX 78229 Facility No. 40-00690 EIN: 74-1153067 Devereux Foundation - Victoria Box 2666 120 David Wade Drive Victoria, TX 77902-2666 Facility No. 40-00021 EIN: 23-1390618 (D) The Oaks Treatment Center 1407 West Stassney Lane Austin, TX 78745 Facility No. 40-00764 EIN: 74-2416121 (C) Quest Hospital Adolescent RTC 7200 West 9th Avenue Amarillo, TX 79106 Facility No.: 00-00000 EIN: 75-2180841 UTAH CPC Olympus View Community Res Cntr 1430 East 4500 Salt Lake City, UT 84117 Facility No. EIN: 33-0176946 483.00 444.00 376.00 313.00 351.00 A4-9
APPENDIX A-4 TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 Rivendell of Utah 5899 West Rivendell Drive West Jordon, UT 84088 Facility No. 41-00745 EIN: 87-0436244 VERMONT Brattleboro Retreat-Tyler RTC 75 Linden Street Brattleboro, VT 05302 EIN: 03-0107360 VIRGINIA Charter Westbrook BHS 1500 Westbrook Avenue PO Box 9127 Richmond, VA 23227 EIN: 54-0858777 Poplar Springs 350 Poplar Drive Petersburg, VA 23805 EIN: 62-1637935 Valuemark - West End BHS 12800 West Creek Pkwy Richmond, VA 23238 Facility No. 42-00345 EIN: 58-2156548 The Pines Treatment Center 825 Crawford Parkway Portsmouth, VA 23704 Facility No. 42-00416 EIN: 54-1465094 (B) 293.00 397.00 498.00 A4-10
TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 APPENDIX A-4 WASHINGTON Community Residential Center at Fairfax 10200 N.E. 132nd Street Kirkland, WA 98034 EIN: 95-1907817 Tamarack Center 2901 West Fort George Wright Spokane, WA 99204-5202 EIN: 91-1216841 423.00 427.00 A4-11