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Applied Behavior Analysis Authorization Requirements

TRICARE is implementing changes to its Autism Care Demonstration (ACD). These changes will be implemented in phases throughout 2021. Find answers to frequently asked questions, view previous TRICARE-hosted webinars and sign up for email updates at www.health.mil/autism. For additional benefit details, visit www.tricare.mil/autism.

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Authorizations

Health Net Federal Services, LLC (HNFS) must authorize applied behavior analysis (ABA) services for all beneficiaries, including those with other health insurance. 

You can check the status of an authorization or download a copy of the approval letter by using our Check Authorization Status tool. 

Eligibility

TRICARE beneficiaries must meet one of the following qualifications to be eligible for ABA services under the ACD:

  • a dependent of an active duty service member enrolled in TRICARE Prime or TRICARE Select 
  • a retiree/retiree family member enrolled in TRICARE Prime or TRICARE Select
  • a National Guard and Reserve member or family member covered under TRICARE Reserve Select or TRICARE Retired Reserve
  • covered under the Transitional Assistance Management Program
  • covered under TRICARE For Life
  • a participant in TRICARE Young Adult
  • a participant in the North Atlantic Treaty Organization or Partnership for Peace
  • no longer TRICARE-eligible, but participates in the Continued Health Care Benefits Program 

Step 1 – Diagnosis and Referral

Beneficiaries must be diagnosed with autism spectrum disorder (ASD) to receive services under the ACD. The diagnosis must be from a TRICARE-authorized primary care manager (PCM) or specialist approved to diagnose ASD. 

Current approved ASD-diagnosing and referring provider types are: 

  • PCMs in the following specialties: pediatricians, family medicine physicians, internal medicine physicians
  • ASD-Diagnosing Specialists: physicians board-certified or board-eligible in behavioral developmental or neurodevelopmental pediatrics, pediatric neurology, or child psychiatry; PhD clinical psychologists; and specific board-certified Doctors of Nursing Practice (DNP) 

Diagnoses and referrals from nurse practitioners, physician assistants or other providers not meeting TRICARE’s qualifications will not be accepted.
 

As of Oct. 1, approved ASD-diagnosing and referring provider types are:

  • PCMs in the following specialties: pediatricians, pediatric family medicine physicians, pediatric nurse practitioners
  • ASD-Diagnosing Specialists: Physicians board-certified or board-eligible in developmental-behavioral or neurodevelopmental pediatrics, pediatric neurology, or child psychiatry; PhD clinical psychologists; and specific board-certified DNPs 

 

REFERRAL FOR ACD SERVICES

After diagnosing a beneficiary with ASD, your provider will submit a referral to HNFS. The referral request contains the following information:

  • age of the beneficiary
  • ASD diagnosis
  • date of initial diagnosis
  • co-morbid diagnosis (if applicable)
  • symptom severity level/level of support (if referral is from an ASD-diagnosing provider)
  • statement the beneficiary needs ABA
  • DSM-5 Diagnostic Checklist (as of Oct. 1, 2021)
     

REFERRAL VERIFICATION 

After receiving the referral for ABA services, HNFS will verify it to:

1. Ensure the referral meets all requirements per TRICARE policy and 

2. Confirm the beneficiary meets all ACD eligibility requirements.

Please allow 2–5 business days for HNFS to verify the referral requirements were met. 
 

TWO-YEAR REFERRAL CYCLE

Referrals for ABA services under the ACD are valid for two years.

Important: Existing ACD beneficiaries were notified of their transition to a new, chronological two-year referral timeline effective July 1. This may impact future reauthorizations as of Oct. 1. 
 

ACTIVE DUTY ELIGIBILITY AND ECHO

All active duty family members must be registered in the Extended Care Health Option (ECHO) program to participate in the ACD. Beneficiaries participating in the ACD will be given a provisional 90-day enrollment into the ECHO program to allow time to complete the registration process. Active duty family members who have not completed ECHO registration by the end of the 90th day of the provisional enrollment will be discontinued from ABA services. Visit our ECHO Registration page for additional information.

Step Two – Initial Assessment

Assiging Providers

After we have verified the referral for ABA services, we will assign it to an ABA provider. This process may take up to 15 business days. 

For referrals verified on or after Aug. 1, HNFS follows an “active provider placement” process when assigning providers to complete assessments. This ensures beneficiaries have access to an ABA provider within TRICARE’s access to care standards. If you have specific provider preferences, HNFS will try to accommodate, but ultimately we must select a provider who can meet access to care standards.
 

Determination letters

Once the referral for ABA services has been approved for an initial assessment, providers and beneficiaries can view a copy of the determination letter online. The letter contains contact information for the beneficiary and ABA provider. HNFS encourages beneficiaries to contact the ABA provider listed on the approval to set up the initial appointment if the ABA provider has not contacted the beneficiary within three days. 

Please contact our ACD customer service line if you:

  • Want to see a different provider than who is listed on the authorization.
  • Are unable to connect with the ABA provider within one week of the date on the determination letter.


Completing the initial assessment

Once a provider is identified, HNFS will authorize the initial assessment. Your assigned provider has 45 days to complete the initial assessment but is required to schedule the first visit with your child to begin the assessment within 28 days from when we first verified the referral. 

If you have preferred appointment times or locations for direct services, your provider may work with you to initiate parent training until your preferences can be accommodated. In these cases, access to care cannot be guaranteed.  

Please note: If you choose to waive access to care standards, you or your provider may be contacted by HNFS so we can document the waiver. 

 

INITIAL ASSESSMENTS

The authorized ABA supervisor (or assistant behavior analyst, if delegated by the ABA supervisor) will conduct the initial assessment. During the assessment, the ABA provider will: 

  • Directly observe, measure and record the beneficiary’s behavior;
  • Ask questions related to the beneficiary’s background, including questions about the beneficiary's condition, diagnoses, family history, and how long the beneficiary has been receiving ABA services;
  • Perform a functional assessment;
  • Gather data from parent/caregiver interview and parent report rating scales;
  • Review results of the parent PDDBI; and 
  • Develop a treatment plan. 

HNFS will contact you or your provider to confirm whether there were any delays in starting the assessment within TRICARE access to care standards. 

Outcome Measures

As of Aug. 1, 2021, HNFS must receive completed outcome measure scores before we can authorize treatment. If we have not received outcome measure scores from your provider, we may contact you to help with their completion. We will work with you to resolve any barriers you have to getting these completed.
 

Outcome Measure Tools

As of Aug. 1, TRICARE requires the following outcome measures for existing and new beneficiaries participating in the ACD based on their age: 

  • Pervasive Developmental Disorder Behavior Inventory (PDDBI), 
  • Vineland Adaptive Behavior Scales, 3rd Edition (Vineland-3), 
  • Social Responsiveness Scale, Second Edition (SRS-2), and
  • Either the Parenting Stress Index, Fourth Edition, Short Form (PSI-4) or Stress Index for Parents of Adolescents (SIPA).

We wil be unable to authorize continued ABA services until required outcome measures are completed.

The name of the person completing all outcome measures and their relationship to the beneficiary must be on all forms. 

Note: The PSI-4 and SIPA are standardized, reliable measures of stress and family dynamics that help to identify where additional support resources may benefit both the family and the beneficiary. The PSI-4 and the SIPA stress indexes and scores are not factors for treatment planning or coverage determination. 
 

Who Can Perform Outcome Measures

Outcome measures can be performed by TRICARE-authorized ASD-diagnosing providers or, when authorized by HNFS, ABA providers (BCBAs or BCBA-Ds).

  • The PDDBI must be completed by the treating ABA provider. 
  • For the other outcome measures, HNFS may proactively authorize beneficiaries to other ABA providers with the ability to complete the SRS-2, Vineland-3 and PSI-4/SIPA within access to care standards. This means for these outcome measures, you may be authorized to an ABA provider who is not your treating provider.  
     

When Are Outcome Measures Required

Outcome measures must be performed at the following intervals: 

Outcome Measure Baseline (must be done before HNFS can authorize treatment)  Every six months Every year
Parent PDDBI X X  
Teacher PDDBI   X  
Vineland-3 X   X
SRS-2 X   X
PSI-4 (age based) X X  
SIPA (age based) X X  

 

  • Baseline data is before the first treatment authorization. For beneficiaries new to the ACD only, we can accept the Vineland-3, SRS-2, SIPA, and PSI-4 scores for up to one year prior to the start of treatment.
  • Every six months/every year renewal dates are based on the date we receive the specific measure. 
  • The PSI-4 and SIPA have overlapping age ranges. The PSI-4 is appropriate for ages 0–12 years and the SIPA is appropriate for ages 11–19 years. For beneficiaries who are age 11–12 years at the time of reauthorization, either measure will be accepted. You do not need to do both.
  • Important: Outcome measures are completed within 90 days of their due date. If we receive outcome measure results too soon, you may need to repeat them within this time frame.

RENEWAL PERIOD

As of May 1, beneficiaries new to the ACD start on a one-year cycle for the Vineland-3 and SRS-2. Existing ACD beneficiaries have been transitioned from their current cycle to the new one-year cycle and were notified of their new dates. 

Future renewal periods will be based on the date the outcome measures are received by HNFS. This means each outcome measure may have its own chronological timeline based on date we received a valid and complete measure. 

HOW TO SUBMIT

Civilian providers can submit outcome measure scores to HNFS electronically. 

Beneficiaries and military hospitals or clinics can submit outcome measure scores via fax to 1-877-910-0945.

Authorization of Treatment

Once the initial assessment process is complete, your ABA provider will submit a treatment request to HNFS. 

HNFS will first verify the following is in place:

  • ACD eligibility
  • Treatment plan with parent goals/engagement 
  • Parent PDDBI scores
  • Outcome measures (required before HNFS can authorize treatment)
  • IEP, when applicable

Once the treatment request has been verified as complete, HNFS will begin the clinical necessity review process. 
 

Clinical Necessity Reviews

As of Aug. 1, 2021, HNFS is required to perform clinical necessity reviews on all treatment plans submitted by ABA supervisors before authorizing ABA services. HNFS staffs qualified, clinical reviewers (BCBAs, BCBA-Ds) to conduct these reviews to ensure the treatment plan coincides with the most appropriate level of care for your child. 

The clinical reviewer will evaluate:

  • The treatment plan
  • Outcome measures
  • Level of clinical support
  • Duration of services
  • Location of services, if applicable (such as school, community)
  • Goals and recommendations
  • Services requested that need to be revised or removed (such as services not covered under the ACD)

It can take HNFS up to five business days to complete the review. Clinical reviewers may request a consultation with the ABA supervisor to discuss elements of the treatment plan. After the consultation, we will either complete a coverage determination or request the provider submit an updated treatment plan for further review. 
 

ABA Service Settings

Part of the clinical necessity review process includes determining the appropriate location where ABA services may be rendered.  

Home

  • Beneficiary's residence 
  • Services rendered by all ABA provider types (as approved and specified in the treatment plan) 
  • Active delivery of ABA services that target the core symptoms of autism spectrum disorder
  • See also home-schooling information in the "School Settings" section below

Clinics/Centers

  • Outpatient clinic or center where beneficiaries receive ABA services
  • Services rendered by all ABA provider types (as approved and specified in the treatment plan) 
  • Active delivery of ABA services that target the core symptoms of autism spectrum disorder
  • Travel to and from a clinic/center not reimbursable 

Daycare (non-preschool):

  • Daycare centers, child development centers, after-school programs
  • Services rendered by all ABA provider types (as approved and specified in the treatment plan) 
  • Active delivery of ABA services that target the core symptoms of autism spectrum disorder
  • ABA provider may not function as support aide or observer during care routines or activities (e.g., lunch, group activities, arts and crafts, etc.) 

School Settings

  • Preschool, public school, private school, home school
  • Services rendered by ABA supervisors (as approved and specified in the treatment plan) 
  • Active delivery of ABA services that target the core symptoms of autism spectrum disorder
  • As of May 1, 2021, new authorizations for ABA services performed by behavior technicians (BTs) or assistant behavior analysts in a school setting not allowed (current authorizations to run through their expiration date) 

Other things to note about ABA services in school settings:

  • The ABA provider may not function as a support aide or observer during care routines or activities (e.g., lunch, group activities, arts and crafts, etc.). 
  • A current individualized education plan is required. ABA services may not duplicate IEP services.
  • Academic or educational goals are not covered under the ACD in any setting, including the school setting. 
  • If your child is homeschooled, authorized ABA services must be rendered outside of home-schooling hours. Home-schooling hours cannot overlap ABA services. 
  • Daycare centers/child development centers/after-school programs are not considered school settings under the ACD. (See “Daycare” section above.)

Please visit www.tricare.mil/ACD for additional information about school settings. 

Community settings

  • Any location not part of a home, outpatient ABA center or clinic, or school setting (includes grocery stores, parks, restaurants, and events such as youth sports or local community activities, as well as medical offices (e.g., doctor visits, physical therapy, etc.) 
  • Services rendered by all ABA provider types (as approved and specified in the treatment plan)
  • Active delivery of ABA services that target the core symptoms of autism spectrum disorder
  • Specific exclusions apply to sporting events, camps and medical appointments for the beneficiary or other family members.
  • Excludes ABA services rendered during other medical appointments (e.g., doctor visits, physical therapy, etc.), to include another family member's appointment.
  • Current authorizations approved prior to Aug. 1 will remain active through the end of the authorization period. 
  • For authorizations approved on or after Aug. 1, HNFS will make specific coverage determinations for ABA services in community settings during the treatment plan clinical necessity review process. 

Please visit www.tricare.mil/ACD for additional information about community settings. 

Telemedicine

  • Secure video conferencing to provide services to beneficiaries at home
  • Audio-only services not allowed under the ACD  
  • Active delivery of ABA services that target the core symptoms of autism spectrum disorder

Please note:

  • For authorizations approved prior to Aug. 1, outcome measures may be rendered via telehealth.
  • For authorizations approved on or after Aug. 1, outcome measures will not be allowed via telehealth, but may be rendered via indirect methods (see “Indirect” section below). 

Indirect

  • Telephone (no video), email, U.S. postal mail (e.g. report writing, reviewing records)
  • Outcome measures performed by TRICARE-authorized ASD-diagnosing providers or, when authorized by HNFS, ABA supervisors via indirect methods. 
     

Approved Authorizations

ABA treatment authorizations are approved in six-month increments. ABA providers may not be reimbursed for servcies rendered prior to the treatment authorization being approved. 

  • Providers and beneficiaries can view copies of treatment authorization determination letters online. 
  • Submitting a request to HNFS is not a confirmation of authorization.
  • HNFS will deny reimbursement for services performed outside the dates approved on the authorization.
  • HNFS does not issue backdated authorizations. If an authorization is canceled due to missing supporting documentation, the authorization will be re-issued from the date HNFS receives all required information. 

Please note: If you were approved for ABA services prior to Aug.1, your authorization remains active through the end of your approved authorization period. 


PARENT ENGAGEMENT AND TRAINING

An important component of a strong, clinical ABA program integrates parents by building their skill set on ABA principles to help them work effectively with their beneficiary to achieve treatment plan goals.

HNFS encourages ABA providers to engage parents early and often to increase confidence and competency. 

Authorization Changes

You (or your ABA provider) can request certain changes to current authorizations. We cannot make changes to expired authorizations.
 

Provider Changes

If you want to change ABA providers, contact our ACD customer service line for help locating a new provider. Please note, while in some instances you may be able to get a second opinion from a different ABA provider, ongoing care from two ABA providers is not permitted. 
 

Moving

We can help in the transfer of ABA services across regions when undergoing a Permanent Change of Station (PCS).

Moving from West (HNFS) to East (Humana Military):

  • Contact our ACD customer service line to notify us of your PCS date and request ABA-related documents previously submitted to HNFS be transferred to Humana Military. We will transfer the documents, including a copy of the ABA referral, the treatment plan and related assessments within 10 business days of the request. 
  • You may be eligible for case management services to assist in the process. Case management nominations can be made online or via the ACD customer service line.
  • Contact Humana Military for more information about receiving ABA services in the East.

Moving from East (Humana Military) to West (HNFS):

  • Contact Humana Military to notify Humana of your PCS date and request ABA-related documents previously submitted to Humana Military be transferred to HNFS. Humana Military will transfer the documents, including a copy of the ABA referral, the treatment plan and related assessments within 10 business days of the request. 
  • After enrollment has been transferred to the West, call HNFS to request an initial ABA assessment. Please mention whether you have already requested the ABA document transfer from Humana Military. 
  • We will honor valid Humana Military referrals in order to authorize initial assessments while care is being established with West region providers. All beneficiaries who transfer from the East Region must receive a new initial assessment and meet all ACD requirements prior to approval of ongoing care. (Beneficiaries must show as eligible in the West Region before HNFS can authorize services.)

Subsequent Authorizations 

If your child’s ABA provider recommends a continuation of ABA services beyond the current six-month treatment period, he or she will submit a new request to HNFS 30 to 60 days prior to the expiration of the existing authorization. 

Similar to the initial request for treatment authorization, HNFS will review the provider’s request for reauthorization to verify the following: 

  • ACD eligibility
  • Updated treatment plan that documents beneficiary progress
  • Parent and teacher PDDBI scores 
    • Teacher PDDBIs may only be completed by the ABA supervisor 
  • Outcome measures
  • An IEP, when applicable
  • Current two-year referral 

It also includes a new clinical necessity review of the treatment plan. HNFS will review all the prior areas outlined in the treatment plan as well as:

  • Progress toward improved symptom presentation
  • Parent engagement
  • Outcome measure changes 

Referral Cycle Check

When we receive requests to reauthorize services, HNFS verifies that your child’s exiting two-year ABA referral is still valid. The ABA referral is valid for two years; therefore, a new referral is not needed at each six-month authorization renewal period.

If the two-year referral will expire before the start of the next six-month authorization period, you will need to work with your TRICARE-authorized ASD-diagnosing and referring provider to obtain a new two-year referral. We will be unable to authorize ongoing services if the two-year referral on file has expired. 

Discharge Plan

Discharge plans are developed between ABA providers and beneficiaries, and include steps to transition care to the family when ABA services are no longer clinically or medically necessary. 

Grievances

A grievance is a written complaint or concern about a medical provider, HNFS or the TRICARE program in general. HNFS conducts a thorough investigation of any concerns and takes actions as necessary to improve services. Find details on the grievance process and how to submit on our Grievances page.

ACD Customer Service

If you have questions, please contact our ABA Customer Service team by phone at 1-844-866-WEST (9378), option 5 (during business hours) or by email at CS_ABA@healthnet.com.