Applied Behavior Analysis Authorization Requirements
TRICARE is implementing changes to its Autism Care Demonstration (ACD). These changes will be implemented in phases throughout 2021. To learn more and to sign up for email updates, visit www.health.mil/autism.
In March and April, TRICARE hosted webinars about the ACD update. Find recordings and slides from these presentations at www.health.mil/autism.
For additional benefit details, visit www.tricare.mil/acd.
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.
TRICARE beneficiaries must meet one of the following qualifications to be eligible for ABA services under the Autism Care Demonstration:
- a dependent of an active duty service member enrolled in TRICARE Prime or TRICARE Select (Active duty family members must register for the Extended Care Health Option [ECHO] to participate in the Autism Care Demonstration. ECHO registration deadlines apply. Learn more on our registering for ECHO page.)
- 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 primary care manager (PCMs) or ASD-diagnosing specialist approved to diagnose ASD.
- family practice physicians
- internal medicine physicians
- pediatric physicians
Specialised ASD-diagnosing providers board-certified/board-eligible in:
- developmental behavioral pediatrics
- neurodevelopmental pediatrics
- child neurology
- adult or child psychiatry
- doctoral-level licensed clinical psychologist
- doctoral-level nurse practitioners
Currently, diagnoses and referrals from nurse practitioners, physician assistants or other providers not meeting TRICARE’s qualifications will not be accepted.
Referral for ACD Services
After diagnosing a beneficiary with ASD, your provider will submit a referral to HNFS.
Currently, if the initial diagnosis is made by the PCM, a specialized ASD diagnosing provider must confirm the diagnosis within one year. Effective July 1, 2021, TRICARE will no longer require a confirming diagnosis.
After receiving the referral for ABA therapy, HNFS will verify it to:
- Ensure it meets all requirements per TRICARE policy and
- 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: We are changing existing ACD beneficiaries to a new, chronological two-year referral timeline. We will notify those affected by July 1, as 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 Autism Care Demonstration (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
After we have verified the referral for ABA therapy, we will assign it to an ABA proviider. This process may take up to 15 business days.
Providers and beneficiaries can view copies of determination letters online.
We encourage you to contact the ABA provider listed on the approval to set up the initial appointment. 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.
An authorized ABA supervisor (or assistant behavior analyst) must conduct the initial assessment, which is used to develop a treatment plan.
Individualized Education Plans (IEP)
A current IEP is required for beneficiaries who are receiving services within a public or private school setting by the ABA supervisor.
Effective May 1, 2021, new authorizations for direct therapy services performed by behavior technicians (BTs) or assistant behavior analysts in the school setting will not be approved. (Current authorizations are permitted to run through their expiration date.) Direct therapy services will now only be authorized to the ABA supervisor (for authorizations approved on or after May 1). ABA provided in the school setting must be a 1:1 ratio rendered only by ABA supervisors (for authorizations approved after May 1). The definition of “school” includes preschool, public school and private school settings.
Discharge plans are developed between ABA providers and beneficiaries, and include steps to transition care to the family when ABA therapy is no longer clinically or medically necessary.
As of Aug. 1, 2021, we must receive completed outcome measures before we can authorize treatment. If we have not received outcome measures 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.
Note: There may be different providers completing each measure based on the preferences of the diagnosing provider.
Who Can Perform Outcome Measures
Outcome measures can be performed by TRICARE-authorized ASD-diagnosing providers or, when authorized by HNFS, ABA providers (BCBA or BCBA-D). We will refer outcome measures to our preferred outcome measure network of providers capable of performing all outcome measures within access to care standards. This means the you may be authorized to an ABA provider who is not your treating provider.
Outcome Measure Tools
TRICARE requires the following outcome measures for existing and new beneficiaries participating in the ACD based on their age:
- Vineland, 3rd Edition (Vineland-3),
- Social Responsiveness Scale, Second Edition (SRS-2),
- Parenting Stress Index, Fourth Edition (PSI-4) (new – effective Aug. 1, 2021),
- Stress Index for Parents of Adolescents (SIPA) (new – effective Aug. 1, 2021), and
- Pervasive Developmental Disorder Behavior Inventory (PDDBI).
The name of the person completing all outcome measures and their relationship to the beneficiary, is required on all forms.
Outcome measures must be performed at the following intervals:
||Baseline (must be done before HNFS can authorize treatment)
||Every six months
|PSI-4 (as of Aug 1, 2021), age based
|SIPA (as of Aug 1, 2021), age based
- Baseline data is before the first treatment authorization. For new beneficiaries only, we can accept the Vineland, SRS, SIPA, and PSI only up to one year prior to the start of treatment.
- Every six months and every year is measured from date we receive the specific measure. This date determines the next chronological interval.
- The PSI and SIPA have overlapping age ranges. The PSI is appropriate for ages 0–12 years and the SIPA is appropriate for ages 11–19 years. For beneficiaries ages 11–12 years at the time of reauthorization, either measure will be accepted. You do not need to do both.
As of May 1, beneficiaries new to the ACD will start on a one-year cycle for the Vineland and SRS-2. We are transitioning existing ACD beneficiaries from their current cycle to the new one-year cycle, and will notify beneficiaries of the new dates by July 1.
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 the receipt date of a valid and complete measure.
HOW TO SUBMIT
Civilian providers can submit outcome measures to HNFS electronically.
Beneficiaries and military hospitals or clinics can submit outcome measures via fax to 1-866-678-0615.
Authorization of Treatment
ABA treatment authorizations are approved in six-month increments. ABA providers may not render any services prior to the treatment authorization being approved.
- 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.
You (or your ABA provider) can request certain changes to current authorizations. We cannot make changes to expired authorizations.
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.
We can help in the transfer of ABA therapy 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 therapy 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 therapy 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.)
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.