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Applied Behavior Analysis Authorization Requirements

Eligibility

TRICARE beneficiaries who meet the following qualifications are eligible to receive ABA services under TRICARE's Autism Care Demonstration:

The beneficiary is:

  • 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, or
  • no longer TRICARE-eligible, but participates in the Continued Health Care Benefits Program 

Diagnosis (Autism Spectrum Disorder)

Eligible beneficiaries must have an autism spectrum disorder (ASD) (F84.0) diagnosed by a TRICARE-authorized physician primary care manager (P-PCM) or by a specialized ASD-diagnosing provider:

  • P-PCM specializing in family practice or pediatrics or internal medicine, or
  • Specialized ASD provider who is a physician board-certified or board-eligible in behavioral developmental pediatrics, neurodevelopmental pediatrics, pediatric neurology, or child psychiatry; PhD clinical psychologist working primarily with children; or board-certified doctor of nursing practice (DNP).*

    Note: Diagnoses and referrals from nurse practitioners, physician assistants and residents/students in organized health care, or other providers not having the above qualifications, will not be accepted unless the referral is co-signed by a P-PCM or ASD diagnosing provider in one of the approved specialties.

*For DNPs credentialed as developmental pediatric providers, dual American Nurses Credentialing Center (ANCC) board certifications are required as either a pediatric nurse practitioner or a family nurse practitioner, and either a child psychiatric mental health nurse practitioner, or a child psychiatric and mental health clinical nurse specialist. Eligible DNPs must also be trained and certified in the ADOS-2.

Beneficiaries diagnosed with ASD, Asperger’s Disorder, Rett Syndrome, Childhood Disintegrative Disorder (CDD) or Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) prior to October 20, 2014, may continue to be eligible for ABA services, as long as they meet current TRICARE policy criteria upon the next ABA benefit review. At which time, the diagnosis must indicate ASD (F84.0).

Authorization Requirements

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

Note: 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 and obtain approval for the initial assessment. Visit our ECHO Registration page for additional information.

  • Authorization requests must be submitted electronically and are processed within 2–5 business days once all required documentation is received.
  • Submitting a request to HNFS is not a confirmation of authorization. 
  • ABA providers can check the status of an authorization or download a copy of the approval letter by using our Check Authorization Status tool. 

Step 1 – Diagnosis and Referral

After diagnosing a TRICARE-eligible beneficiary with autism spectrum disorder (ASD), the physician primary care manager (P-PCM) or specialized ASD provider submits a referral electronically to HNFS. If the beneficiary is referred from a military hospital or clinic, the referral is submitted electronically by the military facility to HNFS.

Referral requests must contain the following elements:

  • age of the beneficiary,
  • ASD diagnosis*,
  • date of initial diagnosis,
  • co-morbid diagnosis (if applicable),
  • symptom severity (if referring provider is a specialized ASD diagnosing provider) and
  • statement the beneficiary needs applied behavior analysis (ABA).

*If the initial diagnosis is made by a P-PCM, the P-PCM must submit a referral for a specialized ASD diagnosing provider who must confirm the diagnosis of ASD within one year. Once the initial diagnosis has been confirmed, the PCM can submit referrals for each of the two year reauthorization cycles. A referral for ABA services from a specialized ASD-diagnosing provider is valid for two years. 

An outcome evaluation referral should be initiated by the referring provider. See Outcome Measures for additional information.

Step 2 – Initial Assessment

When HNFS receives the referral from the P-PCM or ASD diagnosing provider: 

  1. HNFS will review the request and contact the referring provider if additional information is needed. Once all required information is received, HNFS will complete processing of the request within 2-5 business days. 
  2. Once a referral has been approved, 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. 

How HNFS assigns ABA providers on the referral:

  1. If the requesting provider did not name a provider on the request, HNFS will assign to an ABA provider based on appointment availability. 
  2. If the requesting provider did name a specific ABA provider, HNFS will not check for appointment availability and will honor that request. 
    • Important: If the beneficiary wants the first available ABA provider, do not specify a provider on the referral.
  3. If the beneficiary wants to see a different provider than who is listed on the referral, he/she can contact our ACD customer service line for assistance in requesting a change to the approved referral.

Access to care:

  1. If the ABA provider and/or beneficiary are unable to contact with each other within one week, please contact our ACD customer service line for assistance.
  2. Beneficiaries with preferred appointment times and locations may need to work collaboratively with the ABA provider until preferences can be accommodated. During this time, the ABA provider is encouraged to provide increased amounts of parent training and support to allow the family to target initial ABA principles and implementation until the beneficiary is receiving their full hours at their preferred times and locations. 

Beneficiaries can request a change in ABA providers by calling our ACD customer service line. A new referral is not needed. 
 

Assessment details

An authorized ABA supervisor (or as delegated to an assistant behavior analyst) must conduct the ABA assessment, which is used to develop the treatment plan. This assessment must be initiated within the 28-day TRICARE access standard and completed by the 60-day authorization end date. 

If due to unforeseen circumstances, the ABA provider and/or beneficiary need additional time to complete the assessment, please contact our ACD customer service line and request an extension for the initial assessment. Please provide the rationale for the extension. A new referral is not required to extend the initial assessment.

All units billed for the assessment (up to 16 units) must be within a 14-day window. Please see our billing details section for more information on the 97151 CPT® code requirements. 

This assessment must include the following:

  • direct observation, measurement and recording of behavior;
  • background information that clearly demonstrates the beneficiary's condition, diagnoses, family history, and how long the beneficiary has been receiving ABA services;
  • functional assessment;
  • data from parent/caregiver interview and parent report rating scales;
  • authorized ABA supervisor recommendation for the number of weekly units of ABA services under the Autism Care Demonstration, to include the recommended number of weekly units for ABA interventions by the Board Certified Behavior Analyst (BCBA) or the Board Certified Assistant Behavior Analyst or QASP and behavior technicians; and
  • an evaluation using the parent PDD – Behavior Inventory™ (PDD-BI™). The PDD-BI has been expanded to cover beneficiaries from 2 years to 18.5 years old and is required for the initial assessment. Beneficiaries outside of that age range, below or above, will be exempt.
    • Providers must include the following composite T-scores when submitting the PDD-BI with the treatment plan: REPRIT/C, AWP/C, EXSCA/C, REXSCA/C, and autism.   
    • At the initial assessment, only the parent form should be completed (as the BCBA would not have had sufficient contact with the beneficiary).
    • Applied behavior analysis providers may use other assessment tools to assist in writing goals but the integration of the outcomes from the PDD-BI should be a component of goal development. Goals should be determined not only by the PDD-BI but also from direct observation and progress towards individual goals.

The following items may also be included in the assessment: 

  • Completed forms for the ABA provider to properly bill for services rendered, establish care and evaluate the beneficiary’ availability for ABA therapy (such as liability, insurance, release of information, etc.)
  • Additional measures and/or assessments the ABA provider uses within their scope of practice to evaluate baseline rates of behavior excesses and skill deficits. These may include, but are not limited to: ABBLS, Vineland-3, SRS-2, Functional Assessment Screening Tool (FAST), Carolina Curriculum, VB-MAPP, Assessment of Functional Living Skills (AFLS),  Assessment of Functional Living Skills (AFLS), Community-based Skill Assessment (CSA), Adaptive Behavior Assessment System Third Edition (ABAS-3), Gilliam Autism Rating Scale-2 (GARS-2), Essential for Living and The Essential Eight; Scales of Independent Behavior Revised (SIB-R). 


Individualized Education Plan (IEP)

A current IEP is required for beneficiaries who are receiving services within a public or private school setting. This requirement ensures each beneficiary’s engagement with community and school resources is included for a holistic-based ABA assessment. The information in an IEP may prove useful for current and future beneficiary needs. In addition, the level of support needed in a school setting can be helpful when determining the level of support needed in other settings such as the home. Academic goals are not permitted and goals should not overlap with IEP goals. ABA provided in the school setting must be a 1:1 ratio. All treatment plans must specify the location of services clearly to ensure that an IEP is received when TRICARE services are rendered in the school setting. 

Step 3 – Treatment Plan Review

Once the initial assessment is complete, authorized ABA supervisors must submit a copy of the treatment plan and the parent PDD-BI electronically. View our treatment plan guidelines in order to ensure the necessary requirements are included on each plan. All treatment plans submitted to HNFS after Jan. 1, 2019, must include Category I CPT® codes and corresponding recommended units. 

An integral component of a strong clinical ABA program is the engagement with parents to teach ABA principles, for parents to target skills and ensure generalization of skills.

  • The inclusion of parent training and goals in the treatment plan is an opportunity for the ABA provider to support parents in the implementation of ABA goals outside of program hours. 
  • HNFS strongly encourages parent training to be implemented immediately once the ongoing authorization is approved. 
  • The initiation of the parent training and parent implementation of ABA principles around Behavior Intervention Plans and parent goals can be done independent of the direct therapy hours once the ongoing authorization is approved.
  • As the direct therapy hours are scheduled and initiated, parent engagement and implementation can supplement the beneficiary’s hours to ensure ABA principles are integrated throughout their day. 

If HNFS needs to obtain additional clinical necessity information during the review of the treatment plan, HNFS will pend the request “Pended – BCBA Review” and send correspondence to the ABA provider requesting additional information. If the additional information is not received within three business days, the request will be cancelled until the additional information is provided by the ABA provider. 

After review, HNFS will issue an ABA authorization for six months. 

Step 4 – Reassessment (every six months)

Prior to the expiration of each six-month authorization period, the authorized ABA supervisor or Autism Demonstration Corporate Services Provider (ACSP) shall request re-authorization of ABA services.

  • Since the ABA therapy referral is valid for two years, a new referral is not required each six month period (see Step 1). 
  • If a new referral is required for the next two year period, HNFS will cancel the request “Cancel – No Valid MTF/PCM Referral” and notify the ABA provider and the beneficiary. 
  • ABA providers may submit up to 60 days prior to the end of the authorization period to ensure the maximum amount of time for continuity of care. 

The following must be submitted at least 30 days in advance for reassessment:

  • An updated treatment plan that has been updated within 60 days of the authorization expiration date and contains all the requirements listed in the TRICARE Operations Manual. The location of services must be clearly documented on the first page of the treatment plan to indicate if an IEP is necessary.
  • Parent and teacher PDD-BI scores. Providers are required to submit the following scores clearly and legibly, and label the PDD-BI to distinguish which is the parent and which is the teacher/BCBA reports: REPRIT/C, AWP/C, EXSCA/C, REXSCA/C, and autism. The teacher form may be completed by the BCBA. 
  • A current IEP (if the beneficiary is receiving any of the TRICARE hours in the school environment). 

If there is missing documentation, or any of the above-listed items are incomplete, HNFS will cancel the request using "Cancel – ACSP Missing Documentation" and notify the ABA provider and the beneficiary. Once the required documentation is gathered, the ABA provider must submit a new request and include that information. 

Providers must have an approved authorization from HNFS (with an authorization number) prior to rendering ABA services.

  • Submitting a request to HNFS is not a confirmation of authorization.
  • Do not continue to provide ABA services without an approved 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. 

Second Opinions

A second opinion may be warranted in cases where the treating Board Certified Behavior Analyst® (BCBA) lacks sub-specialty expertise to treat a specific target behavior that another BCBA may be specifically trained to address, or if the family/caregiver is not satisfied with the ABA provided by the currently authorized BCBA. When a BCBA seeks consultation from another authorized ABA supervisor, the primary BCBA will remain responsible for the treatment plan and is the sole provider authorized to bill for ABA services.

Families/caregivers may request a second opinion (evaluation only) from another authorized ABA supervisor by calling HNFS. However, only one ABA supervisor is authorized at a time for ABA services for each beneficiary. 

Authorization Changes

Applied behavior analysis (ABA) providers and beneficiaries can request certain changes to current (valid) authorizations. Health Net Federal Services, LLC (HNFS) cannot make changes to expired authorizations.

Unit Modifications

In order to request a change to the number of units authorized by HNFS, providers must submit a new request for ongoing services. If approved, HNFS will update the existing authorization.

This new request must:

  • Include an updated treatment plan that documents the reason for the change and any applicable modifications to the beneficiary's goals.
  • Specify the requested units for all CPT codes.
  • Match what is document in the treatment plan. 

Unit modifications may be approved when there is a significant change in the clinical status of the beneficiary resulting in a modification to the treatment plan and recommended units. These may include but are not limited to: 

  • the number of hours the beneficiary is receiving
  • the number of behavior excesses requiring management of the Behavior Intervention Plan (BIP)
  • the acquisition rate of the beneficiary
  • frequency and rate of modifications to maintain progress
  • the frequency needed to demonstrate modifications to the behavioral technician or parents
  • the complexity of the program requiring modifications
  • the level of generalization of mastered skills
  • the engagement and availability of the family 

Provider Changes

In the event a beneficiary would like to change ABA providers, he or she should contact our ACD customer service line and request a change of ABA providers.

  • HNFS will gather additional information and assist the beneficiary in facilitating the change based on the reasons and availability of other ABA providers. 
  • If the beneficiary has an active referral within the current two-year period, a new referral is not required for provider changes. 
  • In some instances, the beneficiary may be able to seek a second opinion initial assessment from the new provider prior to making the change. HNFS will discuss the options and assist in the transition. 
  • Ongoing care from two ABA providers is not permitted. 

Moving

Your regional contractor 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):

  • Beneficiaries can contact HNFS’ ACD customer service line to notify HNFS of their PCS date and request ABA-related documents previously submitted to HNFS be transferred to Humana Military. HNFS 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. 
  • Beneficiaries 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):

  • Beneficiaries can contact Humana Military to notify Humana of their 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 a beneficiary’s enrollment has been transferred to the West, he/she can call HNFS to request an initial ABA assessment. Please mention whether you have already requested the ABA document transfer from Humana Military. 
  • HNFS 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.)

Discharge, Termination and Provider Changes

Discharge plan

The process of establishing a discharge plan should occur during the initial assessment and each reassessment period.

  • A plan should be developed between the ABA provider and the beneficiary on the short and long term plan to generalize mastered skills, teach new skills in the natural environment and how to transition care to the family when ABA therapy is no longer clinically or medically necessary. 
  • When a beneficiary has met their ABA objectives and is ready for the discharge process, the ABA provider can recommend a step-down in frequency, intensity and duration of services to include an increased amount of parent training and support. 
  • When the beneficiary is ready to transition out of all direct therapy hours and the parents no longer need parent training, the ABA provider should notify HNFS they are discontinuing services and submit a termination report. 
     

Termination of services

In some scenarios, the termination of ABA services may be applicable and the beneficiary may contact HNFS to discussion the transition of care to a new provider.

  • HNFS can facilitate the transition of care to a new ABA provider, if applicable, and assist the beneficiary during this process. 
  • The ABA provider and/or the beneficiary should call our ACD customer service line to discuss termination from ABA services, provide a timeline for the transition and the justification for the termination. 


Provider changes

Please see our ACD Authorization Changes page. 

 

Outcome Measures

All beneficiaries participating in the Autism Care Demonstration must receive an outcome evaluation at baseline (within one year of initial diagnosis) and every two years thereafter while receiving services. 

As of Jan. 29, 2018, the Vineland, 3rd Edition (Vineland-3) and Social Responsiveness Scale, Second Edition (SRS-2) are the required outcome measures for this evaluation. The beneficiary's physician primary care manager (P-PCM) or a TRICARE-authorized specialized autism spectrum disorder (ASD) diagnosing provider can submit the referral for the outcome measures. 

Once referred, the measures can be performed by a TRICARE-authorized ASD-diagnosing provider in one of the following specialties:

  • developmental behavioral pediatrics
  • neurodevelopmental pediatrics
  • child neurology 
  • adult or child psychiatry
  • doctoral-level licensed clinical psychologist
  • doctoral-level nurse practitioners

If the specialized ASD diagnosing provider is not able to complete one or both of the outcome measures, he or she can submit a referral to Health Net Federal Services, LLC (HNFS) requesting a TRICARE-authorized ABA provider (BCBA or BCBA-D) complete them. An approval from HNFS is required for outcome measures performed by an ABA provider. HNFS authorizes one unit per measure for CPT® T1023.

Note: A P-PCM cannot refer a beneficiary to an ABA provider to perform the outcome measures. The referral must be submitted by the specialized ASD diagnosing provider. If the beneficiary’s current ABA provider does not conduct the outcome measures, HNFS will identify an alternate provider to complete the testing via telehealth.

TRICARE requires outcome measures be performed at the following intervals: 

  • Baseline: Within one year of the initial diagnosis the beneficiary must receive the Vineland-3 and SRS-2. 
  • Every two years: Every two years the beneficiary must receive the Vineland-3 and SRS-2.
     

How to Submit

  • ABA providers and civilian specialized ASD diagnosing providers can submit a copy of the testing on behalf of the beneficiary online. (Use the P154 – Outcome Measures request type.)
  • A military hospital or clinic can submit the request via fax to 1-866-678-0615.

 

You can also 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.