Overview
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. HNFS will make specific coverage determinations for ABA services, to include locations, provider types, units, etc., during the treatment plan clinical necessity review process. ABA providers should familiarize themselves with TRICARE requirements for the various settings.
Settings
Home
Definition: Beneficiary's residence
Eligible provider types: All ABA provider types (if authorized and as specified in the approved treatment plan)
Place of service code: 12
Details: See also home-schooling information in the "School Settings" section below.
Clinics/Centers
Definition: Outpatient clinic or center where beneficiaries receive ABA services
Eligible provider types: All ABA provider types (if authorized and as specified in the approved treatment plan)
Place of service code: 11
Details: Travel to and from a clinic/center is not reimbursable.
Daycare (non-preschool)
Definition: Daycare centers, child development centers, after-school programs
Eligible provider types: All ABA provider types (if authorized and as specified in the approved treatment plan)
Place of service code: 99
Details: A non-preschool daycare setting may be considered an eligible location as long as active delivery of ABA services that target the core symptoms of autism spectrum disorder occurs, and the ABA provider does not function as a support aide or observer during care routines or activities (e.g., lunch, group activities, arts and crafts, etc.). The use of these settings must clearly be outlined in the treatment plan including why a home or center location cannot be utilized and how caregivers are incorporated.
School Settings
Definition: Preschool, public school, private school, home school
Eligible provider types:
- ABA supervisors providing active delivery of ABA services (if authorized and as specified in the approved treatment plan).
- As of May 1, 2021, new authorizations for any service performed by behavior technicians (BTs) or assistant behavior analysts under Current Procedural Terminology (CPT®) code 97153 in the school setting will not be approved. Current authorizations are permitted to run through their expiration date but will not be renewed with the BT or assistant behavior analyst rendering direct ABA services in the school setting.
Details: HNFS may authorize ABA supervisors to provide active delivery of ABA services in the school setting under CPT code 97153, targeted to the core symptoms of autism spectrum disorder (ASD). These approved ABA services are focused, time-limited, and in accordance with the requirements of the Autism Care Demonstration (ACD). All exclusions as identified in the ACD under TRICARE Operations Manual, Section 18, Chapter 4 apply.
- A current Individualized Education Program (IEP) is required for beneficiaries if the initial assessment indicates a request for direct ABA services within a public or private school setting by the ABA supervisor under CPT 97153.
- ABA providers are not permitted to render duplicate services to those documented in the IEP.
In the recommendation section of the treatment plan, ABA providers must distinguish between the units rendered in the school setting by the ABA supervisor and the units rendered by the BT or assistant behavior analysts in other locations (i.e., home, center/clinic). ABA supervisors must also designate which specific treatment goals will be targeted in the school setting, the anticipated duration, as well as the fading plan. ABA services approved in the school setting should be for a limited duration.
For a beneficiary who is enrolled in home-schooling, authorized ABA services must be rendered outside of home-schooling hours. Home-schooling hours cannot overlap ABA services.
Academic/educational goals are excluded in all settings, including the school setting. ABA supervisors who have been authorized by HNFS to render ABA services in the school setting are still excluded from targeting educational, academic, and/or vocational areas. ABA is not a replacement for academic needs and/or related areas.
Community Settings
Definition: Any location not part of a home, outpatient ABA center or clinic, or school setting. Community settings include grocery stores, parks, restaurants, and events such as youth sports or local community activities. Community settings also include medical offices (e.g., doctor visits, physical therapy, etc.).
Eligible provider types: All ABA provider types (if authorized and as specified in the approved treatment plan)
Place of service code: 99
Details: For authorizations approved on or after Aug. 1, 2021, HNFS will make specific coverage determinations for ABA services in community settings (to include provider types, units, etc.) during the treatment plan clinical necessity review process.
Specific exclusions apply to sporting events, camps and medical appointments for the beneficiary or other family members. Community locations and activities do not allow for frequent and repeated presentation of treatment opportunities and often target areas not specific to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition's (DSM-5) ASD diagnostic criteria. For example, community settings that address daily living and vocational skills will be excluded from treatment requests. Travel in a vehicle is also an excluded activity for ABA treatment and billing. These portions of any approved community location must not be included in the rendered time of the appointment.
Possible situations in which use of a particular community setting may be approved include:
- When a beneficiary presents with substantial levels of impairment in the core symptoms of ASD and/or severe behavior excesses that have the potential to cause harm to self or others.
- On a limited basis, for social and communication generalization opportunities that would not be possible in the home or center/clinic setting when behavior excesses are significant.
When requesting approval for treatment in a community setting, the setting must directly coincide with treatment related to the DSM-5 (or current version) descriptions of ASD. For example, if a parent reports significant behavior excess that prevents a beneficiary from engaging in a community setting, the provider may request to use that community setting for behavior intervention and parent training specific to these needs.
Community location exclusions and prior authorization requirements apply to all ABA provider types. HNFS will make specific coverage determinations on provider types during the clinical necessity review process. When prior authorized, any ABA provider type may offer ABA services in a community setting under CPT 97153. When the ABA supervisor or assistant behavior analyst is conducting program modification in the community setting, they will use CPT 97155. When an ABA supervisor or assistant behavior analyst is conducting parent training in the community setting, they will use CPT 97156.
Family/caregiver support is critical for beneficiaries generalizing mastered skills into community settings. Family members who are targeting new skills in the community setting should refer to parent training and parent training goals for guidance, as well as feedback and direction from the ABA supervisor or assistant behavior analyst.
Academic/educational goals are excluded in all settings, including the community setting. ABA supervisors and assistant behavior analysts, when prior authorized to render ABA services in the community setting, are still excluded from targeting educational/academic/vocational area.
TRICARE excludes ABA services rendered during other medical appointments (e.g., doctor visits, physical therapy, etc.), to include another family member's appointment.
Indirect
Definition: Email, U.S. postal mail (e.g. report writing, review records)
Eligible provider types: TRICARE-authorized ASD-diagnosing providers or, when authorized by HNFS, ABA supervisors
Place of service code: 99
Details: Applies to rendering of outcome measures
Telemedicine
Definition: The use of secure video conferencing to provide medically and psychologically necessary services to beneficiaries at home. Specific technical requirements, outlined in TRICARE Policy Manual, Chapter 7, Section 22.1, must be met. Telehealth services may be synchronous (two-way audio and video, such as real-time video) or asynchronous (one direction at a time, such as submitting medical history from one party to another). Audio-only services are not allowed under the ACD.
Eligible provider types: ABA supervisors and assistant behavior analysts, based on CPT code (if authorized and as specified in the approved treatment plan)
Place of service code:
- March 31, 2020 through July 31, 2021: Place of service 02 with GT or 95 modifier
- As of Aug. 1, 2021: Place of service 02 or the most appropriate place of service code that allows for accurate billing, with GT or 95 modifier.
The modifier, required for synchronous telehealth, allows the distant site provider to certify the beneficiary or parent was present at an eligible originating site when the telemedicine service was rendered.
Details:
Services billed under CPT 99366 and 99368 may be rendered via telehealth when authorized and performed by ABA supervisors.
Services billed under CPT 97156 may be rendered via telehealth when authorized and performed by ABA supervisors or assistant behavior analysts. Behavior technicians cannot render CPT 97156 services.
- Update to CPT 97156 COVID-19 provision:
- Unlimited parent/caregiver telehealth ended on July 31, 2022.
- Effective July 1, 2022, and implemented on Sept. 6, 2022, TRICARE ended the telehealth copayment waiver previously in place due to the COVID-19 pandemic.
- For authorizations approved on or after Aug. 1, 2021: TRICARE will only reimburse for CPT 97156 services rendered via telemedicine if authorized.
- CPT 97156 services may not exceed eight units per day or the maximum units/month authorized.
- TRICARE will allow for the same-day rendering of CPT 97156 via telemedicine and direct services.
- The first CPT 97156 session must take place within the first 30 calendar days of the treatment authorization.
- Telehealth for CPT 97156 will only be authorized after the initial six-month treatment authorization period has completed.
Services billed under CPT 97151, 97153, 97155, 97157, and 97158 are prohibited for delivery via telehealth.
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