Applied behavior analysis (ABA) providers must comply with medical documentation and billing requirements listed in the TRICARE Operations Manual (TOM), Chapter 18, Section 4; state and federal regulations; and provider participation agreements, policies and guidelines at all times. Providers who fail to demonstrate compliance are subject to additional education, payment recoupment, penalties, and/or more severe administrative actions as required by law and contract.
Health Net Federal Services, LLC (HNFS) reviews provider billing practices to verify services ABA providers bill TRICARE for are:
- TRICARE-approved services under the Autism Care Demonstration (ACD).
- Supported by clear and complete progress notes (medical documentation).
Please familiarize yourself with the types of reviews and guidelines.
Keys to Success
- Becoming familiar with TOM, Chapter 18, Section 4 requirements to ensure medical documentation and billing practices comply.
- Documenting all required elements in progress notes.
- Ensuring claims billed are supported by corresponding medical documentation.
- Providing services in line with TRICARE-approved adaptive behavior services (ABS) Current Procedural Terminology (CPT®) code definitions and requirements.
- Avoiding exclusions.
Autism Corporate Services Provider (ACSP) groups and sole ABA providers are subject to a minimum of 30 record reviews annually. These include administrative and medical documentation reviews and a review of one medical team conference progress note (if available).
Separately and ongoing, HNFS reviews CPT code billing practices of West Region ABA providers to ensure compliance with TOM requirements.
REVIEWS FOR NEW PROVIDERS
- HNFS monitors all new network and non-network ACSPs/sole ABA providers during their initial 180 days of participation in the TRICARE West Region.
- The 30 annual audits frequency that applies to current, established ABA providers does not apply to new providers.
- Following the initial 180 days, we will review a minimum of 10 records for clinical documentation and claims submission for consistency with program.
- We will share audit results with new providers and, if necessary, provide online education addressing inconsistencies with program requirements. Refer to the “Medical Documentation Review Process” section on this page for more details.
HNFS monitors ABA claims data to identify and prevent potentially fraudulent billing practices. Anti-fraud software is used to review claims data and detect potential issues that may include:
- High-dollar, erratic or inconsistent billing and coding patterns.
- Changes in billing frequency.
- Concurrent billing (i.e., billing for two services at the same time).
- Misrepresentation of provider (i.e., filing for a non-rendering provider or non-authorized provider).
- Claims patterns of “impossible days” (provider’s total claims exceed 12 hours per any given calendar day).
- Patterns of high rates of claim errors.
If suspect billing patterns are identified, HNFS engages providers to address the findings and provides education on TRICARE requirements to mitigate ongoing issues. Following the education (within 180 calendar days), HNFS conducts post-payment reviews to verify any suspect billing patterns are resolved. Providers with ongoing suspect billing patterns are referred to our Program Integrity Department.
Medical Documentation Reviews
HNFS conducts medical documentation reviews to ensure compliance with the requirements listed in TOM, Chapter 18, Section 4. These reviews evaluate whether:
- Claims are supported by corresponding medical documentation.
- Progress notes contain all required documentation elements.
- Services documented in progress notes comply with ABS-specific TRICARE-approved CPT codes.
- Any exclusions were rendered during the session.
Please visit our Progress Notes, Billing and Exclusions pages for additional details.
MEDICAL DOCUMENTATION REVIEW PROCESS
ACSPs/sole ABA providers submit medical documentation to HNFS in response to review requests. Please ensure you respond to review requests on or before the due date specified.
- HNFS contacts the ACSP/sole ABA provider to establish initial contact and verify contact information for the audit.
- HNFS sends a written medical documentation request to the ACSP/sole ABA provider.
- HNFS may contact the ACSP/sole ABA provider regarding the written request.
- ACSP/sole ABA provider responds to the written request promptly. Note: Documentation not received by the due date indicated in written requests will negatively impact the audit score.
- HNFS conducts a review to ensure medical documentation/records comply with ACD requirements.
- HNFS sends the ACSP/sole ABA provider a written summary detailing education requirements or findings resulting in recoupment.
- TRICARE requires education for failed audit results. If applicable, HNFS will assign education in the form of online modules targeting error types identified in a provider’s audit. Note: ACSP provider groups may determine which individual providers from their group are to complete assigned online training.
- ACSPs and sole ABA providers who take online training can download/print out their completed Attestation (with completion box checked) to retain for their records or, in the case of ACSPs, provide to their ACSP group or the individual providers at their company.
- HNFS staff will look for improvements specific to previous audit deficit areas but will also evaluate the severity of any new findings.
- HNFS follows up with a final group of reviews. Additional action may include but not be limited to probe audit, prepayment review and/or referral to the Program Integrity department.
Important notes regarding the review process and scoring
- Medical documentation received after the due date is a negative score.
- A determination indicating recoupment is necessary is a negative score. Note: If HNFS is responsible for an overpayment, this will not result in a negative score for the provider.
- HNFS determines review results using the calculation (Total Reviews – Negative Score Reviews) / Total Reviews. A final score of 75% or greater for all records is a passing score.
- Providers who do not achieve a passing score will be referred to the Program Integrity Department.
Audit findings and/or the provider’s final score in the audit may result in any or all of the following:
- Outreach and education
- Payment recoupment
- Referral to HNFS Program Integrity Department
- Probe audit
- Placement into prepayment review
Current Procedural Terminology Code Reviews
- Separate from the medical documentation reviews detailed in the previous sections, HNFS also reviews West Region providers’ billing practices to ensure compliance with ACD and TRICARE-approved ABS CPT code requirements. This includes verifying ABA supervisors render a minimum of one direct visit per month for CPT 97155.*
- Claims billed that do not meet ACD requirements are subject to denial or recoupment.
- Please visit our Billing page for more information on CPT code requirements.
*IMPORTANT: A 10% penalty will be applied to all claims for an authorization period in which the CPT 97155 requirement has not been met. Exception: The 10% penalty may be waived if no CPT 97153 services were rendered in a calendar month.