Overview
All beneficiaries must have complete, valid outcome measure scores for Health Net Federal Services, LLC (HNFS) to process treatment authorization requests.
Outcome measures help providers develop treatment plans and evaluate patient improvements (or regression). Under the Autism Care Demonstration (ACD), TRICARE requires the following age-based outcome measures for beneficiaries:
Additional age-based outcome measures that evaluate parent stress are also required; however, they are not used for developing treatment plans or evaluating patient improvements. Research has shown that parents’ stress levels can impact their child and their child’s environment, which in turn may affect their child’s symptoms. The Parenting Stress Index, Fourth Edition Short Form (PSI-4-SF) and Stress Index for Parents of Adolescents (SIPA) are standardized, reliable measures of stress and family dynamics that help identify where additional support resources may benefit both the family and the beneficiary.
- PSI-4-SF (0 years–12 years and 11 months) or
- SIPA (11 years–19 years and 11 months)
Important: The PSI-4-SF and SIPA have overlapping age ranges. The PSI-4-SF is appropriate for beneficiaries ages 0 years through 12 years and 11 months, and the SIPA is appropriate for individuals ages 11 years through 19 years and 11 months.
- For beneficiaries ages 11 years through 12 years and 11 months at the time of authorization/reauthorization, either the PSI-4-SF or SIPA will be accepted.
- For beneficiaries older than 12 years and 11 months at the time of authorization/reauthorization, the SIPA will be accepted.
Note: HNFS will not request protocols, questions or other assessment materials. See below for frequency details. The two required age-based outcome measures – the PSI-4-SF and SIPA – must be administered before HNFS can authorize initial treatment, and then every six months thereafter. Similar to other outcome measures, providers submit only the PSI-4-SF or SIPA scores (not the protocols, questions or other assessment materials) to HNFS.
Performing Provider
Outcome measures can be performed by TRICARE-authorized autism spectrum disorder (ASD)-diagnosing providers or, when authorized by HNFS, applied behavior analysis (ABA) providers (Board Certified Behavior Analyst® [BCBA®], Board Certification Behavior Analyst – Doctoral® [BCBA-D®], licensed behavior analyst [LBA], or clinical psychologist) who can administer the Vineland-3, SRS-2 and PSI-4-SF/SIPA.
Authorizations
HNFS can authorize outcome measures directly to ABA providers without a referral from the ASD diagnosing and referring provider. While the treating ABA provider is required to administer the PDDBI, HNFS may proactively authorize existing beneficiaries to our preferred network of ABA providers who can complete the Vineland-3, SRS-2 and PSI-4-SF/SIPA to meet access-to-care standards. This means the beneficiary may be authorized to a provider who is not the beneficiary's ABA treating provider.
Note: The PDDBI will continue to be authorized in initial assessments and treatment authorizations for the approved treating ABA supervisor. The ABA supervisor is required to execute the PDDBI Parent Form with the beneficiary's parent/caregiver and complete the PDDBI Teacher Form, when applicable.
HNFS completes a separate authorization for outcome measures (Vineland-3, SRS-2, PSI-4-SF/SIPA) to prevent overlap between the reassessment/PDDBI units and the outcome measure units, as both are under Current Procedural Terminology (CPT®) code 97151.
Treating ABA providers who prefer to complete all ABA outcome measures (Vineland-3, SRS-2, PSI-4-SF/SIPA) for their existing TRICARE patients can submit a request for authorization through a treatment plan update. Requests submitted outside of a treatment plan update will be canceled.
Keep in mind:
- If HNFS has already authorized a beneficiary to another ABA provider for the Vineland-3, SRS-2 and PSI-4-SF/SIPA, the treating ABA provider may submit an authorization request to complete these through the treatment plan at the next reassessment renewal period.
- Treating ABA providers who do not have the ability or expertise to render the Vineland-3, SRS-2 and PSI-4-SF/SIPA can defer to HNFS to authorize these outcome measures to another ABA provider.
- Treating ABA providers who do wish to complete all outcome measures for existing TRICARE patients must be able to complete all additional measures (Vineland-3, SRS-2, PSI-4-SF/SIPA). In other words, outcome measure authorizations for the Vineland-3, SRS-2, PSI-4-SF/SIPA will only be issued to one provider. HNFS will not authorize multiple providers for the same outcome measure and will not divide the Vineland-3, SRS-2, PSI-4-SF/SIPA among multiple providers.
Requirements
The Vineland-3 and SRS-2 must be completed prior to the start of treatment and annually thereafter. The PSI-4-SF or SIPA must be completed prior to the start of treatment and every six months. The PDDBI Parent Form must be completed prior to the start of treatment and every six months thereafter. The PDDBI Teacher Form (to be completed by the treating ABA supervisor only) must be completed every six months.
Required Outcome Measures Intervals
Outcome Measure |
Baseline |
Every 6 Months |
Every Year |
Performed/
Administered By |
---|
PDDBI Parent Form |
X |
X |
|
Treating ABA supervisor (Or delegated to assistant behavior analyst) |
PDDBI Teacher Form |
|
X |
|
Treating ABA supervisor (Cannot be delegated) |
Vineland-3 |
X |
|
X |
TRICARE-authorized ASD-diagnosing providers or, when authorized by HNFS, ABA providers (BCBA, BCBA-D, LBA, clinical psychologist) who can administer the Vineland-3, SRS-2 and PSI-4-SF/SIPA |
SRS-2 |
X |
|
X |
TRICARE-authorized ASD-diagnosing providers or, when authorized by HNFS, ABA providers (BCBA, BCBA-D, LBA, clinical psychologist) who can administer the Vineland-3, SRS-2 and PSI-4-SF/SIPA |
PSI-4-SF (age based) |
X |
X |
|
TRICARE-authorized ASD-diagnosing providers or, when authorized by HNFS, ABA providers (BCBA, BCBA-D, LBA, clinical psychologist) who can administer the Vineland-3, SRS-2 and PSI-4-SF/SIPA |
SIPA (age based) |
X |
X |
|
TRICARE-authorized ASD-diagnosing providers or, when authorized by HNFS, ABA providers (BCBA, BCBA-D, LBA, clinical psychologist) who can administer the Vineland-3, SRS-2 and PSI-4-SF/SIPA |
- Baseline data is before the first treatment authorization. For new beneficiaries only, HNFS can accept the completion of the outcome measures (Vineland-3, SRS-2, PSI-4-SF/SIPA only) up to one year prior to the start of treatment.
- Every six months and every year is measured from the date HNFS receives the specific outcome measure. This date determines the next chronological interval after we complete all realignments.
- The PSI-4-SF and SIPA have overlapping age ranges. The PSI-4-SF is appropriate up to age 12 years and 11 months, and the SIPA is appropriate for beneficiaries ages 11 years through 19 years and 11 months. For beneficiaries ages 11 years to 12 years and 11 months at the time of authorization/reauthorization, either measure will be accepted. For beneficiaries older than 12 years and 11 months, they will need to complete the SIPA.
Important: Outcome measure renewals must be performed within 90 days of their due date. If HNFS receives outcome measure renewal results more than 90 days from their due date, they will be canceled, and the outcome measure will need to be repeated within the prescribed time frame. Additional compensation for repeated outcome measures will not be approved.
HNFS cannot approve treatment authorizations until outcome measures have been completed, and we have received valid scores for all required outcome measures.
Renewal Periods
Beneficiaries new to the ACD will start on a one-year cycle for the Vineland-3 and SRS-2.
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 outcome measure.
Evaluating Progress
For more information on requirements, refer to our Autism Care Demonstration Clinical Necessity Reviews: Evaluating Treatment and Outcome Measure Progress guide.
Submitting Results
Outcome measure results must include the full publisher print report or hand-scored protocol and summary score sheet(s).
Note: Outcome measure results embedded in treatment plans or other clinical documents will not meet submission requirements.
- ABA providers and civilian specialized ASD-diagnosing providers can attach a copy of the outcome measure results through our online authorizations submission tool (log in required). (Provider log in required. Use the P175 – Outcome Measures request type.)
- Beneficiaries and military hospitals or clinics can submit outcome measures via fax to 1-877-910-0945.