Autism Care Demonstration: Referrals for Applied Behavior Analysis Services

After Health Net Federal Services, LLC (HNFS) has confirmed a beneficiary has met all initial eligibility and definitive diagnosis requirements for the Autism Care Demonstration (ACD), if not already received, the TRICARE-authorized primary care manager (PCM) or TRICARE-authorized autism spectrum disorder (ASD)-diagnosing and referring provider must submit an applied behavior analysis (ABA) referral to HNFS. 
 

Referral Submissions to Health Net Federal Services

TRICARE-authorized PCMs or TRICARE-authorized specialized ASD diagnosing and referring providers must submit a referral to HNFS requesting ABA services that contains all required elements.

As of Oct. 1, 2021, the following TRICARE-authorized provider types can diagnose and submit referrals:

Note: Adult beneficiaries who are no longer within the age range of pediatric ASD diagnosing and referring providers must be referred by a doctoral-level clinical psychologist or non-pediatric DNP.

Referral Requirements

ABA referral requests must contain the following:

• Diagnosis
• Comorbid diagnosis (if applicable)
• Symptom severity level/level of support  (1-mild, 2-moderate, 3-severe)
• Statement the beneficiary needs ABA services

Note:

If the beneficiary’s initial ASD diagnosis occurred after age eight, or it has been two or more years since the original diagnosis and this is the first ABA services referral under TRICARE's ACD, we will need a copy (if we do not already have one on file) of the TRICARE-authorized diagnosing provider's diagnostic evaluation with definitive diagnosis of ASD. 

Use the "comment" box to specify reason for referral in your online referral submission. (Military hospitals and clinics: Provide these details in lines 5 and 12 in Referral Management System [RMS] or the "Order Comment" field of Military Health System [MHS] Genesis.)
 

Referral Verification (2–5 Business Days)

After receiving the referral for ABA services, HNFS will:

1. Ensure the referral meets all requirements per TRICARE policy, and 
2. Confirm the beneficiary meets all ACD eligibility requirements.

Please allow two to five business days for HNFS to verify that referral requirements have been met. For incomplete referrals, HNFS will request additional information from the referring provider and pend the request for 10 business days. If the requested information is not received at the end of the tenth business day, the request will be canceled and additional information will need to be submitted to HNFS. 
 

Two-Year Referral Cycle

Referrals for ABA services under the ACD are valid for two years. HNFS cannot accept subsequent two-year referrals more than six months before the end of the current referral cycle. If we receive a subsequent referral more than six months before the current referral expires, the subsequent referral will be canceled as a duplicate. We will process each authorization request under this two-year referral, including provider changes and moving within the TRICARE West Region.
 

DSM-5 Diagnostic Checklist

A completed DSM-5 Diagnostic Checklist is required at enrollment and at each two-year referral renewal cycle.*

• The DSM-5 Diagnostic Checklist identifies the level of support required according to DSM-5 ASD criteria.
• Only TRICARE-authorized ASD diagnosing and referring providers are eligible to complete the checklist. ABA providers are not permitted to complete the checklist. 
  
  Note: The provider who completes the DSM-5 Diagnostic Checklist does not have to be the same provider who completed the original diagnosis. Learn more on our ACD Eligibility & Diagnostic Criteria page.

HNFS can accept a DSM-5 Diagnostic Checklist completed up to 180 days before the end of the referral due date. 

*For beneficiaries enrolled in the program prior to Oct. 1, 2021, HNFS will collect a completed DSM-5 Diagnostic Checklist at the next two-year referral cycle that occurs on or after Oct. 1, 2021, and at each subsequent two-year referral cycle.
 

Active Provider Placement

Once the beneficiary has a verified referral on file, HNFS will begin the process of finding an ABA provider group or sole ABA provider who can render ABA services within access-to-care standards. HNFS has 15 business days from the date we verified the referral to start this process. HNFS will notify beneficiaries once we have started. 

HNFS’ active provider placement process involves authorizing care based on the following:

1. Does the provider currently meet TRICARE’s access-to-care standards for initial assessments and treatment?
2. If more than one provider meets the first criteria, then which provider ranks highest in the steerage model? (Refer to "Steerage Model" below.)

Or, if a parent/caregiver prefers a specific provider and chooses to waive access-to-care standards (waiver must be documented with HNFS), we will authorize care to that provider.

When assigning providers:

1. HNFS contacts ABA providers to confirm availability for the initial assessment and treatment. 
   
   
2. HNFS attempts contact with the beneficiary and/or the parent/caregiver to discuss provider preferences and whether HNFS can meet them; however, ultimately, we will select a provider who can meet access-to-care standards.
   
   
3. HNFS authorizes the initial assessment to an ABA provider group. This assessment must be completed within 28 days, with day one being the date HNFS verified the referral. HNFS will update the start date of the approved initial assessment with the date of the verified referral to ensure ABA providers can independently calculate the 28 days to initiate the assessment process.  
   
   
4. Beneficiaries with preferred appointment times (for example, afternoons) and locations (for example, center-based) for direct services may need to initiate parent/caregiver training until preferences can be accommodated, and access to care is not guaranteed. During this time, the ABA provider can support the family under approved parent training Current Procedural Terminology (CPT^®) codes to target initial ABA principles and implementation until the beneficiary is receiving their full hours at their preferred times and locations.

HNFS will take directed referrals (referrals that name a specific provider) and parent/caregiver preferences into account during the active provider placement process; however, ultimately, HNFS will be required to select providers who will be able to meet the access-to-care standards (unless waived by the parent/caregiver). This includes preferences for location of services (center/clinic vs. home), time of day (morning, afternoon, evening, weekends) and specific providers or attributes.

Note: This process only applies to the initial assessment. HNFS does not apply active provider placement criteria when continuity of care has been established and providers are submitting initial or recurring treatment authorization requests.

Steerage Model

On Jan. 1, 2022, HNFS implemented a steerage model for network ABA providers participating in the ACD. A steerage model determines a provider’s ranking in the network based on their performance against a set of predetermined metrics. The ACD steerage model ranks ABA providers according to access-to-care standards and other quality measures that positively impact TRICARE beneficiaries.

HNFS’ steerage model ranks providers using three quality measures:

• Measure one is tied to the provider’s performance compared with TRICARE’s access-to-care standards for initial assessments (achieved when service delivery occurs within 28 days of the verified referral).
  
  
• Measure two is tied to the provider’s performance compared with TRICARE’s access-to-care standards for treatment (achieved when the last date of service of the assessment [CPT code 97151] in the 14-day window to the first day of adaptive behavior treatment [CPT does 97153, 97155, 97156, 97157, 97158] is in 28 days or less).
  
  
• Measure three is tied to the average number of days from the treatment authorization start date ("service from" date on authorization) to the first parent/caregiver training session (CPT codes 97156 and 97157). 

Note: If a parent requests a specific provider (due to preference on provider, location, time of day, etc.) and chooses to waive access-to-care standards, that provider’s steerage model ranking will not be impacted. 

Beneficiaries are able to search for autism spectrum disorder (ASD)-diagnosing providers, parent-mediated training and respite care providers in our separate ACD-specific directory, which displays results based on steerage model rankings and includes the new filter options.  

The next step is the initial assessment and treatment authorization. View ACD Authorizations – Initial Assessment & First Treatment for details. 

<< Return to the main ACD page.