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Autism Care Demonstration: Frequently Asked Questions

The Defense Health Agency (DHA) published changes to the Autism Care Demonstration (ACD) that is being implemented in phases in 2021.

Please visit www.health.mil/autism to review DHA's comprehensive list of frequently asked questions (click "open" to view the pdf):

If you have questions specific to TRICARE policy, please email DHA at dha.acd@mail.mil

Find additional details, including information specific to the TRICARE West Region, in our FAQs below.

General

Q: What is an ACSP?
A
: The Defense Health Agency (DHA) refers to applied behavior analysis (ABA) centers, groups and clinics as ACD Corporate Services Providers, or ACSPs. ACSPs frequently have contractual agreements with ABA supervisors, and assistant behavior analysts and behavior technicians who operate under supervision.

Q: What is a sole provider?
A
: A sole provider is an ABA supervisor (BCBA, BCBA-D or state licensed/certified ABA provider) who runs an individual practice and delivers direct 1:1 services.

Q: What are the new provider requirements under the ACD?
A
: Some of the new requirements include:

  • Participation agreements: All ACSPs/sole providers must have re-signed ABA participation agreements on file with HNFS.
  • Parent training: Providers must initiate parent training within 30 days of the treatment authorization. Providers also must conduct a minimum of six parent training sessions per authorization period.
  • Program modification: ABA supervisors must render a minimum of one direct visit per month for CPT® 97155 services or a 10% penalty will be applied to all claims for the authorization period.
  • Provider training: Providers must participate in an annual online provider training.
  • Provider rankings and steerage: HNFS will be implementing a steerage model and ranking ABA providers according to quality measures that positively impact beneficiaries. ABA providers who rank highest in the steerage model will be given priority placement in HNFS’ Network Provider Directory and referral assignments within the Access to Care standards.

Please review our ACD Implementation Timeline for additional requirements and dates. We encourage you to review the complete TRICARE Operations Manual, Chapter 18, Section 4 revision, available at https://manuals.health.mil

Provider Participation Agreement

Q: Why are providers being asked to sign new ACD Participation Agreements (or amendments to Agreements)?
A: Per guidelines outlined in the TRICARE Operations Manual, Chapter 18, Section 4, ACD Corporate Services Providers (ACSPs) and sole providers must sign new ACD Participation Agreements. 

Q: What is the process for signing the participation agreements? When will new agreements be sent out and how do we return them?
A: HNFS began the process of reaching out to providers in May with updated participation agreements. 

Network providers are asked to sign and return the participation agreement to: 

HNFS Provider Management
P.O. Box 9410
Virginia Beach, VA 23450-9410 

Non-network providers are asked to sign and return non-network participation agreements to:

TRICARE West 
Provider Data Management
P.O. Box 202106
Florence, SC 29502-2106 

Fax: 1-844-730-1373

Q: What if I do not sign a new ACD Participation Agreement?
A
: HNFS is required to submit a list of providers who do not have updated, signed participation agreements on file by Aug. 1, 2021 to DHA for possible termination from program participation.

Q. I am an East Region provider. Why did I receive a letter from HNFS?
A. HNFS mailed notices containing TRICARE West Region ACD Participation Agreements to some East Region providers. In order to be reimbursed for services provided to a TRICARE West beneficiary, you must have a TRICARE West Participation Agreement on file. If you are an East Region provider who will not be treating TRICARE West beneficiaries, you may ignore the communication. However, if you believe you may treat a TRICARE West beneficiary in the future, you must sign and return the materials.    

Q: Why are providers being asked to submit liability insurance?
A: ACSPs and sole providers must continue to submit proof of liability insurance in the amounts of $1 million per occurrence and $3 million in aggregate; unless state requirements specify greater amounts. The policies must be in the ACSP’s or sole provider’s name.

Q: Where do network providers send copies of insurance policies?
A: Network providers will return insurance policy information to the HNFS point of contact listed in HNFS' email communication to the ACSP or sole provider.

Q: Do non-network providers have to re-sign non-network applications and submit insurance policy information?
A
: Yes. PGBA, our claims processing partner, is reaching out to non-network providers separately. Non-network application information is also available at www.tricare-west.com.  

Q: Will a copy of the signed participation agreement be returned to network and non-network providers? 
A: Upon receipt of your signed contract/agreement materials, HNFS will execute the Provider Participation Agreement and provide you with a signed copy for your records within 30 days.  

Q: Regarding provider participation requirements, is the initial term period of two years negotiable?  We typically like to have one-year terms that renew yearly unless one party terminates.
A
: HNFS’ provider participation agreements are evergreen, meaning that they don’t expire. However, provider participation agreements are ‘at will’ and providers are free to terminate after one year if they choose.

Q: Our company has grown since we originally signed our participation agreement. Do we need to do anything else before July 1, 2021?
A
: Providers should submit an updated TRICARE Provider Roster anytime a provider is added or terminated from the group or when there is a change to demographics or credentialing information. Updated provider rosters can be submitted to HNFS_ABARosters@hnfs.* 

As of July 1, the new dedicated ABA email address for submitting new and updated rosters is HNFS_ABARosters@hnfs.com. Provider groups will also use this email address to submit supporting documentation for behavior technicians (BTs). (For providers other than BTs who need to submit supporting documentation for credentiaing, HNFS will notify you if/when documentation is required and how to submit it.)

Provider Credentialing & Certification Requirements

Q: Regarding behavior technicians (BTs), does the state license suffice (Behavior Analyst Interventionist (BAI)) or is the national Registered Behavior Technician (RBT) certification required?
A
: BTs must hold one of the following prior to applying for TRICARE-authorized provider status: 

  • current Registered Behavior Technician (RBT), 
  • Applied Behavior Analysis Technician (ABAT), 
  • Board Certified Autism Technician (BCAT) certification, or 
  • state certification (required if state certification is available).

Q: Am I required to submit a copy of my CPR – Basic LIFE Support (BLS) certification to HNFS?
A: Yes. HNFS must collect copies of CPR/BLS certification from ABA providers. As of July 1, we collect these during the initial credentialing process for ABA supervisors and assistant behavior therapists, and during the initial certification process for behavior technicians (BTs) (or recredentialing/recertification if not already on file). Note: Groups adding new BTs on or after July 1 must submit copies of the CPR/BLS certification with the updated roster in order for HNFS to meet the required 10-day turnaround for BT certification. 

Q: Will HNFS accept CPR/BLS only from certain certifying bodies? And if so, which ones?
A
: HNFS will accept CPR/BLS certification from any certifying body that meets the requirements listed in TRICARE Operations Manual Chapter 18, Section 4 as follows: 

  • Complete the training for Basic Life Support (BLS) or a Cardiopulmonary Resuscitation (CPR) equivalent certification, as demonstrated by completion of a hybrid course comprised of a web-based instruction component and live component to demonstrate skills on a dummy. Any entirely, in-person course is also acceptable. The certification must be maintained and current.

Q: Am I required to submit a copy of my criminal history background check to HNFS?
A
: Yes. HNFS must collect copies of criminal history background checks from ABA providers. As of July 1, we collect these during the credentialing process for ABA supervisors and assistant behavior therapists, and during the certification process for BTs (or recredentialing/recertification if not already on file). HNFS runs the background checks for all sole providers. Note: Groups adding new BTs on or after July 1 must submit copies of the criminal history background check with the updated roster in order for HNFS to meet the required 10-day turnaround for BT certification. 

Q. Will the contractor perform the criminal background check or do we pay for the background check and send the contractor a copy with the application? 
A
: HNFS collects copies of criminal history background checks from ABA providers. As of July 1, we collect these copies during the initial credentialing process for ABA supervisors and assistant behavior analysts and with roster submissions during the initial certification process for BTs (or recredentialing/recertification if not already on file). Please note, HNFS runs the background checks for all sole providers.

Q: We currently use a background company of our choice for background checks. Is this acceptable?
A
: Providers can use the background check company of their choice, as long as it fulfills the background check requirements outlined in the TRICARE Operations Manual, Chapter 18, Section 4. This includes, but is not limited to, the requirement that criminal history background checks of ABA supervisors, assistant behavior analysts and BTs must include current federal, state and county criminal and sex offender reports for all locations the ABA supervisor, assistant behavior analyst or BT has worked or resided in over the past 10 years.  

Q: How often should the background check be completed? 
A
: Copies of background checks are required during initial credentialing for ABA supervisors and assistant behavior analysts, and initial certification for behavior technicians. For existing ABA providers, HNFS will collect a copy of the background check during recredentialing/recertification if not already on file.

Q: Is there a maximum timeframe between the initial run of the background check and when it's submitted (i.e., completed within 45 days of submission)? Is a background check run at the time of hire acceptable? 
A
: Submission of background check results run at the time of hire are considered current. Provider groups are responsible to continuously monitor their providers after the initial criminal history background check is run and report to the contractor any change in a provider's status that disqualifies the provider from participating in ACD program.

Q: Will there be a section added to the online ABA application for  providers to attach a copies of BLS/CPR certification and criminal history background checks?
A
: No. For ABA supervisors and assistant behavior analysts, ABA providers will submit copies of current BLS/CPR certification and criminal history background check documents during the initial credentialing (or recredentialing if not already on file) process. These documents do not need to be included when submitting rosters for ABA supervisors and assistant behavior analysts.

For BTs, HNFS doesn’t offer an online certification application. ABA providers must include with their roster submission copies of current CPR/BLS certification and current federal, state and county criminal and sex offender reports for each new BT on the roster. All required documentation for each new BT must be in place before the roster can be accepted. 

Q: Will we submit provider rosters for credentialing?
A: Yes, you will submit rosters for all additions, changes and updates for your providers. Please see our ABA Provider Roster page for details.

Q: How do we submit license renewal information to the HNFS?
A: HNFS is required to primary source verify license and certification information. We will work directly with the boards to obtain updated license/certification information and will only reach out to providers if we find that their license/certification has expired.  

ABA Services in Community Settings

Q: What is considered a community setting under the Autism Care Demonstration?
A:
Community settings are 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.). Learn more on our ABA Service Locations page. 

Q: What community settings are not eligible for ABA services?
A:
ABA services rendered in medical offices (e.g., doctor visits, physical therapy, etc.) remain excluded. Additionally, specific exclusions apply to sporting events, camps and medical offices for beneficiaries and family members. These community settings and activities generally do not allow for the frequent and repeated presentation of treatment opportunities specific to the DSM-5’s autism spectrum disorder (ASD) diagnostic criteria. In addition, community settings address daily living and vocational skills, such as traveling in a vehicle, which are not eligible under the Autism Care Demonstration (ACD) and are excluded from treatment plans. Services rendered in excluded community settings are not reimbursable. 

Q: Are there any community settings locations eligible for ABA services?
A: 
Effective for authorizations approved on or after Aug. 1, HNFS will make specific coverage determinations for ABA services in community settings (to include provider types, units, etc.) during the clinical necessity review process. Current authorizations approved prior to Aug. 1 will remain active through the end of the authorization period. 

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. 
  • 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, keep in mind the setting must directly coincide with treatment related to the DSM-5 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. 

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. 

Q: If authorized by HNFS, which provider types will be approved to render ABA services in a community setting?  
A:
HNFS will make specific coverage determinations (regarding provider types, units, etc.) during the clinical necessity review process. 

Q: Are daycare settings or after-school care settings approved community settings?
A:
Yes, daycare or after-school care settings can be approved community settings if deemed clinically necessary to provide the requested ABA services. The ABA provider must provide active delivery of ABA treatment and must not function as a support aide or observer during care routines or activities (i.e., lunch, group activities, arts and crafts). The use of these settings must be described in the treatment plan including why a home or ABA center/clinic location is not available and how caregivers are incorporated. 

Q: If academic/educational services are performed in a community setting (such as an outdoor, hands-on activity day facilitated by the school but hosted in the community setting), can ABA services be rendered?
A: No. Academic/educational goals are excluded in all settings, including the community setting. ABA providers, when prior authorized to render ABA services in the community setting, are still excluded from targeting educational, academic or vocational areas. 

ABA Services in School Settings

Q: Can you define school settings?
A:
The definition of “school” includes preschool, public school and private school settings. Learn more on our ABA Service Locations page. 

Q: Are daycare centers/child development centers/after school programs considered school locations?
A:
Daycare centers/CDCs/after-school programs are not considered academic/school settings and, therefore, may be permitted if clinically appropriate. ABA services in daycare centers/CDCs/after-school programs must be delivered 1:1 and only target interventions for the core symptoms of ASD. Treatment plans with goals targeting academic/educational skills, or BTs functioning as a “support” in any setting will not be approved. All exclusions as identified in the ACD under TRICARE Operations Manual, Section 18, Chapter 4, apply.

Q: Please expand on what ABA supervisor services in the school setting include?
A:
Contractors may only authorize ABA supervisors to provide active delivery of ABA services in the school setting under CPT 97153 that are targeted to the core symptoms of ASD. These approved ABA services are focused, time-limited, and are in accordance with the requirements of the ACD. All exclusions as identified in the ACD under TRICARE Operations Manual, Section 18, Chapter 4, apply.

Q: If the school is in the home environment, can ABA services be rendered during the day when “school” is not in session?
A:
 For a beneficiary who is enrolled in home-schooling, authorized ABA services must be rendered outside of home-schooling hours. Educational/academic goals are excluded, and ABA is not a replacement for academic needs and/or related areas. Home-schooling hours cannot overlap ABA services. All exclusions as identified in the ACD under TRICARE Operations Manual, Section 18, Chapter 4, apply.

Outcome Measures

Q: What outcome measures are required for treatment authorization? 
A:
 TRICARE requires scores for the following outcome measures to be submitted for existing and new beneficiaries participating in the ACD based on their age: 

  • Pervasive Developmental Disorder Behavior Inventory (PDDBI),
  • Vineland, 3rd Edition (Vineland-3), 
  • Social Responsiveness Scale, Second Edition (SRS-2), and
  • Parenting Stress Index, Fourth Edition, Short Form (PSI-4) (new – effective Aug. 1, 2021) (age-based), or
  • Stress Index for Parents of Adolescents (SIPA) (new – effective Aug. 1, 2021) (age-based).

The Vineland-3 and SRS-2 are required to be completed prior to the start of treatment and annually. The SIPA or PSI-4 is required to be completed prior to the start of treatment and every six months. The Parent PDDBI form is required to be completed prior to the start of treatment and every six months and the Teacher PDDBI from (to be completed by the treating ABA supervisor only) is required every six months. 

The name of the person completing all outcome measures and their relationship to the beneficiary is required on all forms. Additionally, providers must submit the full publisher print report. If hand scoring, you must include full calculations and related documents. Outcome measure results included in treatment plans do NOT meet this requirement. 

Learn more on our Outcome Measures page.

Q: Why wasn’t I authorized to complete all of the required outcome measures for my patient?
A:
 While the treating ABA supervisor is required to administer the PDDBI, HNFS may proactively authorize existing beneficiaries to other ABA providers with the ability to complete all additional ABA outcome measures (Vineland-3, SRS-2, PSI-4/SIPA) in order to meet access to care standards. 

Q: I prefer to administer the outcome measures for my patient; however, HNFS authorized them to another provider. What can I do? 
A:
 Note that the treating ABA supervisor is required to administer the PDDBI. Treating ABA supervisors who prefer to complete all additional ABA outcome measures (Vineland-3, SRS-2, PSI-4/SIPA) for their existing TRICARE patients can submit a request for authorization through a treatment plan update. If HNFS has already authorized a beneficiary to another ABA provider, the treating ABA supervisor may submit an authorization request through the treatment plan at the next reassessment renewal period. 

Q: I don’t have experience administering outcome measures; what can I do? 
A: ABA providers who do not have the ability or expertise to render the Vineland-3, SRS-2 and PSI-4/SIPA can defer to HNFS to authorize existing beneficiaries to other ABA providers with the ability to complete all additional ABA outcome measures (Vineland-3, SRS-2, PSI-4/SIPA). 

Q: How are the PSI-4 (or) SIPA outcome measures used?
A
: The PSI-4 and SIPA are standardized, reliable measures of stress and family dynamics that help to identify where additional support resources may benefit both the family and the beneficiary. The PSI-4 and the SIPA stress indexes and scores are not factors for treatment planning or coverage determination. They are not intended to diagnose dysfunction in the parent/adolescent relationship or as screening tools for parental mental health. 

During a clinical necessity review, high stress index scores in either the PSI-4 or the SIPA will prompt the clinical reviewer (BCBA/BCBA-D) to evaluate parent training recommendations, parent engagement and unique circumstances (e.g., spouse recently deployed, medical/surgical procedures, death in family, etc.) to identify additional support services (i.e. case management) that may benefit the family. 

After the coverage determination is complete, the clinical reviewer will contact the family to offer identified additional support resources. ABA providers are not expected to directly address stress or child/parent relationship dynamics in treatment planning; however, HNFS may request additional information from ABA providers about parent training and program engagement to better understand contributing ABA program factors. 

Q: I have concerns that submitting the outcome measure results will violate my user agreement with the psychometric testing agency. Please advise.
A: Submitting outcome measure scores does not violate any acceptable use agreements. Across the industry, a patient’s medical record acts as a tool to validate rendered services and the outcome measure results are a part of the patient’s medical record. Therefore, sharing part or all of the report is not a violation of acceptable use. Upon receipt, HNFS verifies scores are complete and valid (i.e., scores fall within the publisher limits, as applicable) and our qualified BCBA/BCBA-D clinical reviewers:

  • Evaluate the outcome measure scores submitted for the PDDBI, Vineland-3 and SRS-2 as part of the clinical review process and complete a clinical consultation with the ABA supervisor, as needed, to discuss changes in the scores over time.  
  • Use PSI-4/SIPA scores to evaluate for additional supports (i.e., case management) that may benefit the family.

Diagnostic Requirements

Q: Where can a provider find the DHA-approved DSM-5 Diagnostic Checklist?
A: The DHA-approved DSM-5 Diagnostic Checklist can be found here. Only referring providers can complete this form. Treating ABA providers are not permitted to complete the DSM-5 Diagnostic Checklist.

Autism Services Navigators

Q: How will families know who their assigned Autism Services Navigator (ASN) is?
A
: HNFS will assign ASNs to eligible beneficiaries within three business days of enrollment into the ACD. Beneficiaries will be sent a written communication containing their ASN’s name and contact information to the mailing address listed in their profile and will also be able to view this information from their secure inbox on our website.

Q: How and when will providers know who is the beneficiary’s assigned ASN?
A
: As a courtesy, once the ASN is assigned, providers will be sent a written communication containing their patient’s ASN name and contact information.

Q: Can the ASN perform the outcome measures? 
A: No. Outcome measures must be performed by TRICARE-authorized ASD-diagnosing providers or, when authorized by HNFS, ABA supervisors (BCBAs or BCBA-Ds). The ASN's role with outcome measures is to incorporate the results into the beneficiary’s Comprehensive Care Plan.

Q: Are authorization requests submitted to the ASN? 
A: No. All referral and authorization requests are to be submitted directly to HNFS. Civilian providers submit referral and authorization requests through one of two online authorization tools: CareAffiliate (preferred) or the Web Authorization Referral Form (WARF). Military hospitals and clinics submit referrals and authorizations through MHS Genesis.   

Q: If the family is not doing their part, how will the provider be notified (especially if services need to be paused)?
A: The role of the ASN includes helping families meet ACD requirements and remain eligible for the services available through the ACD. If these requirements are not met and HNFS is unable to authorize services, providers will be notified via our determination letter (faxed and viewable through our secure portal).

Billing

Q: What are the newly-allowed CPT® codes and their effective dates?

A: The following CPT codes are eligible for inclusion in authorizations issued on or after Aug. 1, 2021:

  • 97157 – Multiple-Family Group Adaptive Behavior Treatment Guidance
  • 97158 – Group Adaptive Behavior Treatment by Protocol Modification
  • 99366 and 99368 – Medical Team Conference

Existing ACD beneficiaries are not eligible for these codes until their next authorization period. Requests submitted prior will be cancelled. Please visit our ABA Claims & Billing page for details, limitations and definitions.

Q. Why do I have to put session times on claims in military time format?
A: On Aug. 1, we updated our claims systems to allow for automated reading of required session times. To ensure your claims don’t reject, use the “HHMM” military time format. 

Q. Why am I no longer allowed to submit ABA claims with combined services on one line and/or with combined time stamps?
A. Per the TRICARE Operations Manual, Chapter 11, Section 4, paragraph 8.11.4, every session of ABA services must be identified as its own unique line on claims submitted. To ensure your claims don’t reject when billing for multiple services rendered on the same day by the same rendering provider, you must separate out sessions, even if the CPT code is the same. 

Q: Can ABA supervisors still bill CPT 97153 in school and preschool settings?
A:
 Yes, if HNFS authorized the CPT 97153 services. Please note: For new or renewing authorizations approved on or after May 1, 2021, HNFS will only authorize CPT 97153 services when clinically appropriate in a school setting to the authorized ABA supervisor.  

Q: Can assistant behavior analysts submit claims for CPT 97151?
A:
Assistant behavior analysts may be listed as the rendering provider for CPT 97151 services for assessments and reassessment when delegated by the ABA supervisor. This role (for assessments and reassessments) can continue to be delegated when clinically appropriate under 97151. However, as of Aug. 1, new authorizations will have the PDDBI billed under 97151, and the PDDBI Teacher Form must be completed by the ABA supervisor. For the specific task of completing the PDDBI Teacher Form, the assistant behavior analyst cannot be the rendering provider. The ABA supervisor may not delegate the completion of the PDDBI Teacher Form. 

Q: The beneficiary will be unavailable for services the entire month; therefore, no CPT 97153 or 97155 services will be rendered. Will the 10% penalty for not rendering CPT 97155 that month still apply? 
A: The 10% penalty for CPT 97155 may be waived if no CPT 97153 services were rendered within the calendar month. There is no action required by the ABA provider.

Q: Can assistant behavior analysts bill for parent training under CPT 97156?
A:
No. Per TRICARE ACD policy for all ABA CPT codes, assistant behavior analysts and behavior technicians may not bill for any ABA services as they are not independent providers according to their certification. However, assistant behavior analysts can render CPT 97156.

Note: For all ABA CPT codes, the billing provider is the authorized ABA supervisor, and the rendering provider (Box 24 of the claim form) is the provider who actually performed the service. 

Q: Can I still bill HCPCS T1023 for outcomes measures past Aug. 1, 2021?
A: If authorized prior to Aug. 1, 2021, you can continue to use T1023 to bill for outcome measures through the end of the current authorization period. HNFS will not accept/approve requests to modify T1023 to CPT 97151 on authorizations approved prior to Aug. 1. Please wait until the next authorization renewal that occurs on our after Aug. 1.  

Q: Currently, ABA providers cannot bill telehealth parent training on the same day as other services. When COVID provisions end, will this change?
A:
 In order to account for CPT code changes taking effect Aug. 1, 2021, the Defense Health Agency revised it's policy on parent/caregiver guidance via telehealth as of Aug. 1, with some exceptions for beneficiaries with existing authorizations. Please see our news article and ABA Service Locations page for details.  

Reimbursement 

Q: Will network contracted rates change?
A: No. All ABA providers are paid the lesser of 100% of the TRICARE Maximum Allowable Charge or 100% of billed charges. Your new contract will continue to reflect this.

Q: Has TRICARE recently updated the ABA rates?
A: Yes. Find current ABA rates at www.health.mil/rates. Please note, there are two new sets of rates:

  • Effective May 1, 2021: DHA’s annual rate updates to ABA maximum allowed amounts; and
  • Effective Aug. 1, 2021: DHA’s maximum allowed amounts for other Autism Care Demonstration (ACD) services.

Q: The ABA Maximum Allowed Amounts Schedule from TRICARE’s website indicates the licensure levels as: BCBA, BCBA-D and Assistant Behavior Analyst. What is TRICARE’s definition of “Assistant” as it relates to the rates?
A
: Assistant behavior analysts must:

  • Have a bachelor’s degree or above in a qualifying field as defined by the state licensure/certification where defined or in the absence of state licensure/certification, a degree in a field accepted by a certification body approved by the Director, DHA.
  • Have a current:
    • Unrestricted state issued license or state certification if in a state that offers state licensure or state certification; or
    • Certification from the BACB or the Qualified Applied Behavior Analysis (QABA) certification board.

Q: Effective Aug. 1, 2021, TRICARE will require all ABA claims be reimbursed via electronic funds transfer (EFT). How do I set up EFT?
A: Correct, HNFS is required to reimburse ABA sole providers and ACD Corporate Services Providers (ACSPs) for ACD services via electronic funds transfer (EFT). Note that this requirement does not apply to ABA providers who work in a multi-specialty practice. If you are an ABA sole provider or ACSP who has not yet signed up for EFT, visit our EFT/ERA page to get started. Registering for EFT requires having signature authority, meaning you are authorized to disburse funds, sign checks and add, modify or terminate bank account information. New enrollments can take up to 45 days to process once all information is received. Please visit our Claims Submission page for more information. 

Q: Will I need a National Provider Identification Number (NPI) to bill for services? 
A: Yes. All providers, including BTs, must have an NPI in order to bill for services under the ACD. (Note: While this is a new requirement for the ACD, HNFS already requires an NPI for reimbursement.) The NPI on the claim determines where we will send payment.

Q: How can I apply for an NPI?
A: NPIs are generated by a system called the National Plan and Provider Enumeration System (NPPES) and issued by the U.S. Department of Health and Human Services (HHS) through the Centers for Medicare and Medicaid Services (CMS). Learn more at https://nppes.cms.hhs.gov.

Quality Monitoring & Oversight

Q: Can another ABA supervisor (BCBA or BCBC-D) deliver CPT 97155 in a given month instead of the primary ABA supervisor? For example, the primary BCBA is out for the month or takes time off for a period during the month. 
A
: While it is preferable for the responsible ABA supervisor to render the direct minimum requirement for CPT 97155, HNFS allows any TRICARE-authorized, ACD-approved ABA supervisor in the ACSP provider group to meet this requirement to account for time off and other issues.

Q: If there were no CPT 97153 services rendered within a calendar month, can it be assumed the direct minimum requirement for CPT 97155 will be waived? 
A: Yes; if no CPT 97153 services are rendered within a calendar month, the CPT 97155 minimum requirement is waived and a claims penalty would not apply. 

Provider Education and Training

Q: When will the required provider training be available? Will it be virtual or in-person?
A: The ACD provider training is an online module that will be available by Jan. 1, 2022 (A .pdf version will be available for those with internet accessibility issues). We will notify ACSPs and Sole Providers in advance of the online training requirement.

Q: How often will the training be offered? 
A:
HNFS' online trianing module will be available for providers to access 24/7.

Q: How long will the training take?
A:
Expect the training to last between one and two hours. Completion time will vary based on the individual.

Q: Will all ABA providers have to take the training?
A: All ACSPs (group owners) and Sole Providers must take the annual training. While not required for all of an ACSP’s employed or contracted providers (for example, behavior analysts, assistant behavior analysts, BTs), all ACSPs and Sole Providers should distribute the information to their staff.

Q: Where can I sign up?
A: Be sure to check back on our website, as we will post additional details as implementation approaches. Once the training module is available, we will notify providers of its availability, how to access it and the due date.  

Q: How long do we have to complete the training and what happens if we do not comply?
A:
HNFS will assign the annual training to existing ACSPs and Sole Providers in January 2022, and to new providers within 90 days of joining the network. You will have 90 days to complete the training once assigned. On day 91, providers who have not completed the training are subject to a 10% penalty on all claims. Non-compliant providers can remedy this penalty by completing the training. We will communicate additional details about this training later this year.

Q: Will providers have a grace period to complete the provider education? 
A:
The training roll-out will take place in phases. HNFS will notify you via email once the course is assigned. Providers will have 90 days to complete the training once assigned. 

Provider Steerage Model

Q: A new component of the ACD is a steerage model for assigning providers. How will this work?
A: Effective Jan. 1, 2022, each provider in HNFS’ ACD provider network will receive a quality rating based on two predetermined quality measures. One measure is tied to access-to-care standards; the second measure tracks the average number of days from the initial authorization to the first parent training session. Providers with high quality ratings will receive priority placement in our Network Provider Directory and referral assignments. The steerage model allows us to connect beneficiaries with the highest quality of providers and to incentivize providers to adhere to quality standards. We will provide additional details once the two quality measures have been finalized. 


 

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