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Frequently Asked Questions 

Autism Care Demonstration (ACD) Update

The Defense Health Agency (DHA) published changes to the ACD that will be implemented in phases in 2021.

Please visit www.health.mil/autism to review DHA's comprehensive list of frequently asked questions:

We offer 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 network 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 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: Why are providers being asked to submit my 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 return signed contracts and insurance policies?
A: Network providers will return contracts/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

Credentialing Requirements

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, 2021, we will collect these during the credentialing/recredentialing process for ABA supervisors and assistant behavior therapists, and with roster submissions during the certification/recertification process for behavior technicians.*

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 will collect these during the credentialing/recredentialing process for ABA supervisors and assistant behavior therapists, and with roster submissions during the certification/recertification process for behavior technicians.* Please note, HNFS runs the background checks for all Sole Providers.

*Note for behavior technicians (BTs): Groups adding new BTs on or after July 1 must submit copies of the CPR/BLS certification and criminal history background check with the updated roster in order for HNFS to meet the required 10-day turnaround for BT certification. Email the copies with the updated roster to HNFS at HNFS_ABARosters@hnfs.com.

ABA Services in School Settings

Q: Can you define school settings?
A:
The definition of “school” includes preschool, public school and private school settings.

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 (TOM), 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 TOM, 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 TOM, Section 18, Chapter 4, apply.

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

Q: Can assistant behavior analysts submit claims for CPT code 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, 2021, 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: Can assistant behavior analysts bill for parent training under CPT code 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 code 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: Currently, ABA providers cannot bill telehealth parent training on the same day as other services. When COVID provisions end, will this change?
A:
The government will provide guidance to the contractors for this question at the point the national emergency period is ended.

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: Effective Aug. 1, 2021, TRICARE will require all ABA claims be reimbursed via electronic funds transfer (EFT). How do I set up EFT?
A: You can set up a new EFT account by completing and submitting an EFT Authorization Agreement. We will send a secondary EFT verification form that must be completed within 90 days. Registering for EFT requires having signature authority, meaning you are authorized to disburse funds, sign checks and add, modify or terminate bank account information.

Q: Will I need a National Provider Identification Number (NPI) to bill for services? 
A: Yes. All providers, including behavior technicians, 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.

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. We will notify ACSPs and Sole Providers in advance of the online training requirement.

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, behavior technicians), all ACSPs and Sole Providers should distribute the information to their staff.

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.

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, with the second still being finalized. 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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