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Autism Care Demonstration: Outcome Measures

The following has been updated per the requirements outlined in TRICARE’s revised Autism Care Demonstration (ACD). We will continue to update this content over the implementation period (through Jan. 1, 2022) as new requirements and changes go into effect. 

Overview

As of Aug. 1, 2021, all beneficiaries must have complete, valid outcome measure scores in order for HNFS to process treatment authorization requests. 

TRICARE requires the submittal of scores from the following outcome measures (click on the links for printable reference guides):

See below for frequency details. The two new age-based outcome measures required as of Aug. 1 – the PSI-4 and SIPA – must be administered before HNFS can authorize initial treatment, and again every six months. Similar to other outcome measures, providers submit only the PSI-4 or SIPA scores (not the questions or calculations) to HNFS.

Please note: 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. 
 

Who Can Perform Outcome Measures?

Outcome measures can be performed by TRICARE-authorized ASD-diagnosing providers or, when authorized by HNFS, ABA providers (BCBA or BCBA-D) who can administer the Vineland-3, SRS-2 and SIPA/PSI-4. 
 

Outcome Measure Authorizations

As of May 1, 2021, HNFS can authorize outcome measures directly to ABA providers without a referral from the primary care manager or ASD-diagnosing 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 SRS-2, Vineland-3 and PSI-4/SIPA in order to meet access to care standards. This means the beneficiary may be authorized to an ABA provider who is not his or her 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 Parent PDDBI with the beneficiary and complete the Teacher PDDBI form, when applicable.

HNFS completes a separate authorization for outcome measures (Vineland-3, SRS-2, PSI-4/SIPA) to prevent overlap between the reassessment/PDDBI units and the outcome measure units, as both are under CPT 97151.

Treating ABA providers who prefer to complete all 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. 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/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/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/SIPA). In other words, outcome measure authorizations for the Vineland-3, SRS-2, PSI-4/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/SIPA amongst multiple providers. 
     

When Are Outcome Measures Required?

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

Required Outcome Measures Intervals 

Outcome Measure Baseline (must be done before HNFS can authorize treatment)  Every six months Every year
Parent PDDBI X X  
Teacher PDDBI   X  
Vineland-3 X   X
SRS-2 X   X
PSI-4 (as of Aug 1, 2021), age based X X  
SIPA (as of Aug 1, 2021), age based X X  

 

  • 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/SIPA only) up to one year prior to the start of treatment.
  • Every six months and every year is measured from date HNFS receives the specific measure. This date determines the next chronological interval after we complete all realignments. 
  • The PSI-4 and SIPA have overlapping age ranges. The PSI-4 is appropriate for ages 0–12 years and the SIPA is appropriate for ages 11–19 years. For beneficiaries aged 11–12 years at the time of reauthorization, either measure will be accepted. Beneficiaries do not need to do both.

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 cancelled 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 authorizations until complete and valid scores for all required outcome measure are submitted.
 

Renewal Periods

Beginning May 1, beneficiaries new to the ACD will start on a one-year cycle for the Vineland-3 and SRS-2. We have aligned existing ACD beneficiaries to a new, chronological two-year referral timeline. All existing beneficiaries have been notified via letter correspondence of their realignment, as this will impact future authorizations.  

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 measure.  
 

How to Submit

Outcome measure results must include the full publisher print report or hand-scored protocol and summary score sheet(s).

Note: Outcome measure results imbedded into treatment plans or other clinical documents do 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. (Provider log in required. Use the P175 – Outcome Measures request type.)

  • Beneficiaries and military hospitals or clinics can submit outcome measures via fax to 1-866-678-0615.

Billing Code Transition (T1023 to CPT 97151)

May 1–July 31, 2021

  • One (1) unit per measure per applicable cycle with HCPCS code T1023 authorized. 
  • Under T1023, outcome measures may be rendered via telehealth and can be authorized to any network provider. Use of GT modifier and place of service “02” is required. 

Effective Aug. 1, 2021

  • One (1) unit per measure per applicable cycle with CPT® 97151 authorized. 
  • Under 97151, outcome measures may be rendered via indirect methods. Telehealth is not permitted. 

HNFS issues separate authorizations for the outcome measures with the applicable code (T1023, CPT 97151) to ensure distinction of services. 

Authorizations approved by HNFS prior to Aug. 1 will be permitted to run through their existing dates, with outcome measures billable under T1023. 
 

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