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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 currently requires ACD participants to complete and submit scores for the Pervasive Developmental Disorder Behavior Inventory (PDDBI) (parent/teacher, when applicable); the Vineland, 3rd Edition (Vineland-3) and the Social Responsiveness Scale, Second Edition (SRS-2). As of Aug. 1, TRICARE also requires the Parenting Stress Index, Fourth Edition (PSI-4) Short Form (0–12 years old) or the Stress Index for Parents of Adolescents (SIPA) Profile Form (11–19 years old). Similar to other outcome measures, providers submit only the PSI-4 or SIPA scores (not the questions or calculations) to HNFS. 

While the treating ABA provider is required to administer the PDDBI, HNFS may proactively authorize existing beneficiaries to other ABA providers with the ability to complete the SRS-2, Vineland-3 and PSI-4/SIPA in order to meet access to care standards. HNFS can now authorize outcome measure evaluations directly to ABA provider groups and a referral is not required.

HNFS completes a separate authorization for outcome measures (Vineland-3, SRS-2, PSI/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. 

 

Outcome Measure Tools

TRICARE requires the following outcome measures for existing and new beneficiaries participating in the ACD based on their age. Click on the titles below for printable fact sheets specific to each outcome measure: 

The Vineland-3 and SRS-2 must be completed prior to the start of treatment and annually. The SIPA or PSI-4 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. 

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.

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.

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. 
 

Renewal Periods

Beginning May 1, beneficiaries new to the ACD will start on a one-year cycle for the Vineland-3 and SRS-2 (see table below). 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. 

Effective Aug. 1, 2021, HNFS will be unable to approve authorizations until complete and valid scorres for all required outcome measure are submitted.
 

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. 

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. At this time, HNFS will refer outcome measures to our preferred outcome measure network of providers capable of performing all four outcome measures for any beneficiary within 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. 

TRICARE requires outcome measures be performed at the following 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, SIPA/PSI-4 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 ages 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. 

How to Submit

Outcome measure results must include the full publisher print report or hand-scored protocol and summary score sheet(s). Outcome measure results imbedded into the treatment plan or other clinical documents do not meet the 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 P154 – 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 97151)

May 1–July 31, 2021

  • HNFS will authorize 1 unit per measure per applicable cycle with HCPCS code T1023. 
  • 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

  • HNFS will authorize 1 unit per measure per applicable cycle with CPT® code 97151. 
  • Under 97151, outcome measures may be rendered via indirect methods. Telehealth will not be permitted. 

HNFS will issue separate authorizations for the outcome measures with the applicable code (T1023, 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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