Understanding Access-to-Care Standards When Accepting New Autism Care Demonstration Patients

Tuesday, July 2, 2024

Meeting Autism Care Demonstration (ACD) access-to-care (ATC) standards helps applied behavior analysis (ABA) providers uphold quality of care and provide services to patients more quickly. When ABA providers agree to meet TRICARE’s ATC standards, they agree to comply with the requirements detailed below. If ABA providers are unable to verify if they will be able to meet the ACD ATC standards, they may not receive referrals for new beneficiaries.

Active Provider Placements

Health Net Federal Services, LLC (HNFS) will call to verify an ABA provider can accept a new patient within ATC standards. This means we need to know if the provider can:

Upon receipt of the assessment authorization, complete the first date of service of the initial assessment within 28 days of the start date of the authorization.
Complete the remaining assessment services within 14 days of the first service date of the initial assessment.
Complete the first direct treatment session (Current Procedural Terminology [CPT®] codes 97153, 97155, 97156, 97157, 97158) within 28 days of the last day of the 14-day initial assessment window.

Note: We will not have specific beneficiary or treatment details at the time of this call. We will solely be checking for provider availability based on TRICARE’s ACD ATC standards.

Meeting ATC Standards

When evaluating their availability to meet treatment ATC standards in response to our outreach, if an ABA provider needs to:

Hire, certify and train behavior technicians or
Accommodate specific times or locations (morning/evening, day of week, home vs. clinic) or specific provider attributes (such as gender), as requested by the family, then…

…upon receipt of an approved authorization for treatment, the provider can use parent/caregiver training sessions, or the ABA supervisor can provide direct services until the full authorized treatment hours can be fulfilled to meet the treatment ATC standards.

Keep in mind, all direct treatment CPT codes listed above qualify to meet treatment ATC standards. ABA providers are not required to render all authorized direct treatment hours immediately upon authorization of treatment. However, HNFS expects ABA providers will be adequately staffed to render authorized units within a reasonable period following approval of treatment.

Tip! To help ABA providers meet assessment ATC standards, please make sure you are receiving HNFS’ authorization faxes so you can respond promptly to authorizations for new beneficiaries.

Upon receipt of an approved assessment authorization, providers should immediately schedule the first visit and ensure all remaining assessment visits are completed within the 14 calendar day window. ABA providers will not be reimbursed for assessment visits performed outside of this window. The authorization from HNFS is good for 45 days to allow enough time for ABA providers to meet initial assessment ATC standards and complete the assessment within 14 calendar days.

Changes in Availability

Let HNFS know within five business days from receipt of an approved assessment authorization if you cannot schedule the patient’s initial assessment appointment within 28 days of the service start date listed on the authorization. We will contact the family to verify the reason and determine next steps for the patient.

Note: ABA providers who confirm they can accept a beneficiary within ATC standards cannot request an extension unless the family agrees and informs us of the first scheduled visit date. HNFS will not issue initial assessment extensions without family agreement and confirmation of the scheduled date.

For families who have waived access to care for their preferences, if we receive an extension request and the family confirms the first date of the initial assessment and agrees to the extension, we will update the authorization to approve 14 calendar days from the first scheduled assessment date.

For more information on TRICARE’s ATC standards, please visit our ACD Authorizations: Initial Assessment and First Treatment page.