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Autism Care Demonstration: Pointers for Compliant Treatment Plan Goals

Tuesday, August 29, 2023

Health Net Federal Services, LLC’s (HNFS) clinical necessity reviewers must carefully consider treatment plan goals before approving a treatment plan to authorize services. These considerations include what core autism spectrum disorder (ASD) symptoms goals treat and whether rendering a specific goal would include TRICARE-prohibited direct treatment areas. We offer the following tips to help you submit compliant treatment plan goals on first submission.

  1. Use clear and measurable criteria. Measures should be age-appropriate, clinically significant to the beneficiary, and demonstrate levels of progress.

  2. Include baseline and goal details. These must clearly show a core ASD symptom being addressed in relation to an action by the beneficiary. For example:
    • Baseline: (1) Makes repeated actions with a toy car and (2) does not play with the toy car at appropriate age level.
    • Baseline: (1) Has a socially inappropriate response to sarcasm that blocks meaningful relationships and (2) does not use sarcasm.
  3. Write goals with ABA principles (for example, chaining, differential reinforcement) related to activities of daily living (ADL) ready to be targeted in parent/caregiver training. Core ASD-related symptoms may occur within an ADL or academic objective, but ABA tasks must not focus on completing or improving ADLs, academic, or vocational objectives. Do not target specific ADL or vocational skills such as journaling, using money, using a calendar, writing an email, etc. These tasks are TRICARE policy exclusions when they require teaching or prompts. However, core ASD symptoms within these tasks can be targeted separately.

  4. Describe improvements in behaviors that lead to the same single outcome (referred to as response classes). If applicable, reference these in the beneficiary’s behavior intervention plan.
    • (Goals) Tolerance: Remain in area and refrain from a behavior excess; Coping: Requesting escape 
    • (Behavior intervention plans) Using differential reinforcement of other behavior (DRO); Teaching replacement or incompatible behavior
  5. Use ABA terminology in place of common psychological terms. As an example, cognitive behavior therapy uses the word “desensitization,” which in ABA relates to  “differential reinforcement,” an approach where the ABA provider increases reinforcement amounts based on improved performance (for example, increased time in the presence of environmental antecedents). If you need to use non-ABA terms, you must explain how they relate to help our reviewers determine whether they are evidenced based ABA treatment strategies under the ACD.

Refer to TRICARE Operations Manual (TOM), Chapter 18, Section 4 for more information on treatment plan requirements. For more information on treatment plan goals, please review our Guide for Treatment Plan Goals.