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TRICARE® Autism Care Demonstration Program Reminders

Thursday, April 25, 2019

Health Net Federal Services, LLC (HNFS) offers the following reminders about TRICARE’s Autism Care Demonstration. Please visit  Applied Behavior Analysis detail page and review the updated TRICARE Operations Manual (TOM), Chapter 18  for the latest information.

New rates – May 1, 2019
The Defense Health Agency recently posted updated applied behavior analysis (ABA) rates at www.health.mil/rates. These rates, which are updated annually, are effective for dates of service on or after May 1, 2019. Please note: The new rates will include a rate for T1023. Providers should refer to this rate rather than the non-facility, non-physician rate for 96102.

Location of services
Where services are rendered (home, centerbase, school) is a critical component of the benefit review process. HNFS must establish the need for collecting an Individualized Education Plan (IEP) for any TRICARE beneficiary receiving applied behavior analysis (ABA) services in a school setting. Please specify the location of services on the first page of the treatment plan so we can easily identify this required element.

Weekly/monthly units
HNFS authorizes units under 97153 weekly and 97155/97156 monthly. If you do not specify in the treatment plan how many units you are requesting per week for 97153 and per month for 97155/97156, we will authorize weekly units for 97153 based on four weeks per month. Please review authorization approval details to ensure that the number of units on the authorization is accurate.

Narrative summaries/session notes
TRICARE requires all rendering ABA clinicians maintain narrative summaries that relate to the goals and objectives outlined in a beneficiary’s treatment plan. These narrative summaries, also referred to as session notes, must correspond to ABA claims filed for that beneficiary. Providers do not need to submit the session notes with ABA claims; however, HNFS may request them for claims payment during an audit. HNFS will compare the beneficiary’s session notes to the provider’s claims to verify all required documentation exists and is adequate to support the charges.

HNFS offers general recommendations on these key requirements; visit our Medical Documentation Requirements and Session Notes from the Applied Behavior Analysis detail page.