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Autism Care Demonstration: Validated Assessment Tools and Definitive Diagnosis Requirements

Tuesday, February 15, 2022

As of Oct. 1, 2021, TRICARE requires a definitive diagnosis of autism spectrum disorder (ASD) before a beneficiary can be enrolled into the Autism Care Demonstration (ACD) or renew ACD enrollment at the two-year referral cycle. Diagnosis occurs under the TRICARE basic benefit and must be supported by the results from one of the five validated assessment tools approved for use under the ACD. If a beneficiary’s diagnostic evaluation lacks one of the required assessment tools, they will be considered ineligible for the ACD. Please familiarize yourself with the diagnosis and assessment tool requirements of the ACD to help avoid any delays in patient care.

Who can diagnose ASD? The following are approved ASD-diagnosing and referring provider types under the ACD:

  • Primary care managers: pediatric family medicine; pediatric physicians; pediatric nurse practitioners
  • ASD-diagnosing specialists: physicians board-certified or board-eligible in developmental behavioral pediatrics, neurodevelopmental pediatrics, child neurology or child psychiatry; PhD clinical psychologists; board-certified doctors of nursing practice (DNPs) who meet criteria

What validated assessment tools does TRICARE accept? PCMs/ASD-diagnosing specialists must submit results from the current version of one of the following approved validated assessment tools. 

  • Screening Tool for Autism in Toddlers and Young Children (STAT)
  • Autism Diagnostic Observation Schedule-Second Edition (ADOS-2)
  • Autism Diagnostic Interview-Revised (ADI-R)
  • Childhood Autism Rating Scale-Second Edition (CARS-2)
  • Gilliam Autism Rating Scale, Third Edition (GARS-3) (also requires a diagnostic evaluation demonstrating other methodology to supplement the parent questionnaire was used) 

This is a one-time requirement. For beneficiaries new to the ACD as of Oct. 1, 2021, results are collected prior to ACD enrollment with the initial ABA referral. For beneficiaries enrolled prior to Oct. 1, results are collected at the next two-year referral cycle that occurs on or after Oct. 1.

What else must be included with ABA referrals? PCMs/ASD-diagnosing specialists must complete and attach a DSM-5 Diagnostic Checklist to the initial ABA referral and again to each subsequent two-year referral. (ABA providers may not complete this.) The provider who completes the DSM-5 Diagnostic Checklist does not have to be the same provider who originally diagnosed the beneficiary. 

What is HNFS’ Definitive Diagnosis Referring Provider Attestation? To proactively prevent gaps in care for beneficiaries enrolled to the ACD prior to Oct. 1, 2021, referring providers can complete and submit a Definitive Diagnosis Referring Provider Attestation, which fulfills both the DSM-5 Diagnostic Checklist and assessment tool requirements. This may be submitted prior to the beneficiary’s two-year referral cycle. Find this attestation on our ACD Forms page. (ABA providers may not complete the attestation.) Referring providers also have the option of submitting a DSM-5 Diagnostic Checklist and the results from any version of one of the above-listed assessment tools for this beneficiary population.

Visit our website for complete details about the Autism Care Demonstration and www.health.mil/autism. We continue to offer a dedicated ACD customer service line at 1-844-866-WEST (9378), option 5 Monday through Friday, 5 a.m. to 9 p.m. (Pacific time).