The following has been updated per the requirements outlined in TRICARE’s revised Autism Care Demonstration. We will continue to update this content over the implementation period (through Jan. 1, 2022) as new requirements and changes go into effect. See our ACD Timeline for additional details.
As of Aug. 1, 2021, all beneficiaries participating in the Autism Care Demonstration (ACD) must submit outcome measures prior to Health Net Federal Services, LLC (HNFS) authorizing treatment.
Outcome Measure Tools
TRICARE requires the following outcome measures for existing and new beneficiaries participating in the ACD based on their age:
- Vineland, 3rd Edition (Vineland-3),
- Social Responsiveness Scale,
- Second Edition (SRS-2),
- Parenting Stress Index,
- Fourth Edition (PSI-4) (new – effective Aug. 1, 2021),
- Stress Index for Parents of Adolescents (SIPA) (new – effective Aug. 1, 2021), and
- Pervasive Developmental Disorder Behavior Inventory (PDDBI).
The Vineland-3 and SRS-2 are required to be completed prior to the start of treatment and annually. The SIPA or PSI is required to be completed prior to the start of treatment and every six months. The Parent PDDBI form is required to be completed prior to the start of treatment and every six months and the Teacher PDDBI from (to be completed by the treating ABA supervisor only) is required 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 that will be required as of Aug. 1 – the PSI-4 and SIPA – must be administered before HNFS can authorize initial treatment, and again every six months.
Beginning May 1, beneficiaries new to the ACD will start on a one-year cycle for the Vineland and SRS-2. We are transitioning existing ACD beneficiaries from their current cycle to the new one-year cycle, and will notify beneficiaries of the new dates by July 1.
After the realignment of outcome measure renewal dates, 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 all required outcome measures are submitted with complete and valid scores.
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, SRS-2 and SIPA/PSI.
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.
T1023 to 97151 Transition
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.
TRICARE requires outcome measures be performed at the following intervals: