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Autism Care Demonstration Authorizations – Initial Assessment & First Treatment

Overview 

A Health Net Federal Services, LLC (HNFS) approval is required for applied behavior analysis (ABA) services for all beneficiaries, including those with other health insurance. 

  • Authorization requests must be submitted electronically and are processed within 2–5 business days once all required documentation is received.
  • Submitting a request to HNFS is not a confirmation of authorization. 
  • ABA providers can check the status of an authorization or download a copy of the approval letter by using our Check Authorization Status tool. 

Not sure what HNFS' authorization status codes mean? Reference this printable ACD authorization status code and determination reasons guide to better understand request statuses and potential action required. 

Step 1 - Initial Assessment

After HNFS has verified the referral for ABA services, we may pend the request for initial provider placement (“Pended – Initial Provider Placement”) for up to 15 business days. 

Once the referral for ABA services is authorized for the initial assessment, ABA providers can start the initial assessment.


Access to Care Standards

Initial Assessment: 

  • ABA providers must provide the first date of service of the assessment (CPT 97151) within 28 calendar days from the date HNFS verified the referral after receiving an approved authorization to start the initial assessment.  
  • As HNFS has up to 15 business days to complete active provider placement, the ABA provider needs to ensure the first date of service of CPT 97151 is completed within 28 days of the “service from date” on the initial assessment authorization.
  • HNFS confirms the access to care requirement was met for the initial assessment or obtains rational if not met. ABA providers are expected to respond to requests for information regarding the confirmation of meeting the access to care standards.

Treatment: 

  • ABA provider must provide CPT 97153, 97155 or 97156 services within 28 calendar days of the last date of service in the 14-day window that is allowed for 97151 after receiving an approved authorization to start treatment. 
    • CPT codes 97157 and 97158 are included in the requirement above.
    • ABA providers must render the first occurrence of parent training (CPT 97156 or 97157) within 30 days of approval of the first treatment authorization. 
    • HNFS confirms access to care requirements were met for treatment or obtains rational if not met. ABA providers are expected to respond to requests for information regarding the confirmation of meeting the access to care standards.
  • HNFS will not backdate authorizations and prior authorization is required. 

We encourage ABA providers to submit the request for treatment promptly following the last day of the assessment to help reduce the length of time between the end of the assessment period and the approval to initiate treatment. 
 

Assessment approval letters

Providers and beneficiaries can view a copy of the determination letter online (log in to access your secure inbox and/or our Check Authorization Status tool). 

The letter contains contact information for the beneficiary and ABA provider. HNFS encourages beneficiaries to contact the ABA provider listed on the approval to set up the initial appointment if the ABA provider has not contacted the beneficiary within three days.

  • If the beneficiary wants to see a different provider than who is listed on the authorization, he/she can contact our ACD customer service line for assistance in requesting a change to the approved authorization.
  • If the ABA provider and/or beneficiary are unable to connect with each other within one week, please contact our ACD customer service line for assistance.
     

Initial Assessment Requirements

An authorized ABA supervisor (or as delegated, an assistant behavior analyst) must conduct the initial assessment, which is used to develop the treatment plan. This assessment must begin once the authorization has been approved within the 28-day TRICARE access to care standard and be completed within the 14-calendar day allowance from the first date of service. Initial assessment authorizations are approved for 45 days to facilitate meeting ATC standards and the 14-calendar day window.

If, due to unforeseen circumstances, the ABA provider and/or beneficiary need additional time to complete the assessment, the ABA provider should contact our ACD customer service line and request an extension for the initial assessment. Please provide the rationale for the extension. A new referral is not required to extend the initial assessment and ABA provider should not call the referring provider (civilian or military) to request an extension. 

All units billed for the assessment must be within the 14-day window. Please see our Billing and Claims section for more information on CPT 97151 requirements. 

Initial assessments must include direct service with the beneficiary and can include additional indirect methods to complete the treatment plan and recommendations. 

This assessment must include the following:

  • direct observation, measurement and recording of behavior;
  • background information that clearly demonstrates the beneficiary's condition, diagnoses, family history, and how long the beneficiary has been receiving ABA services;
  • functional assessment;
  • data from parent/caregiver interview and parent report rating scales;
  • treatment plan that meets all TRICARE Operations Manual, Chapter 18, Section 4; and 
  • results of the parent PDDBI
     

Recommended Units and Request for Treatment Authorization

Recommended units align with best practices and refer to the amount of eligible CPT code units necessary to achieve desired treatment outcomes based on clinical necessity. Requests for authorization should reflect the amount of units recommended for the treatment of a particular beneficiary and their family.  

  • Requests for authorized units must be based on a combination of the symptom domains and levels of support required per DSM-5 criteria, outcome measure results (for treatment plan updates) and the capability of the beneficiary to actively participate in ABA services.
  • Recommendations and requests for treatment authorization must be submitted as units and will not be accepted in other formats (i.e., hours) for each relevant ABA CPT code.
  • Treatment plans must include recommendations for monthly parent training hours, submitted as units.
    • If parent/caregiver participation is not possible, the treatment plan must reflect the reason and mitigation efforts undertaken by the provider to resolve.
    • A minimum of six parent training sessions must be conducted over the six month treatment authorization.
  • The treatment plan must identify the location of service for each requested CPT code (home, clinic/center, school, community, and daycare).
  • The treatment plan must indicate sole or tiered delivery model. 
     

Service Locations

Please review definitions/guidelines for home, clinics/centers, daycares, school settings, and community settings on our Locations for ABA Services page. 
 

Discharge plan

The process of establishing a discharge plan should occur during the initial assessment.

  • A discharge plan should be developed between the ABA provider and the beneficiary on the short and long-term plan to generalize mastered skills, teach new skills in the natural environment and steps to transition care to the family when ABA services are no longer clinically necessary. 

Step 2 – Request for Treatment Authorization

Once the initial assessment process is complete, ABA providers must submit their treatment authorization request. ABA providers must submit a complete packet meeting all requirements prior to HNFS conducting the clinical necessity review. HNFS will verify the following requirements are met before starting the clinical necessity review:

  • TRICARE eligibility
  • ACD eligibility
  • Treatment plan with parent goals/engagement 
  • Parent PDDBI scores
  • IEP, when applicable
  • Outcome measures


TRICARE and ACD eligibility

Please see our ACD Eligibility page for details. 
 

Treatment Plans

As of Aug. 1, 2021, there are new requirements and a new format for treatment plans. The treatment plan should be organized into the following main categories:

  • Identifying Information
  • Reason for Referral
  • Background Information
  • Summary of Assessment Activities (when applicable)
  • Goals
  • Progress
  • Recommendations & Units
  • Signatures

Treatment plans must include all data points and areas outlined in the TRICARE Operations Manual.

View our Treatment Plan Guide to ensure the necessary requirements are included.


Parent PDDBI scores

Providers are required to submit the full publisher print report or hand-scored protocol and summary score sheet(s) clearly and legibly, and label the PDDBI to distinguish which is the parent and which is the teacher form. As of Aug. 1, 2021, HNFS will not accept PDDBI scores imbedded within the treatment plan as a table. If completing the PDDBI scoring manually, submit all documents related to scoring. Invalid or incomplete scoring will not be accepted. The PDDBI must include the name of the respondent and relationship to the beneficiary. Visit our Outcome Measures page to learn more.
 

Individualized Education Program (IEP)

Contractors may only authorize ABA supervisors to provide active delivery of ABA services in the school setting under CPT 97153 that are targeted to the core symptoms of ASD. If applicable, an IEP must be submitted with the treatment plan. ABA providers may not render duplicate services to those documented in the IEP.
 

Outcome Measures

All beneficiaries must have complete, valid outcome measure scores in order for HNFS to process treatment authorization requests. See Outcome Measures for complete details.

TRICARE requires ACD participants to complete and submit scores for the following outcome measures:

  • Pervasive Developmental Disorder Behavior Inventory (PDDBI) (parent/teacher, when applicable)
  • Vineland, 3rd Edition (Vineland-3)
  • Social Responsiveness Scale, Second Edition (SRS-2)
  • Parenting Stress Index, Fourth Edition, Short Form (PSI-4-SF) (0 years–12 years) or the Stress Index for Parents of Adolescents (SIPA) Profile Form (11 years–19 years and 11 months). Similar to other outcome measures, providers submit only the PSI-4-SF or SIPA scores (not the questions or calculations) to HNFS.

If the ABA provider has submitted the request for treatment, the treatment plan, the parent PDDBI, and the IEP (when applicable) but the outcome measures remain outstanding, HNFS will contact the beneficiary to facilitate their completion by the approved provider. We may authorize beneficiaries to an ABA provider other than the treating provider who has the ability to complete all additional ABA outcome measures (Vineland‐3, SRS‐2, PSI‐4-SF/SIPA) in order to meet access to care standards.
 

CLINICAL NECESSITY REVIEWS

HNFS is required to perform clinical necessity reviews, and clinical consultations if necessary, on all compliant treatment authorization requests prior to issuing coverage determinations. Please visit our Clinical Necessity Reviews page for complete details. 

Providers must have an approved  treatment authorization (with an authorization number) prior to rendering reimbursable ABA services. 

  • Submitting a request to HNFS is not a confirmation of authorization.
  • Do not provide reimbursable ABA services without an approved authorization. HNFS will deny reimbursement for services performed outside the dates approved on the authorization.
  • HNFS does not issue backdated authorizations. If an authorization is pended or canceled due to missing supporting documentation or an incomplete clinical necessity review (to include the consultation with the ABA supervisor or an update to a treatment plan), the authorization will be re-issued from the date HNFS receives all required information.   
     

Parent Engagement and Training

An important component of a strong, clinical ABA program integrates parents by training them on ABA principles to work effectively with the beneficiary to achieve goals, helping parents target skills tailored to the improvement of the beneficiary and ensure generalization of skills.

The inclusion of parent training and goals in the treatment plan is an opportunity for the ABA provider to support parents in the implementation of ABA goals outside of program hours. 

  • HNFS strongly encourages the implementation of parent training immediately once the treatment authorization is approved. As of Aug. 1, 2021, ABA providers are required to have parent training (CPT 97156 or 97157) initiated within 30 days of the first approved treatment authorization.
  • The initiation of the parent training, parent implementation of ABA principles around Behavior Intervention Plans and parent goals can be done independent of the direct ABA service hours once the ongoing authorization is approved.
  • As the direct ABA service hours are scheduled and initiated, parent engagement and implementation can supplement the beneficiary’s hours to ensure ABA principles are integrated throughout their day.  


For information on subsequent authorizations, visit our ACD Authorizations: Subsequent Authorizations page. 


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