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Autism Care Demonstration: Clinical Necessity Reviews

Overview

HNFS is required to perform clinical necessity reviews, and clinical consultations (a live, phone review of the treatment plan with the ABA supervisor) if necessary, on all treatment authorization requests prior to issuing coverage determinations. All clinical necessity reviews and clinical consultations are conducted by qualified reviewers (i.e., BCBA, BCBA-D). Clinical necessity reviews follow a standardized approach and require a complete review of the treatment plan, including initial baselines, recommended goals, target areas, parent training goals, outcome measure scores, and recommendations. 

Note: Authorizations approved prior to Aug. 1, 2021 will remain active through the end of the authorization period. 

Step 1 – Administrative Document Review

Before the clinical necessity review process can begin, HNFS conducts an administrative review to verify the following requirements: 

  • the patient’s TRICARE eligibility, 
  • the patient’s ACD eligibility, 
  • a valid two-year referral for applied behavior analysis (ABA) services,
  • a complete treatment plan that meets all TRICARE requirements (including all required sections and location of services), 
  • outcome measure scores and related data points (including the name/credentials of the respondent, and their relationship to the beneficiary):
    • Pervasive Developmental Disorder Behavior Inventory (PDDBI), completed by both the parent/caregiver and ABA supervisor 
    • Vineland, 3rd Edition (Vineland-3), 
    • Social Responsiveness Scale, Second Edition (SRS-2), and 
    • Parenting Stress Index, Fourth Edition, Short Form (PSI-4-SF) or Stress Index for Parents of Adolescents (SIPA) Profile Form,
  • signatures of both the parent/caregiver and ABA supervisor on all outcome measures, and 
  • an individual education program (IEP) when treatment is recommended in the school setting.  

ABA supervisors can streamline this administrative review by submitting treatment authorization requests that contain the following: 

  • complete treatment plan that meets all TRICARE requirements, 
  • updated PDDBI scores and related data points, (including name/credentials of the respondent and their relationship to the beneficiary),
  • updated PSI-4-SF or SIPA
  • other outcome measure scores and related data points (Vineland-3 and SRS-2), if authorized, and 
  • an IEP, if applicable.  

The administrative document review can take up to five business days. If required elements are missing or incomplete, HNFS will notify the referring and/or treating provider and pend the request for up to 10 days to allow time for the missing information to be submitted. After 10 business days, HNFS will cancel the request. Once submitted, we will repeat the administrative review and reset the review timeline.

Please note:

  • We will cancel requests that are missing ACD program eligibility (definitive diagnosis) or outcome measures. Processing will resume once ACD eligibility is met. 
  • We will not pend requests that are only missing the IEP; rather, we’ll request this during the clinical necessity review. If an IEP is not available at the time of the clinical necessity review and school services by an ABA supervisor is being requested, additional information or consultations maybe required to clarify the scope of services. 

Step 2 - Clinical Necessity Review 

HNFS staffs qualified, clinical reviewers (BCBAs, BCBA-Ds) called Autism Clinical Care Analysts (ACCAs) to conduct clinical necessity reviews and, if necessary, clinical consultations with the ABA supervisor. Each ACCA follows a standardized approach to evaluate the treatment plans submitted by the ABA supervisor while taking into account the individual needs of each beneficiary.

Clinical necessity reviews ensure the treatment plan coincides with the most appropriate level of care for the beneficiary. The clinical reviewer considers the following overarching areas for clinical necessity: 

  • Level of clinical support (including review of outcome measures and progress over time)
  • Treatment plan
  • Efficacy of treatment implementation 
  • Dose response (intensity, frequency, duration)
  • Duration of services and individualized discharge planning
  • Other rendered services

The review includes the identification of treatment exclusions and any missing required treatment plan elements. The review also considers dose recommendation, level of impact, duration of services, response to treatment and other evidence-based treatments. 

The reviewer evaluates all clinical documentation including, but not limited to: 

  • baseline data, progress summaries and ongoing data collection, 
  • recommended goals, 
  • parent training goals, treatment participation and generalization of skills,
  • behavior intervention plans
  • outcome measure scores, changes to the scores over time and compared to documented skills/deficits targeted in the treatment plan,
  • exclusions (for detailed information, visit our Exclusions page and review TRICARE Operations Manual, Chapter 18, Section 4) 
  • required treatment plan information (i.e., beneficiary name, date of birth, initial assessment date, date of reassessment, subscriber DoD Benefits Number or SSN, referring provider information, diagnostic severity level, date of diagnosis, co-morbid and medication information, school and other services treatment hours, total number of years receiving ABA, and location of services, etc.)
  • individualized discharge plans and criteria, and 
  • CPT code recommendations. For example:
    • CPT 97158 is reviewed for which goals will be targeted and the necessary generalization or skill sets required for the beneficiary to fully benefit from a group format for treatment.
    • Code recommendations follow appropriate format: 97153 recommended weekly, 97155, 97156, 97157, 97158 recommended monthly and 97151, 99366, 99368 recommended per treatment period.
  • Community location recommendations are reviewed for specific locations, provider type and target goals specific to each proposed location. Service recommendations must be focused, time-limited, and in accordance with the requirements of the ACD.
  • IEP review for school location recommendations:
    • School locations requests are reviewed for overlap between IEP and ABA program goals, amount of services and goals specific to the school location, as well as proposed limited durations of the school based treatment by the ABA supervisor.

Once the clinical necessity review is complete, the ACCA will either make a coverage determination, request additional information or clarification and/or request a clinical consultation with the ABA supervisor.

The clinical necessity review can take up to five business days. If required elements are missing, HNFS will notify the referring and/or treating provider and pend the request for up to 10 days to allow time for the missing information to be submitted. After 10 business days, HNFS will cancel the request. Once submitted, we will repeat the clinical review and reset the review timeline.

Step 3 – Clinical Consultation and/or Additional Documentation 

HNFS may require consultations with the responsible, treating ABA supervisor to address and resolve areas regarding clinical necessity, exclusions or other areas that may require consultation and resubmission of the treatment plan prior to a coverage determination. 

Treatment plans that contain exclusions or that are missing required information must be modified and resubmitted. For details on exclusions, please review TRICARE Operations Manual, Chapter 18, Section 4. 

  • For resubmissions of treatment plans only (additional information requests): ABA providers will have 10 business days to submit an updated treatment plan. Areas requested for modification or addition will be listed in a faxed communication and include instructions on how to resubmit. Once received, we conduct a second clinical necessity review and, as long as the request is now compliant, we will make a coverage determination within five business days. 

    Note: If the updated treatment plan still does not meet ACD guidelines, HNFS will notify the provider via fax and/or during the clinical necessity consultation, and the timeline will reset.
  • For clinical consultations in addition to updated treatment plans: HNFS will attempt to contact the treating ABA supervisor by the fifth day of the clinical necessity review. We will pend the request for up to 10 days to allow time for a meeting to be scheduled and conducted if initial contact is not made. It’s important ABA supervisors respond timely to our requests for consultations. After the clinical consultation is complete, the ABA provider has up to 10 business days to submit an updated treatment plan. Once received, a second clinical necessity review is conducted and, as long as the request is now compliant, we will make a coverage determination within five business days. If we are unable to connect with the ABA provider to schedule the consultation and/or do not get the treatment plan in a timely manner, we will cancel the request and resume processing once these actions occur. 

Processing Timelines

  • HNFS will complete an administrative document review of the request for authorization within two to five business days of receipt by the ABA provider. The administrative review includes: 
    • Verification of eligibility 
    • Verification ACD program requirements are met 
    • Verification of a valid referral 
    • Verification of a comprehensive care plan (beneficiaries with Autism Services Navigators only) 
    • Verification of a complete and valid PDDBI (parent form/teacher form, as applicable) 
    • Verification of a complete and valid Vineland-3, SRS-2 and PSI-4-SF/SIPA 
    • Verification of minimum treatment plan requirements (i.e., location of services, etc.) 
  • HNFS will complete the administrative review (if compliant with items listed above), the clinical necessity review and send correspondence by the fifth business day. 
  • If there are no changes to the treatment plan, HNFS will complete a coverage determination and send correspondence by the fifth business day. 
  • If a provider consultation is required, HNFS will attempt to contact the treating ABA supervisor by the fifth business day. If no contact is made, a request to meet within the next 10 days will be faxed to the ABA supervisor. HNFS will cancel the request for authorization if the consultation is not completed within 10 business days. The treating ABA supervisor will need to complete the consultation and resubmit the treatment plan and/or additional information for a second review for coverage determination. 
  • If additional information is required, HNFS will notify the treating ABA supervisor, either via faxed letter correspondence or during the provider consultation, that modifications to the treatment plan must be completed. The ABA supervisor has up to 10 business days to resubmit the treatment plan with modifications. Once received, HNFS will complete the clinical necessity review on the now complete treatment plan within five business days for a coverage determination. 
  • Responding to requests for consultation and/or additional information in a timely manner is the ABA supervisor’s responsibility and helps to prevent potential gaps in care. HNFS will not issue any backdated or retro authorizations under any circumstances. The treating ABA provider is encouraged to submit the request for reauthorization up to 60 days in advance to allow for the review process, consultation process and re-review, if necessary.  

Authorization Codes & Determination Reasons

Log in to our secure provider portal to check authorization status. Reference this printable ACD authorization status code and determination reasons guide to better understand status codes and determination reasons. 

Key Points

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

  • Submitting a request to HNFS is not a confirmation of authorization.
  • Do not provide ABA services without an approved authorization. HNFS will deny reimbursement for services performed outside the dates approved on the authorization.
  • Subsequent authorizations for continuing treatment can be submitted up to 60 days in advance and no less than 30 days in advance of when a current authorization expires. 
  • 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. 

Definition and Guidelines 

  • Clinical necessity review: All treatment requests are reviewed for clinical necessity prior to authorization and may include requests for additional information, clinical consultation and/or require modifications to treatment plans. 
  • Clinical necessity consultation: A live phone review of the treatment plan with the ABA supervisor to discuss programming, outcome measures, exclusions, etc. Clinical necessity consultations will occur with all initial treatment plan submissions and as neded for ongoing treatment requests. 
  • Late reauthorization request: ABA providers who submit reauthorization requests less than 30 calendar days from the expiration date of the current authorization are at risk for non-payment, should the existing authorization expire before HNFS approves the renewal request. 
  • Requests for authorization submission process: Submit all requests for authorization of care to HNFS using our online authorization submission tools.
  • Requests for reauthorization: If continued services are clinically indicated, prior to the expiration of each six-month treatment authorization period (as early as 60 calendar days in advance but no later than 30 calendar days in advance), the ABA provider must submit a reauthorization for ABA services. 
  • Treatment plan: A written document outlining the ABA supervisor’s plan of care for TRICARE beneficiaries receiving ABA services. 
     

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