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Autism Care Demonstration: Subsequent Authorizations & Continuing 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. 

Step 1 – Reassessment and Treatment Plan Update

To prepare for reauthorization of care, ABA providers must complete a reassessment and treatment plan update every six months. 

HNFS requires ABA providers to submit their request electronically for authorization of treatment. ABA providers must submit a complete packet meeting all requirements prior to HNFS conducting the clinical necessity review. Upon receipt of a request for continued treatment, HNFS will verify the following requirements are met:

  • TRICARE eligibility
  • ACD eligibility
  • Treatment plan with parent goals/engagement 
  • Parent and Teacher PDDBI scores 
  • Current outcome measures 
  • IEP, when applicable
  • Current two-year referral 

The ABA provider must submit the following at least 30 days and no more than 60 days in advance of the current authorization’s expiration for reassessment:
 

Updated treatment plan

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.

The treatment plan must include identification of new behavior targets, objectives, and goals, to include modifications based on the cumulative six-month assessment of the PDDBI and other outcome measure evaluations. Updated treatment plans must include rationale for a lack of progress including, but not limited to, stagnation or regression on goals, the PDDBI scores, parent training goals, generalization and discharge planning. The ABA supervisor should provide updates to the behavior intervention plan, as applicable, and update graphs marking the progression of targeted behavior excesses. 
 

Parent and teacher 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. HNFS cannot 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. The responsible ABA supervisor must complete the teacher form of the PDDBI. Visit our Outcome Measures page to learn more.
 

Parent training and goals

An integral component of a strong clinical ABA program is the engagement with parents to teach ABA principles, for parents to target skills 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. 
  • During each subsequent request for treatment, the ABA provider should outline the parent training and engagement in the ABA program. Parents are expected to learn ABA principles, participate in ABA services being rendered in each location provided (i.e., home, center/clinic), generalize mastered skills to new environments/people and during the progression of ABA services, learn the skills to target new skills and address behavior excesses across environments. The ABA provider plays an integral role in delivering a parent training program that will empower families to successfully manage the diagnosis outside of program hours and long term. 
     

Request for treatment reauthorization/recommended units

If continued ABA services are indicated, the treatment plan must specify recommendations for each CPT® code to include the location of services. 

  • For each relevent ABS CPT code, the recommendations for treatment must be submitted as units. We cannot accept other formats (i.e., hours).
  • Updates to unit recommendations should be based on data analysis and beneficiary progress/lack of progress. 
  • Requests for units must reflect a combination of the symptom domains and levels of support required per DSM-5 criteria, outcome measure results, and the capability of the beneficiary to actively participate in ABA services.
  • Treatment plans must include recommendations for monthly parent training, submitted as units.
    • ABA providers must render the first occurrence of parent training (CPT 97156 or 97157) within 30 days of approval for ongoing treatment authorization. 
    • 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 reauthorization period.
    • Treatment plan updates must document the number of parent training units rendered over the previous treatment period.
  • The treatment plan must identify the location of service for each requested CPT code (home, clinic/center, school, community, and daycare).
    • If CPT 97153 is being rendered by an ABA supervisor in the school setting, rationale for short-term intervention and an IEP is required.  
    • Authorizations for any service performed by behavior technicians (BTs) under CPT 97153 in the school setting will not be approved.
       

Service Locations

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

CLINICAL NECESSITY REVIEWS

HNFS is required to perform clinical necessity reviews, and clinical consultations if applicable, on all compliant treatment authorization requests prior to issuing coverage determinations. Qualified, clinical reviewers (i.e., BCBAs, BCBA-Ds) will conduct these reviews/consultations. Please visit our Clinical Necessity Reviews page for complete details.

ABA providers may not be reimbursed for any services rendered prior to the reauthorization being approved by HNFS.

  • 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. 

Step 2 – Referral Cycle Check

HNFS will perform a referral cycle check after receiving the request for reauthorization. If the referral cycle due date is past the date of the next reauthorization start date, HNFS will request the beneficiary obtain an updated referral prior to approval. 

  • HNFS realigned all existing beneficiaries’ referral cycle dates per the new definition in the TRICARE Operations Manual. All families have been notified in writing of their new referral cycle dates. 
  • The timeline for all new and existing ACD referrals submitted after May 1, 2021 starts on the date HNFS confirms the verified referral. 

Since the ABA referral is valid for two years, a new referral is not required at each six-month authorization renewal period, for provider changes or PCS transfers within the two year cycle.

If a new referral is required for the next two year period, HNFS will cancel the request and notify the ABA provider and the beneficiary. Follow the instructions provided on our Referrals for ABA Services page for more information on the requirements for the referring provider to submit a new referral.

Note: For beneficiaries referred by a military hospital or clinic, please do not contact that military facility when a new referral is required. HNFS will send correspondence to the referring provider and beneficiary. 
 

DSM-5 Diagnostic Checklist

As of Oct. 1, 2021, a completed DSM-5 Diagnostic Checklist is required at enrollment and at each subsequent two-year referral renewal cycle.* The DSM-5 Diagnostic Checklist identifies the level of support required according to DSM-5 ASD criteria. Only TRICARE-authorized ASD-diagnosing and referring providers are eligible to complete the checklist. ABA providers are not permitted to complete the form.

Note: The provider who completes the DSM-5 Diagnostic Checklist does not have to be the same provider who completed the original diagnosis. Learn more on our Eligibility & Diagnostic Criteria page.

*For beneficiaries enrolled in the program prior to Oct. 1, 2021, HNFS will collect a completed DSM-5 checklist at the next two-year referral cycle that occurs on or after Oct. 1, 2021, and at each subsequent two-year referral cycle.

Step 3 – Outcome Measure Cycle Check

After the referral cycle check is complete, HNFS will perform an outcome measure cycle check. 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.

Discharge, Termination and Provider Changes

Discharge: Discharge planning should occur during each reassessment, and discharge from ABA services should occur when ABA services are no longer clinically necessary.

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 transition care to the family when ABA services are no longer clinically necessary.  

When a beneficiary has met their ABA objectives and is ready to begin discharge, the ABA provider can recommend a step-down in frequency, intensity and duration of services to include an increased amount of parent training and support. ABA providers may request authorization for parent-training-only authorizations (CPT 97156, 97157) during the discharge process or if barriers to rendering direct ABA services prevent the active delivery of ABA services. 

When the beneficiary is ready to transition out of all direct ABA service hours and the parents no longer need parent training, the ABA provider is required to submit a discharge report to HNFS. Discharge report writing is not a billable activity. ABA provider should notify HNFS regarding the discontinuation of services and submit the termination report electronically using the ACD ABA Discharge Report Submission request profile type. 

Termination of Services and Provider Changes

In some scenarios, the termination of ABA services may be applicable and the beneficiary or ABA provider may contact HNFS to discuss the transition of care to a new provider.

  • HNFS can facilitate the transition of care to a new ABA provider, if applicable, and assist the beneficiary during this process. 
  • The ABA provider and/or the beneficiary should call our ACD customer service line to discuss termination from ABA services, provide a timeline for the transition and the justification for the termination.
  • Termination from ABA services by the ABA provider may not occur abruptly. ABA providers must provide a minimum of 45 days’ notice to both HNFS and the beneficiary prior to termination. 
  • ABA providers must submit discharge reports to HNFS (discharge report writing is not a billable activity). 

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