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Referrals for ABA Services

After Health Net Federal Services, LLC (HNFS) has confirmed a beneficiary has met all initial eligibility and definitive diagnosis requirements for the Autism Care Demonstration (ACD), if not already received, the TRICARE-authorized primary care manager (PCM) or specialized ASD-diagnosing provider must submit an ABA referral to HNFS. 

Referral Submissions to HNFS

TRICARE-authorized primary care managers (PCM) or specialized ASD-diagnosing providers must submit a referral to HNFS requesting ABA services that contains all required elements.

On Oct. 1, 2021, TRICARE updated which PCM and ASD diagnosing provider types are qualified to submit this referral.

As of Oct. 1, 2021, the following TRICARE-authorized provider types can diagnose and submit referrals:

Primary Care Managers ASD-Diagnosing Specialists
  • pediatricians
  • pediatric family medicine physicians
  • pediatric nurse practitioners
  • physicians board-certified or board-eligible in:
    • developmental behavioral pediatrics
    • neurodevelopmental pediatrics
    • child neurology
    • child psychiatry
  • PhD clinical psychologists
  • Board-certified doctors of nursing practice (DNPs) who meet criteria

 

Referral Requirements 

ABA referral requests must contain the following:

  • co-morbid diagnosis (if applicable)
  • symptom severity level/level of support  (1-mild, 2-moderate, 3-severe)
  • statement the beneficiary needs ABA services

Note:

If the beneficiary’s initial ASD diagnosis occurred after age eight, or it has been two or more years since the original diagnosis and this is the first ABA services referral under TRICARE, HNFS will need to collect a one-time diagnostic evaluation from a TRICARE-authorized ASD-diagnosing and referring provider indicating a definitive ASD diagnosis (if not already on file). 

Use the "comment" box to specify reason for referral in your online referral submission. (Military hospitals and clinics: Provide these details in lines 5 and 12 in RMS or the "Order Comment" field of MHS Genesis.)   

 

Referral verification (2–5 business days)

After receiving the referral for ABA services, HNFS will:

  1. Ensure the referral meets all requirements per TRICARE policy, and 
  2. Confirm the beneficiary meets all ACD eligibility requirements.

Please allow 2–5 business days for HNFS to verify the referral requirements were met. For incomplete referrals, HNFS will request additional information from the referring provider and pend the request for six business days. If the requested information is not received at the end of the sixth business day, the request will be cancelled and need to be resubmitted once complete. 

Two-Year Referral Cycle

Referrals for ABA services under the ACD are valid for two years. HNFS can accept subsequent two-year referrals no sooner than six months prior to the end of the current referral cycle. If we receive a subsequent referral earlier than six months before the current referral is set to expire, it will be cancelled as a duplicate. We process each authorization request, including provider changes and when the beneficiary moves within the TRICARE West Region, under this two-year referral. 

We have aligned existing ACD beneficiaries to a new, chronological two-year referral timeline. All existing beneficiaries have been notified via letter correspondence of their realignment, as this will impact future authorizations. 

As of Oct. 1, 2021, a completed DSM-5 Diagnostic Checklist is required at enrollment and at each 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 DSM-5 checklist. ABA providers are not permitted to complete the form. 
  • Note: The provider who completes the DSM-5 checklist does not have to be the same provider who completed the original diagnosis. Learn more on our ACD Eligibility & Diagnostic Criteria page.

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

Active Provider Placement

Once the beneficiary has a verified referral on file, HNFS will begin the process of finding an ABA group or sole provider who can render ABA services within access-to-care standards. We have 15 days from the date we verified the referral to start this process. We will notify beneficiaries once we’ve started. 

HNFS’ active provider placement process involves authorizing care based on the following:

  1. Does the provider currently meet TRICARE’s access-to-care standards for initial assessments and treatment?
  2. If more than one provider meets the first criteria, then which provider ranks highest in the steerage model ? (See "Steerage Model" below.)

Or, if a parent prefers a specific provider and chooses to waive access-to-care standards (must document this waiver with HNFS), we will authorize care to that provider.

When assigning providers:

  1. HNFS contacts ABA providers to confirm availability for the initial assessment and treatment. 

  2. HNFS attempts contact with the beneficiary and/or the parent/caregiver to discuss provider preferences and whether HNFS can meet them, but ultimately will select a provider who can meet access to care standards.

  3. HNFS authorizes the initial assessment to an ABA provider group. This assessment must be completed within 28 days, with day one being the date HNFS verified the referral. HNFS will update the start date of the approved initial assessment with the date of the verified referral to ensure ABA providers can independently calculate the 28 days to initiate the assessment process.  

  4. Beneficiaries with preferred appointment times (i.e., afternoons) and locations (i.e., center base) for direct services may need to initiate parent training until preferences can be accommodated, and access to care is not guaranteed. During this time, the ABA provider can support the family under approved parent training CPT® codes to target initial ABA principles and implementation until the beneficiary is receiving their full hours at their preferred times and locations.

Directed referrals (referrals received with a named provider) and parent preferences will be taken into account during the active provider placement process, but ultimately, HNFS is required to select providers who can meet the access-to-care standards. This includes parent preferences for location of services (center/clinic vs. home), time of day (morning, afternoon, evening, weekends) and specific providers or attributes.

Note: This process only applies to the initial assessment. HNFS does not apply active provider placement criteria when continuity of care has been established and providers are submitting initial or recurring treatment authorization requests. 
 

Steerage Model

On Jan. 1, 2022, HNFS implemented a steerage model for network ABA providers participating in the ACD. A steerage model determines a provider’s ranking in the network based on their performance against a set of predetermined metrics. The ACD steerage model ranks ABA providers according to access-to-care standards and other quality measures that positively impact TRICARE beneficiaries.

HNFS’ steerage model ranks providers using three quality measures:

  • Measure one is tied to the provider’s performance compared with TRICARE’s access-to-care standards for initial assessments (achieved when service delivery occurs within 28 days of the verified referral).

  • Measure two is tied to the provider’s performance compared with TRICARE’s access-to-care standards for treatment (achieved when the last date of service of the assessment (CPT® 97151) in the 14-day window to the first day of adaptive behavior treatment (CPT 97153, 97155, 97156, 97157, 97158) is 28 days or less).

  • Measure three is tied to the average number of days from the treatment authorization start date (service from date on authorization) to the first parent training session (CPT 97156 and 97157). 

Note: If a parent requests a specific provider (due to preference on provider, location, time of day, etc.) and chooses to waive access-to-care standards, that provider’s steerage model ranking will not be impacted. 

We are finalizing enhancements to our Network Provider Directory to reflect steerage model rankings for ABA providers; meaning when beneficiaries search for ABA providers in their area, providers with the highest value ranking per the steerage model will show up first. Additionally, beneficiaries will be able to specifically search for autism spectrum disorder (ASD) diagnosing providers, parent-mediated training, and respite care providers. Until those updates are completed, we offer a separate ACD-specific directory that displays results based on steerage model rankings and includes the new filter options.  

 

The next step is the initial assessment and treatment authorization. View ACD Authorizations – Initial Assessment & First Treatment for details. 

 

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