1.0 PURPOSE
The Comprehensive Autism Care Demonstration
(“Autism Care Demonstration”) provides TRICARE reimbursement for Applied
Behavior Analysis (ABA) services to TRICARE eligible beneficiaries diagnosed
with Autism Spectrum Disorder (ASD). Beneficiary eligibility is outlined
in
paragraph 7.0.
The purpose of the Autism Care Demonstration (ACD) is to further
analyze and evaluate the appropriateness of the ABA tiered-delivery
model under TRICARE in light of current and anticipated certification
board guidelines. Currently, there are no established uniform ABA
coverage standards in the United States (U.S.). The ACD seeks to
establish appropriate provider qualifications for the proper diagnosis
of ASD and for the provision of ABA services, assess the feasibility
and advisability of establishing a beneficiary cost-share for ABA
services for ASD, and develop more efficient and appropriate means
of increasing access and delivery of ABA services under TRICARE
while creating a viable economic model and maintaining administrative
simplicity. The overarching goal of this demonstration is to analyze,
evaluate, and compare the quality, efficiency, convenience, and
cost effectiveness of ABA services that do not constitute proven
medical care provided under the medical benefit coverage requirements
that govern the TRICARE Basic Program.
2.0 BACKGROUND
2.1 ASD affects
essential human behaviors such as social interaction, the ability
to communicate ideas and feelings, imagination, and the establishment
of relationships with others. The TRICARE Basic Program offers a
comprehensive health benefit providing a full array of medically
necessary services to address the needs of all TRICARE beneficiaries
with a diagnosis of ASD. The TRICARE Basic Program provides Occupational
Therapy (OT) to promote the development of self-care skills; Physical
Therapy (PT) to promote coordination/motor skills; Speech-Language
Pathology (SLP) services to promote communication skills; child
neurology and child psychiatry to address psychopharmacological
needs; clinical psychology for psychotherapy; and psychological
testing; and neurodevelopmental and developmental behavioral pediatrics
for developmental assessments. The full range of medical specialties
to address the additional medical conditions common to this population
are covered.
2.2 Behavior analysis is the scientific study
of the principals of learning and behavior, specifically about how
behavior affects, and is affected by, past and current environmental
events in conjunction with biological variables. ABA is the application
of those principles and research findings to bring about meaningful
changes in socially important behaviors in everyday settings. ABA,
by a licensed and/or certified behavior analyst, focuses on treating
behavior difficulties by changing an individual’s environment (i.e.,
shaping behavior patterns through reinforcement and consequences).
ABA is delivered optimally when family members/caregivers actively participate
by consistently reinforcing the ABA interventions in the home setting
in accordance with the prescribed Treatment Plan (TP) developed
by the behavior analyst.
2.3 The Behavior Analyst Certification
Board (BACB) has established national guidelines for behavior analysts
and assistant behavior analysts. The 2014 BACB publication for credentialing
of Registered Behavior Technicians (RBTs) established national competency
standards and registration for the Behavior Technicians (BTs) (formerly
ABA Tutors) who interact with ASD-diagnosed beneficiaries for multiple
hours per day. The Qualified Applied Behavior Analysis (QABA) certification
board also offers a certification for BTs, the Applied Behavior
Analysis Technician (ABAT), as well as a certification for assistant
behavior analysts, Qualified Autism Services Practitioner (QASP). The
Behavioral Intervention Certification Council (BICC) certification
for BTs (Board Certified Autism Technician, BCAT) is also acceptable. If
a State requires licensure or certification, the ABA provider is
required to possess that State licensure or certification to be
a TRICARE authorized or network provider. National certification standards
are evolving. The American Medical Association (AMA) implemented
Category III Current Procedural Terminology (CPT) codes (defined
as a temporary set of codes for emerging technologies, services,
and procedures) for ABA services (effective July 1, 2014), for the
purpose of allowing time for data collection to determine the case
for widespread usage of the ABA CPT codes as established “medical”
treatment.
3.0 Demonstration
Goals
Demonstration goals include:
3.1 Analyzing
and evaluating the appropriateness of the ACD under TRICARE in light
of current and future BACB Guidelines for “Applied Behavior Analysis
Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare
Funders and Managers” (2014 or current edition);
3.2 Determining
the appropriate provider qualifications for the proper diagnosis
of ASD and for the provision of ABA, and assessing the added value
of assistant behavior analysts and BTs beyond ABA provided by Board
Certified Behavior Analysts (BCBAs);
3.3 Assessing, across the TRICARE
regions and overseas locations (see
paragraph 9.0), the ASD beneficiary
characteristics associated with full utilization of the ACD’s tiered
delivery model versus utilization of sole provider BCBA services
only, or non-utilization of any ABA services, and isolating factors
contributing to significant variations across TRICARE regions and
overseas locations in delivery of ABA;
3.4 Determining what beneficiary
age groups utilize and benefit most from ABA interventions;
3.5 Assessing
the relationships between receipt of ABA services and utilization
of established medical interventions for children with ASD, such
as SLP services, OT, PT, and pharmacotherapy; and
3.6 Assessing
the feasibility and advisability of establishing a beneficiary cost-share
for ABA services as a treatment for ASD.
4.0 Definitions
4.1 Applied Behavior
Analysis (ABA)
According to the BACB Guidelines
for “Applied Behavior Analysis Treatment of Autism Spectrum Disorder:
Practice Guidelines for Healthcare Funders and Managers” (2014 or
current edition), ABA is “a well-developed scientific discipline
among the helping professions that focuses on the analysis, design,
implementation, and evaluation of social and other environmental
modifications to produce meaningful changes in human behavior. ABA
includes the use of direct observation, measurement, and functional
analysis of the relations between environment and behavior. ABA
uses changes in environmental events, including antecedent stimuli
and consequences, to produce practical and significant changes in
behavior. These relevant environmental events are usually identified
through a variety of specialized assessment methods. ABA is based
on the fact that an individual’s behavior is determined by past
and current environmental events in conjunction with organic variables
such as their genetic endowment and physiological variables. Thus,
when applied to ASD, ABA focuses on treating the problems of the
disorder by altering the individual’s social and learning environments.”
4.2 ABA Assessment
A developmentally appropriate assessment and
reassessment tool must be used for formulating an individualized
ABA TP and is conducted by an authorized ABA supervisor. For TRICARE purposes,
an ABA assessment shall include data obtained from multiple methods
to include direct observation, the measurement, and recording of
behavior. A functional assessment that may include a functional
behavior analysis, as defined in
paragraph 4.15, may be required to address
problematic behaviors. Data gathered from a parent/caregiver interview
and a parent report rating scales are also required.
4.3 ABA Specialized
Interventions
ABA methods designed to improve
the functioning of a specific ASD target deficit in a core area affected
by the ASD such as social interaction, communication, or behavior.
The ABA provider delivers ABA services to the beneficiary through
direct administration of the ABA specialized interventions during
one-on-one in-person (i.e., face to face) interactions with the
beneficiary. ABA services may be comprehensive (addressing many
treatment targets in multiple domains) or focused (addressing a small
number of treatment targets, such as specific problem behaviors
and/or adaptive behaviors).
4.4 ABA Tiered Delivery Model
A service delivery model that includes the
use of supervised assistant behavior analysts and/or BTs, in addition
to the authorized ABA supervisor, to implement a TP designed by
the authorized ABA supervisor. The tiered delivery model is contrasted
with the sole provider model which includes only the use of the
authorized ABA supervisor. Supervised assistant behavior analysts
may assist the authorized ABA supervisor in clinical support and
case management duties to include the supervision of BTs and the
provision of parent(s)/caregiver(s) treatment guidance.
4.5 ABA TP
A written document outlining the ABA service plan
of care for the individual, including the expected outcomes of ASD
symptoms. For TRICARE purposes, the ABA TP shall consist of an “initial
ABA TP” based on the initial ABA assessment, and the “ABA TP Update”
that is the revised and updated ABA TP based on periodic reassessments
of beneficiary progress toward the objectives and goals. Components
of the ABA TP include: the identified behavior targets for improvement,
the ABA specialized interventions to achieve improvement, and the
short-term and long-term ABA TP objectives and goals that are defined
below.
4.5.1 ABA
TP Objectives
The short, simple, measurable
steps that must be accomplished in order to reach the short-term
and long-term goals of ABA services.
4.5.2 ABA TP Goals
These are the broad spectrum, complex short-term
and long-term desired outcomes of ABA services.
4.6 Assistant
Behavior Analyst
The term “assistant behavior
analyst” refers to supervised Licensed Assistant Behavior Analyst (LABA), Board
Certified Assistant Behavior Analyst (BCaBA), and QASP.
4.7 Authorized
ABA Supervisor
An authorized ABA supervisor,
whether or not currently supervising, is defined as a Licensed Behavior
Analyst (LBA), BCBA, BCBA-Doctorate (BCBA-D), or other master’s
level or above TRICARE authorized ABA providers practicing within
the scope of their state licensure or state certification.
4.8
Autism
Spectrum Disorder (ASD)
For ACD eligibility,
the covered ASD diagnosis is Autism Spectrum Disorder (F84.0) according
to the Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5)/Autistic Disorder according to the International
Classification of Diseases, Tenth Revision, Clinical Modification. According
to DSM-5, Autistic Disorder, Asperger’s Disorder, and Pervasive
Developmental Disorder, Not Otherwise Specified (PDD-NOS) were converted
into the single diagnosis of ASD (F84.0). Beneficiaries diagnosed
with one of the five ASD diagnoses under the DSM, Fourth Edition,
Text Revision: Autistic Disorder, Rett’s Syndrome, Childhood Disintegrative
Disorder (CDD), Asperger’s Disorder, and PDD-NOS may continue to
be eligible for the ACD. However, previously diagnosed beneficiaries
(those diagnosed prior to October 20, 2014) receiving ABA services
for these disorders must have their diagnosis updated to conform
to the DSM-5 criteria upon the next Periodic ABA Program Review
per
paragraph 8.4. This update of the diagnosis
does not necessarily require a new diagnostic evaluation. The beneficiary
must possess the diagnosis of ASD (F84.0) to continue eligibility
in the ACD. Rett’s Syndrome and CDD alone are no longer considered
an ASD in the DSM-5 and therefore beneficiaries diagnosed with Rett's Syndrome
or CDD after October 20, 2014 are not eligible for ABA unless a
secondary diagnosis of ASD is also present. The ASD diagnosis must
specify the symptom severity level according to the DSM-5 criteria
(Level 1 = mild, Level 2 = moderate, or Level 3 = severe).
4.9
Behavior
Intervention Plan
Behavior Intervention Plans must include
an operational definition of the target behavior excesses and deficits,
prevention and intervention strategies, schedules of reinforcement,
and functional alternative responses. Behavior Intervention Plans
shall be submitted along with any TP identifying a target behavior
excess or deficit.
4.10 Behavior
Technician (BT)
The term “behavior technician”
refers to high-school graduate level paraprofessionals who deliver
one-on-one ABA services to beneficiaries under the supervision of
the authorized ABA supervisor, and includes RBTs, ABATs, and BCATs.
4.11 Behavior
Analyst Certification Board (BACB)
The BACB
is a nonprofit 501(c)(3) corporation established to “protect consumers
of behavior analysis services worldwide by systematically establishing,
promoting, and disseminating professional standards.” The BACB certification offers
the BCBA for master’s level and above behavior analysts, the BCaBA
certification for bachelor’s level assistant behavior analysts,
and the Registered Behavior Technician (RBT) credential for BTs with
a minimum of a high school education.
4.12 Behavioral
Intervention Certification Council (BICC)
The
BICC was established in 2013 to promote the highest standards of
treatment for individuals with ASD through the development, implementation,
coordination, and evaluation of all aspects of the certification
and certification renewal processes. BICC is an independent and
autonomous governing body for the BCAT certification program, a
certification for BTs.
4.13
Direct
Supervision of BTs
(this paragraph only applies to
ABA services provided through December 31, 2018)
Authorized ABA supervisors
must provide ongoing supervision to BTs for a minimum of 5% of the
total hours spent providing one-on-one ABA services per a 30 consecutive
day period per beneficiary. Supervision in excess of 20% of the
ABA hours per a 30 consecutive day period under the tiered delivery
model shall result in contractor consultation with the authorized
ABA supervisor and a review by the MCSC’s Medical Director or designee to
determine whether the individual beneficiary’s needs are of such
high complexity that the sole provider model is indicated. Direct
supervision of every BT must include at least two face-to-face,
synchronous contacts per a 30 consecutive day period during which
the supervisor observes the BT providing services. One of these
contacts must be one-on-one direct supervision whereby the authorized
ABA supervisor, or the assistant behavior analyst delegated to provide
supervision to the BT, directly observes the BT providing the face-to-face,
one-on-one ABA services to one beneficiary at a time. The other direct
observation supervision may take place in a group format whereby
the authorized ABA supervisor observes each member of one team delivering the
ABA services one at a time, each taking turns. At least one of the
supervision sessions within the 30 consecutive day period, per beneficiary,
individual or group, must be conducted in person (not remotely). The
contractor shall work with the authorized ABA supervisor to ensure
that the 5% requirement is met, to include adjusting the percent
requirement when in instances such as when the beneficiary is ill
or absent or when the BT is ill or absent.
4.14 Family/Caregiver
Family/Caregiver follows the
32 CFR 199.2(b) definition: [t]he spouse,
natural parent, child and sibling, adopted child and adoptive parent,
stepparent, stepchild, grandparent, grandchild, stepbrother and
stepsister, father-in-law, mother-in-law of the beneficiary, legal
guardian or provider as appropriate. No other individual is considered
“family” or “caregiver” under the ACD.
4.15
Functional
Behavior Analysis
The process of identifying
the variables that reliably predict and maintain problem behaviors that
typically involve: identifying the problem behavior(s); developing
hypotheses about the antecedents and consequences likely to trigger
or support the problem behavior; and, performing an analysis of
the function of the behavior by testing the hypotheses.
4.16 Pervasive
Developmental Disabilities Behavior Inventory (PDDBI) (Cohen, I.L.
and Sudhalter, V. 2005 or current edition)
The
PDDBI is an informant-based rating scale that is designed to assist
in the assessment (for problem behaviors, social, language, and
learning/memory skills) of children who have been diagnosed with
ASD. The PDDBI provides age-standardized scores for parent and teacher
ratings. Applicable for ages 2-18.5 years.
Note: Per guidance
from the PDDBI manual and the publisher, the teacher form may be completed
by the teacher or the authorized ABA supervisor.
4.17 Qualified
Applied Behavior Analysis (QABA) Certification Board
QABA “is an organization established in 2012
to meet para-professional credentialing needs identified by behavior
analysts, ABA providers, insurance providers, government departments,
and consumers of behavior analysis and behavior health services.”
QABA offers the QASP certification for bachelor’s level assistant
behavior analysts, and the ABAT certification for a minimum of a
high school education or equivalent.
4.18
Remote Supervision
(this
paragraph only applies to ABA services provided through December
31, 2018)For the purposes
of the ACD, authorized remote supervision is defined as supervision
through the use of real time (synchronous) methods. Real-time is
defined as the simultaneous “live” audio and video interaction between
the authorized ABA Supervisor, or assistant behavior analyst, and
the BT, with the beneficiary present, by electronic means such that
the occurrence is the same as if the individuals were in the physical
presence of each other. Such is usually done by electronic transmission over
the Internet through a secured Health Insurance Portability and
Accountability Act (HIPAA) compliant program. See TRICARE Policy
Manual (TPM),
Chapter 7, Section 22.1 for appropriate HIPAA compliance
criteria.
4.19 Social Responsiveness Scale,
Second Edition (SRS-2) (Constantino, or current edition)
The SRS-2 identifies social impairment associated
with ASD and quantifies its severity. Applicable for ages 2-1/2
to 99 years.
4.20 Vineland Adaptive Behavior
Scale, 3rd Edition (Vineland-3) (Sparrow, S.S. et.al, or current edition)
The Vineland-3 is a valid and reliable measure
of adaptive behavior for individuals diagnosed with intellectual
disabilities and developmental disabilities (to include ASD). The
Vineland-3 consists of an interview, a parental/caregiver, and teacher rater
forms. Applicable for ages birth to 90 years.
5.0
Provider
Roles in The ACD
5.1 ASD Diagnosing
And Referring Providers
5.1.1 ASD
diagnosing and referring providers include: TRICARE-authorized Physician-Primary Care
Manager (P-PCM) or by a specialized ASD diagnosing provider. TRICARE
authorized P-PCMs for the purposes of the diagnosis and referral
include: TRICARE authorized family practice, internal medicine, and
pediatric physicians. Authorized specialty ASD diagnosing providers
include: TRICARE-authorized physicians board-certified or board-eligible
in developmental-behavioral pediatrics, neurodevelopmental pediatrics,
child neurology, adult or child psychiatry; doctoral-level licensed clinical
psychologists, or board certified doctors of nursing practice (DNP).
For DNPs credentialed as developmental pediatric providers, dual
American Nurses Credentialing Center (ANCC) board certifications
are required as follows: 1) either a Pediatric Nurse Practitioner
or a Family Nurse Practitioner; and 2) either (Family, or Child/Adolescent)
Psychiatric Mental Health Nurse Practitioner (PMHNP) or a (Child/
Adolescent) Psychiatric and Mental Health Clinical Nurse Specialist
(PMHCNS). For DNPs credentialed as psychiatric and mental health
providers, single ANCC board certification is required as follows:
as either a (Family or Child/Adolescent) PMHNP or a PMHCNS.
5.1.2 Diagnoses and referrals from Nurse Practitioners
(NPs) and Physician Assistants (PAs) or other providers not having
the above qualifications shall not be accepted.
5.2 Role Of A
Second Authorized ABA Supervisor
5.2.1 Consultation
Only one authorized ABA supervisor is authorized
to provide for ABA services for each beneficiary at a time. Families/caregivers
may seek consultation from another authorized ABA supervisor where
the treating authorized ABA supervisor lacks sub-specialty expertise
to treat a specific target behavior that another authorized ABA
supervisor is specifically trained and competent to address. When
a primary authorized ABA supervisor seeks consultation from another
authorized ABA supervisor, the primary authorized ABA supervisor
will remain responsible for the TP and is the sole provider authorized
to bill for ABA services.
5.2.2 Second Opinion
Families/caregivers may obtain a referral for
a second opinion for ABA services from another authorized ABA supervisor once per
authorization period. A referral for an evaluation only for a second
opinion and a prior authorization is required. Families/caregivers
may request to switch to another authorized ABA supervisor, as appropriate for
ongoing treatment. Only the authorized ABA supervisor who is responsible
for the ABA TP is authorized to bill for ABA services. The concept
of one treating provider overseeing a specific type of treatment
per episode of care with the option to seek a second opinion is
consistent with TRICARE Reimbursement Manual (TRM),
Chapter 1, Section 16 which specifies requirements
for TRICARE second opinion coverage under the TRICARE Basic Program
for surgical and non-surgical benefits.
5.3 ABA
Delivered As A Team Approach
Autism Demonstration
Corporate Services Providers (ACSPs) who administer ABA services using
a team approach can involve multiple BCBAs, assistant behavior analysts,
and BTs treating one beneficiary. One authorized ABA supervisor
must be named as responsible for the overall treatment of each beneficiary
on the ABA TP. The ACSP shall bill for services under the ACSP as
an autism clinic.
6.0
ABA
PROVIDER REQUIREMENTS
6.1 Authorized
ABA supervisors (BCBA, BCBA-Ds, or other qualified TRICARE authorized independent
providers) must meet all of the following requirements:
6.1.1 Have a
master’s degree or above in a qualifying field as defined by the
state licensure/certification where defined or certification requirements from
the BACB; and
6.1.2 Have a current, unrestricted state issued license
or state certification if practicing in a state that offers state
licensure or state certification, or
6.1.3 Have a current certification from BACB (
http://www.bacb.com)
as either a BCBA or a BCBA-D where such state-issued license or
certification is not available.
6.1.4 Enter into a Participation Agreement,
Addendum A, approved by the Director, Defense Health
Agency (DHA) or designee.
6.1.5 If applicable, employ directly or contract
with assistant behavior analysts and/or BTs.
6.1.6 Report to the contractor within 30 calendar
days of notification of a state sanction or BACB sanction issued
to the BCBA or BCBA-D for violation of BACB Professional and Ethical
Compliance Code for Behavior Analysts (
https://www.bacb.com)
or notification of loss of BACB certification. Loss of state licensure
or certification, or loss of BACB certification shall result in
termination of the Participation Agreement with the authorized ABA
supervisor with an effective date of such notification. Termination of
the Participation Agreement by the contractor may be appealed to
DHA in accordance with the requirements of
Chapter 13.
6.1.7 Maintain all applicable business licenses and
employment or contractual documentation in accordance with Federal,
State, and local requirements and the authorized ABA supervisor’s
business policies regarding assistant behavior analysts and BTs.
6.1.8 Meet all applicable requirements of the states
in which they provide ABA services, including those states in which
they provide remote supervision of assistant behavior analysts and
BTs and oversee ABA services provided where the beneficiary is receiving
services.
6.1.9 Cooperate fully with a designated
utilization and clinical quality management organization which has
a contract with the DoD for the geographic area in which the provider
does business.
6.1.10 Authorized
ABA supervisors under the Autism Care Demonstration: Serve as direct supervisors
of the assistant behavior analysts and BTs and ensures that the
quality of the ABA services provided by assistant behavior analysts
and BTs meets the minimum standards promulgated by the applicable
certifying body recommendations, rules, and regulations.
6.1.11 Supervision must be provided in accordance
with the state licensure and certification requirements in the state
in which ABA services are practiced where such state-issued license
or certification is available.
6.1.12 The
following training is required:
• Basic Life Support
(BLS) or a Cardiopulmonary Resuscitation (CPR) equivalent certification,
as demonstrated by completion of a hybrid course comprised of a web-based instruction
component and live component to demonstrate skills on a dummy.
• For BCBAs and BCBA-Ds
who supervise assistant behavior analysts and/or BTs through December
31, 2018, an eight-hour, competency-based training
covering the BACB’s Supervising Training Curriculum Outline and
three hours of continuing education related to supervision during
each BACB certification cycle. This requirement does
not apply to ABA services provided on or after January 1, 2019.
6.2 Assistant
behavior analysts must meet all of the following requirements:
6.2.1 Have a
bachelor’s degree or above in a qualifying field as defined by the
state licensure/certification where defined or certification requirements from
a certification body approved by the Director, DHA; and
6.2.2 Have a current certification
from a certification body approved by the Director, DHA; and
6.2.3 Have a current, unrestricted
state issued license or state certification in a state that offers state
licensure or state certification.
Note: Should a state
licensure or state certification specify criteria for an assistant
behavior analyst that results in a previously authorized TRICARE
assistant behavior analyst not meeting the requirements for state
licensure or state certification, that provider may be recognized
by TRICARE as only a BT without having to obtain the BT certification
(if allowed by state law) and shall be subject to all BT requirements
(supervision, reimbursement, and may no longer complete the functions
of an assistant behavior analyst) once the state licensure language
becomes effective. A credential as an ABA provider must be maintained.
6.2.4 (This
paragraph only applies to ABA services provided through December
31, 2018.) Assistant behavior analysts must receive
supervision in compliance with the BACB or QABA (or those of another
certification body approved by the Director, DHA) rules and regulations.
Only direct supervision, where the authorized ABA supervisor directly
observes the assistant behavior analyst providing services with
the beneficiary or the beneficiary’s parents/caregivers, will be
reimbursed. Indirect supervision, to include but not limited to,
a review and discussion of case load, data collection procedures,
and professional development, is not reimbursable under TRICARE.
6.2.5 A supervised assistant behavior analyst working
within the scope of their training, practice, and competence may
assist the authorized ABA supervisor in various roles and responsibilities
as determined appropriate by the authorized ABA supervisor and delegated
to the assistant behavior analyst, consistent with the most current
BACB Guidelines for “Applied Behavior Analysis Treatment of Autism
Spectrum Disorder: Practice Guidelines for Healthcare Funders and
Managers” (2014 or current edition) and current BACB and/or QABA
certification requirements (or requirements of another certification
body that is approved by Director, DHA, for TRICARE purposes). Assistant
behavior analysts must work under the supervision of an authorized
ABA supervisor who meets the requirements specified in
paragraph 6.1.
6.2.6 The assistant behavior analysts have the requisite
bachelor’s degrees to qualify for the BCaBA certification exam administered
by the BACB or the QASP certification exam administered by QABA
(or exam of another certification body that is approved by Director,
DHA, for TRICARE purposes). The authorized ABA supervisors are ultimately
responsible for the delivery of care including the TP, and the contractor
shall deny claims for unsupervised services of an assistant behavior
analysts.
Note: The following documents will be maintained
in the authorized ABA supervisor and each assistant behavior analyst’s
file: the BACB BCaBA Annual Supervision Verification Form or the
QABA Fieldwork Verification Form.
6.2.7 The
following training is required:
• BLS or a CPR equivalent
certification, as demonstrated by completion of a hybrid course comprised
of a web-based instruction component and a live component to demonstrate
skills on a dummy.
• Eligibility requirement
to conduct supervision
(required through December
31, 2018):
• For BCaBAs who supervise
BTs, an eight-hour, competency-based training covering the BACB’s
Supervising Training Curriculum Outline and three hours of continuing education
related to supervision during each BACB certification cycle.
• QABA certified QASPs
must have completed the supervisory training, and possess the supervisory
designation, S, in order to supervise any BT.
6.3 Behavior
Technicians (BTs)
A BT may not conduct the
ABA assessment, or establish a child’s ABA TP. Claims for BTs who
are not properly supervised in accordance with ACD requirements
will be denied. BTs must meet the following requirements:
6.3.1 All BTs must possess a current RBT,
ABAT, or BCAT certification, or state certification, or certification
from a body approved by the Director, DHA, before applying for TRICARE-authorized provider
status.
Note: Should a state licensure or certification specify
criteria for an assistant behavior analyst that results in a previously
authorized TRICARE ABA provider not meeting the requirements for
licensure/certification, that provider may be recognized as only
a BT without having to obtain the BT certification (if allowed by
state law) and shall be subject to all BT requirements (supervision,
reimbursement, and may no longer complete the functions of an assistant
behavior analyst) once the state licensure language becomes effective.
Additionally, should a state licensure or state certification specify
a BT certification type, that state designation must be followed.
6.3.3 Once a BT has completed BACB, QABA, or BICC
certification requirements, or state certification, has passed the
BT examination, completed BLS or CPR equivalent certification, and
a completed BT approval application has been submitted to the contractor,
the contractor may place the BT in a provisional status, not to
exceed 90 days, to allow for rendering of billable services pending
final application approval. ABA supervisors are encouraged to contact
the regional contractor to verify the date provisional status begins
for each BT. If the BT is not approved for TRICARE certification
for any reason within 90 days, then recoupment of claims paid by
the contractor shall occur.
6.3.4 (This
paragraph only applies to ABA services provided through December
31, 2018.) BTs must obtain ongoing supervision for
a minimum of 5% of the hours spent providing one-on-one ABA services per a 30 consecutive day
period per beneficiary. See
paragraph 4.13 for the definition of direct supervision. Remote
supervision is approved (see
paragraph 4.18).
6.4 Autism Care
Demonstration-Corporate Services Providers (ACSPs)
ACSPs include autism centers, autism clinics
and individual authorized ABA supervisors with contractual agreements
with individual assistant behavior analysts and BTs under their
supervision.
6.4.1 The ACSP shall:
6.4.1.1 Submit
evidence to the contractor that professional liability insurance
in the amounts of one million dollars per claim and three million
dollars in aggregate, is maintained in the ACSP’s name, unless state
requirements specify greater amounts;
6.4.1.2 Submit
to the contractor all documents necessary to support an application
for designation as a TRICARE ACSP;
6.4.1.3 Enter into
a Participation Agreement,
Addendum A,
approved by the Director, DHA or designee (i.e., the contractor);
6.4.1.4 Employ
directly or contract with qualified authorized ABA supervisors,
assistant behavior analysts, and/or BTs;
6.4.1.5 Certify
that all authorized ABA supervisors, assistant behavior analysts,
and BTs employed by or contracted with the ACSP meet the education,
training, experience, competency, supervision, and ACD requirements
specified herein;
6.4.1.6 Comply
with all applicable organizational and individual licensing or certification requirements
that are extant in the State, county, municipality, or other political
jurisdiction in which ABA services are provided under the ACD;
6.4.1.7 Maintain
employment or contractual documentation in accordance with applicable Federal,
State, and local requirements, and corporate policies regarding
authorized ABA supervisors, assistant behavior analysts, and BTs;
6.4.1.8 Comply
with all applicable requirements of the Government designated utilization
and clinical quality management organization for the geographic
area in which the ACSP provides ABA services; and
6.4.1.9 Comply
with all other requirements applicable to TRICARE-authorized providers.
6.5 Provider
Background Review
6.5.1 The
contractor shall obtain a Criminal History Review, as specified
in
Chapter 4, Section 1, paragraph 8.0, for ACSPs
who are individual providers with whom the contractor enters into
a Participation Agreement.
6.5.2 ACSPs, other than those specified
in
paragraph 6.5.1, shall:
6.5.2.1 Obtain
a Criminal History Review of authorized ABA supervisors directly
employed by or contracted with the ACSP.
6.5.2.2 Obtain
a Criminal History Background Check (CHBC) of assistant behavior
analysts and BTs who are directly employed by or contracted with
the ACSP.
6.5.3 The authorized ABA supervisor
shall obtain a CHBC of assistant behavior analysts and BTs directly
employed by or contracted with the authorized ABA supervisor.
6.5.4 The CHBC
of assistant behavior analysts and BTs shall:
6.5.4.1 Include
current Federal, State, and County Criminal and Sex Offender reports
for all locations the assistant behavior analyst or Behavior Technician
has resided or worked during the previous 10 years; and
6.5.4.2 Be completed
prior to the assistant behavior analyst or BT providing ABA services
to TRICARE beneficiaries.
7.0
BENEFICIARY
ELIGIBILITY
7.1 The contractor shall cover ABA services under
this demonstration for dependents of active duty, retirees, and
TRICARE eligible Reserve Components, participants in member plus
family coverage under TRICARE Reserve Select (TRS) and TRICARE Retired
Reserve (TRR), individuals covered under the Transitional Assistance
Management Program (TAMP) or TRICARE for Life (TFL), participants
in TRICARE Young Adult (TYA), North Atlantic Treaty Organization
(NATO) or Partnership for Peace (PfP) dependent beneficiaries, and
those individuals no longer TRICARE eligible who are participating
in the Continued Health Care Benefits Program (CHCBP).
7.2 Eligible
beneficiaries for this demonstration must:
7.2.1 Have been diagnosed with ASD
specified in
paragraph 4.8 by a TRICARE-authorized ASD diagnosing
provider specified in
paragraph 5.0.
7.2.2 Dependents of Service members
must be registered in Extended Care Health Option (ECHO) per
paragraph 10.0 as
a requirement of the ACD and will continue to receive the other supplemental
services offered under ECHO such as respite care, Durable Equipment
(DE), and additional OT, PT, and SLP services beyond those offered
under the Basic Program.
7.3 Eligibility for benefits under
the ACD ceases as of 12:01 a.m. of the day after the end of the ACD, or
when the beneficiary is no longer eligible for TRICARE benefits.
7.4 Ineligibility
for the ACD does not preclude eligible beneficiaries from receiving
otherwise allowable services under TRICARE.
7.5 For those
beneficiaries whose diagnostic testing or specialized ASD diagnosing
provider evaluation does not confirm the diagnosis of ASD, the current
authorization will continue until expiration. ABA services will
not be reauthorized. The contractor will work with the family to
transition the beneficiary out of the ACD and identify other treatments
appropriate for this beneficiary (see
paragraph 4.8).
8.0 policy
8.1
Referral
and Authorization
8.1.1 Referral
8.1.1.1 A referral for ABA services under the ACD
is required. A P-PCM or specialized ASD diagnosing provider may
submit the referral for ABA services. The beneficiary must be diagnosed
with ASD using DSM-5 criteria in accordance with
paragraph 5.1.1. The referral
for ABA services must contain documentation of the age of the child
and year of the initial ASD diagnosis, documentation of any co-morbid
psychiatric and medical disorders, and level of symptom severity (level
of support required per DSM-5 criteria under ASD). Level of symptom
severity shall be submitted by the specialized ASD diagnosing provider.
The diagnosing/referring provider shall provide a copy of the referral
for ABA services to the beneficiary’s parent(s)/caregiver(s). If
the initial diagnosis is made by a P-PCM, the P-PCM must submit
a referral for a specialized ASD diagnosing provider who must confirm
the diagnosis of ASD within one year.
8.1.1.2 The
specialized ASD diagnosing provider shall complete the outcome measures
as described in
paragraphs 8.2.2.2 and
8.2.2.3.
If the specialized ASD diagnosing provider cannot complete the outcome
measures requirement within one year of the initial diagnosis, then
the specialized ASD diagnosing provider shall submit a referral
to the managed care support or TOP contractor for outcome measures
to be completed by another TRICARE authorized provider in accordance
with
paragraphs 8.2.2 and
8.2.3.
8.1.2 Authorization
8.1.2.1 Upon receipt of the referral for ABA services,
the contractor shall issue an authorization for six months of ABA
services based on the referral request. To the extent practicable,
each contractor authorization shall identify a specific TRICARE
authorized ABA supervisor with an opening to accept the TRICARE
beneficiary. This individualized approach is designed to provide
families with timely access to ABA services. However, beneficiary
families are free to choose any TRICARE authorized ABA network provider
once the authorization is received or, with the managed care support
or TOP contractor’s assistance, select a non-network provider if
a network provider is no available.
8.1.2.2 The provision of ABA services under the ACD
shall include:
8.1.2.2.1 The initial
ABA assessment by the authorized ABA supervisor to include functional behavior
analysis and behavior intervention plan (if needed), initial TP
development, direct one-on-one ABA services as specified in the
approved TP, reassessment to evaluate progress, TP updates and parent(s)/caregiver(s)
treatment guidance. The initial ABA assessment and treatment plan
must be completed and submitted to the contractor prior to the commencement
of billable one-on-one ABA services (0364T/0365T) by any other provider
type.
8.1.2.2.2 Beneficiaries
will receive ABA services provided solely by master’s level or above authorized
ABA supervisor and/or under the tiered delivery model, where an
authorized ABA supervisor will plan, deliver, and/or supervise an
ABA program. Both models are authorized and the model selected shall
be based on the needs of the beneficiary as well as provider availability.
The authorized ABA supervisor is supported by supervised assistant
behavior analysts and/or paraprofessional certified BTs who work
one-on-one with the beneficiary with ASD in the home and in the
community to implement the ABA intervention protocol designed, monitored,
and supervised by the authorized ABA supervisor.
8.1.2.3 Prior to the expiration of each six month authorization
period, as early as 60 days in advance, the authorized ABA supervisor
or ACSP shall request re-authorization of ABA services for the next
six months from the contractor as supported by submission of the
every six month ABA reassessment and TP Update that include documentation
of progress using the PDDBI.
8.1.3 Subsequent
Referrals And Authorizations
Every
two years from the initial authorization (i.e., after the beneficiary
has received ABA services for two consecutive years or four six-month
authorization periods), a new referral for ABA services and a new
referral for outcome measures from the P-PCM or specialized ASD
diagnosing provider is required. The contractor shall conduct the
periodic ABA services program review for clinical necessity prior
to authorization of another six months of ABA in accordance with
paragraph 8.4.
Clinical necessity refers to services that a licensed or otherwise
authorized TRICARE provider of ABA services for the diagnosis of ASD
determines are clinically indicated and appropriate to address a
beneficiary’s diagnosed condition, beyond what is determined as
medically necessary under TRICARE regulations. This review should
take into account current status, progress toward meeting ABA TP
objectives and goals, and referring provider and parental input.
The TRICARE Regional Contractors’ Medical Director or designee reviews
and approves authorizations for clinically necessary care.
Note: New
authorizations will not be required as a result of the transition
from Category III CPT codes to Category I codes, meaning the current
authorization will run its full period. Subsequent requested and
approved authorizations will be issued with the Category I CPT.
8.2 Outcome
Evaluations
8.2.1 The Senate Armed Services
Committee directed the Secretary of Defense to provide quarterly
reports on the effectiveness of care among military dependents participating
in the program. The Secretary will report, at a minimum, the health-related
outcomes for beneficiaries under the program.
8.2.2
Outcome
Measures
For all beneficiaries participating
in the ACD, outcome evaluations must be completed and reported,
using norm-referenced, valid, and reliable evaluation tool (see
DD form 1423). Outcome measures may be completed via telehealth
(see the TPM,
Chapter 7, Section 22.1 for requirements).
8.2.2.1 PDDBI
This outcome measure must be completed at
baseline and every six months. Only the Parent form is required
at baseline. The Parent form and the Teacher form must be submitted
every six months thereafter to align with the treatment plan submission
and reauthorization. The teacher form may be completed by the teacher
or the BCBA/BCBA-D. Responsibility for the completion of the Teacher
form by the BCBA/BCBA-D cannot be delegated except to a teacher
who meets the requirements specified in the PDDBI Manual. Domain/Composite
Score Summary Table must be submitted to the regional contractor.
Only authorized ABA supervisors are eligible to submit the PDDBI to
the managed care support or TOP contractor. For reimbursement of
the PDDBI submitted by the BCBA, see
paragraphs 12.1.6 and
13.7.
8.2.2.2
Vineland-3
This outcome measure must be completed at baseline
(within one year of the initial diagnosis) and every two years thereafter
to align with the Periodic ABA Program Review. The Parent form,
the Interview form, or the Teacher form will be accepted. The Score
Summary Profile, to include the Maladaptive Behavior Results Submission,
must be submitted to the regional contractor. The Vineland shall
be completed and submitted by the specialized ASD diagnosing provider.
If the specialized ASD diagnosing provider cannot complete the requirement
per
paragraph 8.1.1.2, the following providers
may be authorized by the managed care or TOP contractor:
• A
TRICARE authorized independent provider (TRICARE authorized independent providers
must use the assessment code for their discipline for reimbursement);
or
• A
BCBA/BCBA-D (for reimbursement of the Vineland-3 submitted by the
BCBA/BCBA-D, see
paragraphs 12.1.6 and
13.7);
or
• Parents/caregivers
may provide the TRICARE authorized independent provider or the authorized
ABA supervisor a school-completed Interview or Teacher form for submission
to the regional contractor to meet this requirement. (The school
is not eligible for reimbursement as these individuals are not TRICARE
authorized independent providers.)
8.2.2.3
SRS-2
This outcome measure must be completed at baseline
(within one year of the initial diagnosis) and every two years thereafter
to align with the Periodic ABA Program Review. The Parent form is
required. The Total Score Results and Treatment Subscale Results
must be submitted to the regional contractor. The SRS-2 shall be
completed and submitted by the specialized ASD diagnosing provider.
If the specialized ASD diagnosing provider cannot complete the requirement
per
paragraph 8.1.1.2, the following providers
may be authorized by the managed care or TOP contractor:
• A
TRICARE authorized independent provider (TRICARE authorized independent providers
must use the assessment code for their discipline for reimbursement);
or
• A
BCBA/BCBA-D (for reimbursement of the SRS-2 submitted by the BCBA/BCBA-D,
see
paragraphs 12.1.6 and
13.7).
8.2.3 All
outcome measures shall be completed and submitted by their respective
deadlines. Beneficiaries who are unable or unwilling to meet this
requirement shall be identified by the managed care support or TOP
contractors, and the case managers shall assist in either resolving
the lack of testing or termination from the ACD and all ABA services.
The contractors shall document non-compliance in the beneficiary’s
record.
8.2.4 To support efficiency of provider
time, we encourage each contractor to implement tools which would
allow the network providers to electronically submit results of
these outcome measures to the contractor through a secure, HIPAA-compliant,
web-based application.
8.2.5 As required in
paragraph 8.1.1.2,
the outcome measures shall be completed/submitted by the specialized
ASD diagnosing provider. If the specialized ASD diagnosing provider
is not able to complete the outcome measures requirements within
one year of the initial diagnosis, then the specialized ASD diagnosing
provider shall submit a referral for authorization to the managed
care support or TOP contractor who will identify another TRICARE
authorized provider, to include an eligible BCBA, who is eligible
to complete the measures. Claims for a Vineland-3 and/or SRS-2 submitted
by a BCBA without prior authorization will be denied. No authorizations
will be issued for outcome measures completed by a BCBA prior to
January 1, 2018.
8.3 ABA
Assessments and TPs completed by the authorized ABA supervisor shall
include:
8.3.1 The
beneficiary’s name, date of birth, date the initial ABA assessment
and initial ABA TP was completed, the beneficiary’s DoD Benefit
Number (DBN) or other patient identifiers, name of the referring
provider, background and history (to include the number of hours
enrolled in school, the number of hours receiving other support
services such as OT, PT, and SLP, and how long the child has been
receiving ABA services), objectives and goals, and ABA service recommendations.
The ABA assessment shall include results of the assessments conducted
to identify specific treatment targets and the ABA service procedures
to address each target.
8.3.2 Background and history shall include information
that clearly reports the beneficiary’s condition, diagnoses, medical
co-morbidities (to include prescribed medications), family history,
and how long the beneficiary has been receiving ABA services.
8.3.3 The initial ABA assessment must identify objectively
measured behavioral excesses and deficits that impede the beneficiary’s
safe, healthy, and independent functioning in all domains applicable (language,
development, social communication, and adaptive behavior skills). This assessment
may require a behavior intervention plan for each target behavior
excess and deficit (see
paragraph 4.9). The initial ABA assessment
will include the PDDBI parent form Domain/Composite Score Summary
Table.
8.3.4 The initial ABA assessment
must state that the beneficiary is able to actively participate
in ABA services as observed by the authorized ABA supervisor or
ACSP during the ABA assessment.
8.3.5 The initial ABA TP shall include clearly defined,
measurable targets in all relevant DSM-5 symptom domains as identified
in the initial assessment, and objectives and goals individualized
to the strengths, needs, and preferences of the beneficiary and
his/her family members.
8.3.6 The initial ABA TP and all TP updates shall
also include all measurable objectives and goals for parent/caregiver
treatment guidance on implementation of selected treatment protocols
with the beneficiary at home and in multiple other settings. The
protocols shall be selected jointly by the authorized ABA supervisor
and the parent(s)/caregiver(s). Participation by the parent(s)/caregiver(s)
is expected, and continued authorization for ABA services is contingent
upon their involvement. If parent(s)/caregiver(s) participation is
not possible, the TP shall document why not (i.e., the parent/caregiver
is deployed, is physically unable to deliver the ABA services, etc.).
8.3.7 Documentation on the initial ABA TP shall also
include the authorized ABA supervisor’s recommendation for the number
of weekly hours of ABA services under the ACD to include the recommended
number of weekly hours for ABA services provided by BTs. TPs are
individualized and treatment goals and hours of ABA services are
determined by the DSM-5 symptom domains and severity levels (levels
of supports required per DSM-5 ASD criteria), and capability of
the beneficiary to participate actively and productively in ABA
services. Recommendations for hours shall reflect the clinical needs
of each beneficiary. However, recommended ABA services shall take
into account whether the child is attending school, the time available
in the beneficiary’s schedule for ABA services, and individual beneficiary
needs.
8.3.8 ABA reassessments and TP updates
shall document the evaluation of progress for each behavior target
identified on the initial ABA TP and prior TP updates. Documentation
of the ABA reassessment and TP update shall be completed every six
months and include all of the following but not limited to (the
contractor may request additional information based on best practices):
• Date
and time the reassessment and TP update was completed.
• ABA provider conducting
the reassessment and TP update.
• Evaluation of progress
on each treatment target (i.e., Met, Not Met, Discontinued).
• Revisions to the ABA
TP must include identification of new behavior targets, objectives, and
goals, to include TP modifications based on the six month assessment of the
PDDBI and other outcomes measures evaluation. Note: If no progress
has been made, the managed care support or TOP contractor shall
engage the authorized ABA supervisor who will incorporate revisions
to the individual treatment plan to address the lack of progress.
• Recommendation for
continued ABA services to include a recommendation for the number
of weekly hours of one-on-one ABA services, including documentation
of clinical necessity of additional hours required, under the ACD.
• The reassessments
and TP updates are required to be conducted every six months and must
be dated as being conducted during that time frame. The reassessments
and TP updates, to include the PDDBI, may be submitted once every six
month reassessment period. Reassessments must be completed and submitted
by the sixth month for review for continued reauthorization. Any
delay in submission of the ABA reassessment and TP updates may delay
or terminate continued authorization for ABA services.
• The
TP and TP updates shall contain signatures by the authorized ABA
supervisor, and the parent/caregiver to ensure the parent/caregiver
is fully cognizant of the care being provided to their child.
8.4
Periodic
ABA Program Review
The following criteria
are established to determine if/when ABA services are no longer appropriate:
8.4.1 Loss of eligibility for TRICARE benefits as
defined in
32 CFR 199.3.
8.4.2 The authorized ABA supervisor has determined
one or more of the following:
• The patient has met
ABA TP goals and is no longer in need of ABA services.
• The patient has made
no measurable progress toward meeting goals identified on the ABA
TP after successive progress review periods and repeated modifications
to the TP.
• ABA
TP gains are not generalizable or durable over time and do not transfer
to the larger community setting after successive progress review
periods and repeated modifications to the TP.
• The patient can no
longer participate in ABA services (due to medical problems, family problems,
or other factors that prohibit participation).
8.5 ABA
Benefits
The following ABA services are authorized
under the ACD to TRICARE eligible beneficiaries diagnosed with ASD
by an appropriate provider.
8.5.1 An initial beneficiary ABA assessment performed
one-on-one by an authorized ABA supervisor to include administration
of appropriate assessment tools, and a functional behavior assessment
and analysis when appropriate.
8.5.2 Development of the initial ABA TP with objectives
and goals.
8.5.3 Provision of one-on-one ABA services delivered
directly by the authorized ABA supervisor or delivered by the supervised assistant
behavior analyst and/or BT.
8.5.4 Monitoring of the beneficiary’s progress toward
ABA TP objectives and goals specified in the initial ABA assessment
and TP through the ABA reassessment and TP updates by the authorized ABA
supervisor.
8.5.5 Providing treatment guidance
to family member(s)/caregiver(s) by the authorized ABA supervisor
or delegated to the supervised assistant behavior analyst to provide
ABA services in accordance with the ABA TP.
8.5.6 Supervision of the delivery of BT one-on-one
ABA services to the beneficiary by the authorized ABA supervisor,
in accordance with these policies (authorized through
December 31, 2018).
9.0
ABA
Provided Under The TRICARE Overseas Program (TOP)
9.1 ABA services shall only be
authorized to be provided by either a BCBA or a BCBA-D in countries that
have BCBA and BCBA-Ds certified by the BACB. Tiered delivery model
ABA services (assistant behavior analyst and BT services) are not
authorized in the TOP. All providers overseas shall meet the requirements
outlined in this Chapter.
9.2 The TOP contractor shall verify
compliance with all requirements outlined in the ACD.
9.3 International
providers certified by the BACB as a BCBA or BCBA-D are eligible
to become TRICARE authorized providers of ABA services for the TOP.
9.4 Where there
are no BCBAs or BCBA-Ds certified by the BACB within the TRICARE
specialty care access standards in the host nation, there is no
ABA benefit under the ACD.
9.5 The contractor shall work
with the TOP Office to identify the most appropriate claim form
to use depending on the host nation country and the overseas provider’s
willingness to use the Centers for Medicare and Medicaid Services
(CMS) 1500 Claim Form.
9.6 The contractor shall report
allegations of abuse to the host nation authorities responsible
for child protective services and to the BACB in accordance with
applicable law (including Status of Forces Agreements), and to state
license or certification boards as appropriate.
9.7 Reimbursement
of TOP claims for ABA services obtained overseas shall be based
upon the lesser of billed charges, the negotiated reimbursement
rate, or the Government-directed reimbursement rate foreign fee
schedule. (See
Chapter 24, Section 9 and
the TRM,
Chapter 1, Section 35 for additional guidance).
10.0
ECHO
Program
The ECHO program as currently outlined
in
32 CFR 199.5 remains
unaffected, except all ABA services will be provided under the ACD.
Participation in the Autism Care Demonstration by ADFMs requires
enrollment in Exceptional Family Member Program (EFMP) and registration
in ECHO and shall constitute participation in ECHO for purposes
of ECHO registered beneficiary eligibility for other ECHO services.
This will allow ADFMs to continue to receive the other supplemental
services offered under ECHO such as respite care, DE, and additional
OT, PT, and SLP services beyond those offered under the TRICARE
Basic Program without unnecessary delays. In addition, ADFMs registered
in ECHO shall be assigned an ECHO case manager and shall receive
care coordination as they move from duty station to duty station
from both the contractor and ECHO case management. The allowed costs
of these supplemental ECHO services, except ECHO Home Health Care
(EHHC), accrue to the Government’s maximum fiscal year cost-share
of $36,000. ADFMs are to follow the ECHO registration procedures outlined
in TPM,
Chapter 9, Section 3.1. That section outlines
ECHO registration requirements to include provisional status and,
in certain circumstances, waiver of the EFMP requirement. To meet
the ECHO registration requirement of the ACD only, the DHA Clinical
Operations Division Chief or their designee may approve an additional
90 day provisional status (up to 180 days total) in exceptional circumstances
on a case-by-case basis. The provisional status will terminate upon
completion of the registration process or at the end of the 90 or 180
day period, whichever occurs first. The authorization and Government
liability for ACD benefits will terminate at the end of the provisional 90
or 180 day period. The Government will not recoup claims paid for
ACD benefits provided during the provisional period.
11.0
Reimbursement
11.1 TRICARE
will reimburse ACSPs, BCBAs, BCBA-Ds or authorized ABA supervisors
for ABA services planned by these TRICARE authorized providers,
and delivered by supervised assistant behavior analysts and/or paraprofessional
BTs, or delivered by the authorized ABA supervisor themselves. Only ACSPs
or authorized ABA supervisors may receive TRICARE reimbursement
for ABA services. Assistant behavior
analysts and/or BTs receive compensation from their authorized ABA
supervisor. Authorized ABA supervisors who are employed directly
or contracted with a TRICARE authorized ACSP receive compensation
from the ACSP. ABA services must meet the minimum standards established
by the current BACB Task List, the BACB Professional Disciplinary
Standards, the BACB Guidelines for Responsible Conduct for Behavior
Analysts, and current BACB and/or QABA rules and regulations (or those
of another certification body that is approved by Director, DHA,
for TRICARE purposes) when rendered by supervised assistant behavior
analysts or BTs who meet all applicable ACD requirements and the
minimum standards required under state regulation in the geographic
location where the ABA services are delivered.
11.2 Network
and non-network provider claims, under the ACD shall be submitted
electronically using the Category III CPT codes defined in
paragraph 12.0.
Starting
on and after January 1, 2019, network and non-network provider claims,
under the ACD shall be submitted electronically using the Category
I CPT codes defined in paragraph 12.0.
11.3 Claims shall be reimbursed using the ABA Category
III CPT codes. These codes apply to the provision of ABA services
in all authorized settings (office, home, or community setting). Starting
on and after January 1, 2019, claims shall be reimbursed using the
Category I CPT codes.
11.4 Application of HIPAA taxonomy designation.
All claims for ABA CPT codes shall include the HIPAA taxonomy designation
of each provider type. Each provider on a claim form must be identified by
the correct HIPAA taxonomy designation. The designations to be used
are:
• 103K00000X Behavior
Analyst for master’s level and above;
• 106E00000X
Assistant Behavior Analyst;
• 106S00000X
Behavior Technician.
12.0
ACD
approved CPT Codes
All
claims submitted for services performed on or after January 1, 2019
shall be cross-walked automatically to the new Category I CPT codes
for ABA services under the existing authorization. Initial authorizations
issued on or after January 1, 2019 shall be submitted using the
new Category I codes for ABA services. When a prior authorization
(issued before January 1, 2019) expires, the new authorization shall
be submitted using the Category I codes after January 1, 2019. For
services rendered through December 31, 2018, Category III codes
will still be submitted.
12.1
Category III
CPT Codes (For Dates of Service Through to December 31, 2018)12.1.1 CPT
0359T - ABA Assessment and ABA TP
12.1.1.1 The initial ABA assessment, ABA TP development,
and the ABA reassessments and TP updates, conducted by the authorized
ABA supervisor during a one-on-one encounter with the beneficiary
and parents/caregivers, shall be coded using CPT 0359T, “Behavior
Identification Assessment.”
12.1.1.2 Elements of ABA assessment include:
• One-on-one
observation of the beneficiary.
• Obtaining a current
and past behavioral functioning history, to include functional behavior
analysis if appropriate.
• Reviewing previous
assessments and health records.
• Conducting interviews
with parents/caregivers to further identify and define deficient adaptive
behaviors.
• Administering
assessment tools.
• Interpreting
assessment results.
• Development of the
TP, to include design of instructions to the supervised assistant behavior
analysts and/or BTs (under the ACD).
• Discussing findings
and recommendations with parents/caregivers.
• Preparing the initial
ABA assessment, semi-annual ABA re-assessment (to include progress
measurement reports), initial ABA TP and semi-annual ABA TP updates.
12.1.1.3 CPT 0359T
is an untimed code, meaning this code is reimbursed as a single
unit of service procedure provided by an authorized ABA supervisor
(or as delegated to an assistant behavior analyst), rather than
for timed increments related to how long it takes to complete the
assessment and ABA TP (CPT Assistant, June 2014). CPT 0359T may
be reported twice during the first six month period (initial and
re-authorization) and then once every six months for the ABA reassessment,
progress measurement report, and TP update.
12.1.2 CPT 0360T and 0361T - Observational Behavioral
Follow-Up Assessment - Supervised Fieldwork
Supervision
of BTs by authorized ABA supervisors shall be in accordance with
paragraph 4.13.
Each TRICARE beneficiary under the ACD must receive a minimum of
one direct supervision contact per a 30 consecutive day period per
BT.
12.1.2.1 Direct
supervision (i.e., supervised fieldwork), is conducted to ensure
the quality of BT services delivered during one-on-one ABA services
with the beneficiary. Supervised fieldwork also provides an opportunity
for the authorized ABA supervisor (or as delegated to an assistant
behavior analyst) and the BT to use direct observation to identify
and evaluate factors that may impede expression of the beneficiary’s
adaptive behavior. Beneficiary areas assessed during CPT 0360T and 0361T
include cooperation, motivation, visual understanding, receptive
and expressive language, imitation, requests, labeling, play, leisure,
and social interactions (CPT Assistant, June 2014). TRICARE modified
CPT 0360T and 0361T to cover supervised fieldwork. Individual and
group supervision are authorized (see
paragraph 4.13). Indirect
supervision, whereby the authorized ABA supervisor or the supervised
assistant behavior analyst meets with a BT without the beneficiary
present to review the treatment plan on one or more beneficiaries,
is excluded from coverage under Category III CPT codes 0360T/0361T
under TRICARE.
12.1.2.2 Authorized
ABA supervisors and assistant behavior analysts, who complete the
BACB eight-hour supervisory training course and competency, shall
use CPT 0360T for the first 30 minutes and 0361T for each additional
30-minute increment of supervised field work of assistant behavior
analysts and BTs. Authorized ABA supervisors are the only providers
that shall bill and receive reimbursement for supervised field work.
Supervision may be delegated to the assistant behavior analyst who
is then the rendering provider. Billing for the rendering provider
must still be completed by the authorized ABA supervisor. If the
rendering provider is an assistant behavior analyst, reimbursement
shall be at the assistant behavior analyst rate per
paragraph 13.1.
Indirect supervision shall not be reimbursed.
12.1.2.3 The MCSC shall issue at least two units of
0360T to each beneficiary per BT to ensure that the two supervision
sessions requirement is met.
12.1.2.4 All remote
supervision shall include the GT modifier when submitting
claims for remote supervision.
12.1.3 CPT 0364T and 0365T - Adaptive Behavior Treatment
by Protocol
These codes are intended to code
for the direct one-on-one ABA services delivered per ABA TP protocol
to the beneficiary. Direct one-on-one ABA services are most often
delivered by the supervised BT or assistant behavior analyst under
the tiered delivery model, but they can also be delivered by the
authorized ABA supervisor under the sole provider or tiered delivery
model. CPT 0364T is coded for the initial 30 minutes of ABA protocol
services provided during one-on-one with the beneficiary, and
CPT 0365T shall be coded for each additional 30 minutes.
Note: Authorized ABA
supervisors direct the overall treatment by designing the overall
sequence of stimulus and response fading procedures, analyzing the
BT recorded progress data, and judging whether adequate progress
is being made.
12.1.4 CPT 0368T and 0369T - Adaptive Behavior Treatment
by Protocol Modification
These are codes
used by authorized ABA supervisors (or as delegated to an assistant behavior
analyst) for direct one-on-one time with one beneficiary to develop
a new or modified protocol. These codes may also be used to demonstrate
a new or modified protocol to a BT and/or parents/caregivers. CPT
0368T and 0369T are timed 30-minute increment codes. These codes
are also used for “treatment team meetings” where the authorized
ABA supervisor, the parents/caregivers, the assistant behavior analysts,
and/or BTs meet as a team to discuss the treatment modifications. “Treatment
team meetings” will be authorized for protocol modification. These
codes (CPT 0368T and 0369T) can also be used for transition/discharge
reassessments and TP updates when circumstances require transition/discharge
from ABA services.
Note: An example of
when transition/discharge reassessments may be required could be
when a military family moves. The authorized ABA supervisor would
modify the previous ABA TP protocol to incorporate changes in context
and the environment. The modified protocol would then be provided to
the BT and parents/caregivers to facilitate the desired behavioral
target (such as reducing tantrums).
12.1.5 CPT
0370T - Family Adaptive Behavior Treatment Guidance
This code is used by the authorized ABA supervisor
(or as delegated to an assistant behavior analyst) for guiding the
parents/caregivers to utilize the ABA TP protocols to reinforce adaptive
behaviors without the beneficiary present during a one-on-one encounter.
Authorized ABA supervisors may delegate family/caregiver teaching
to assistant behavior analysts working under their supervision but
only the authorized ABA supervisor may bill for this service using
this code.
12.1.6 Healthcare
Common Procedure Coding System (HCPCS) T1023 - OUTCOME MEASURES
SUBMITTED BY BCBA/BCBA-D
This code is used
by only the BCBA/BCBA-D for the purpose of reimbursement for submission
of required data for the ACD outcomes measures (Vineland-3, SRS-2,
and PDDBI). See
paragraph 8.2.2 for submission requirements
and required data elements. For outcomes measures administered via
telehealth, claims must include the modifier
GT.
12.2 Category
I CPT Codes (For Dates of Service Beginning January 1, 2019)Concurrent billing is excluded
for all ACD Category I CPT codes except when the family and the beneficiary
are receiving separate services and the beneficiary is not present
in the family session.
12.2.1 CPT 97151 - Behavior Identification
Assessment12.2.1.1 The
initial ABA assessment, ABA TP development, and the ABA reassessments
and TP updates, conducted by the authorized ABA supervisor during
a one-on-one encounter with the beneficiary and parents/caregivers,
shall be coded using CPT 97151, “Behavior Identification Assessment.”
12.2.1.2 Elements of ABA assessment include:
• One-on-one
observation of the beneficiary.
• Obtaining
a current and past behavioral functioning history, to include functional behavior
analysis if appropriate.
• Reviewing
previous assessments and health records.
• Conducting
interviews with parents/caregivers to further identify and define
deficient adaptive behaviors.
• Administering
assessment tools.
• Interpreting
assessment results.
• Development
of the TP, to include design of instructions to the supervised assistant behavior
analysts and/or BTs (under the ACD).
• Discussing
findings and recommendations with parents/caregivers.
• Preparing
the initial ABA assessment, semi-annual ABA re-assessment (to include progress
measurement reports), initial ABA TP and semi-annual ABA TP updates.
12.2.1.3 This code is intended for reporting
initial assessments and reassessments by the authorized ABA supervisor
once every six months.
12.2.1.4 CPT 97151 is a timed code (per
15 minutes), meaning this code is reimbursed per authorized units
provided by an authorized ABA supervisor (or as delegated to an
assistant behavior analyst). CPT 97151 shall be authorized for 16
units (four hours) for the initial request of ABA services to complete
an initial ABA assessment and TP development. CPT
97151 must be used within 14 calendar days of the first date of
service for CPT 97151 and is a use or lose concept. An exception
to the 14-day rule can be granted by the Contractors in situations
out of the provider’s control. CPT 97151 may be authorized reported
twice during the first six month period (initial and re-authorization)
and then once every authorization period for the ABA reassessment,
progress measurement report, and TP update.
12.2.1.5 After the initial assessment, CPT 97151 shall
be authorized for 16 units (four hours) for reassessments and TP
updates for every subsequent authorization.
12.2.2 CPT 97153 - Adaptive Behavior
Treatment By ProtocolThis
code is intended to be used for direct one-on-one ABA services delivered
per ABA TP protocol to the beneficiary. Direct one-on-one ABA services
are most often delivered by the supervised BT or assistant behavior
analyst under the tiered delivery model, but they can also be delivered
by the authorized ABA supervisor under the sole provider or tiered
delivery model. CPT 97153 is coded per 15 minutes (per unit) of
ABA protocol services provided during one-on-one with the beneficiary.
12.2.3 CPT 97155 - Adaptive Behavior
Treatment By Protocol ModificationThis
code is used by authorized ABA supervisors (or as delegated to an
assistant behavior analyst) for direct one-on-one time with one
beneficiary to develop a new or modified protocol. This code may
also be used to demonstrate a new or modified protocol to a BT and/or
parents/caregivers with the beneficiary present. The focus of this
code is the addition or change to the protocol. CPT 97155 is a timed,
15-minute, increment code.
Note: Team
meetings of any type are not reimbursable under CPT 97155.
12.2.4 CPT 97156 - Family Adaptive Behavior
Treatment GuidanceThis
code is used by the authorized ABA supervisor (or as delegated to
an assistant behavior analyst) for guiding the parents/caregivers
(with or without the beneficiary present) to utilize the ABA TP
protocols to reinforce adaptive behaviors. Authorized ABA supervisors
may delegate family/caregiver teaching to assistant behavior analysts
working under their supervision but only the authorized ABA supervisor
may bill for this service using this code. CPT 97156 is a timed,
15-minute, increment code.
12.2.5 Healthcare
Common Procedure Coding System (HCPCS) T1023 - Outcome Measures Submitted
By BCBA/BCBA-DThis
code is used by only the BCBA/BCBA-D for the purpose of reimbursement
for submission of required data for the ACD outcomes measures (Vineland-3,
SRS-2, and PDDBI). See paragraph 8.2.2 for
submission requirements and required data elements. For outcomes
measures administered via telehealth, claims must include the modifier GT.
12.2.6 Second opinion authorizations
(for 16 units of 97151 and 1 unit of T1023) are permitted to overlap
with another approved authorization. Two “ongoing” authorizations
of direct service (CPT codes 97153, 97155, and 97156) are not permitted.
13.0 Reimbursement
Rates
13.1 Reimbursement of claims in accordance with
paragraphs 12.1 and 12.2 will
be established based on independent analyses of commercial and CMS
ABA reimbursement rates. The national rates for ABA services will
then be adjusted by geographic locality using the Medicare Geographic
Practice Cost Indices (GPCIs).
13.2 ABA
reimbursement rates will be updated at the same time as the Annual
CHAMPUS Maximum Allowable Charge (CMAC) Update, which normally occurs
in March or April. The rates will also be posted at
http://www.health.mil/rates.
These updates shall be implemented and comply with
Chapter 1, Section 4, paragraph 2.4.
13.3 For claims
with a date of service prior to the implementation of the April
1, 2016 ABA Reimbursement Rates, reimbursement of claims will be:
• The
negotiated rate; or
• The reimbursement
rates for the covered ABA CPT codes:
• CPT 0359T. The Initial
ABA assessment and ABA TP and every six month ABA reassessment and
TP update by the authorized ABA supervisor (or as delegated to an assistant
behavior analyst). CPT 0359T is a single unit of service code reimbursed
at $500.00.
• CPT
0364T and 0365T. Adaptive Behavior Treatment by Protocol. These
codes are generally used by the BT for one-on-one ABA services with
the beneficiary. Authorized ABA supervisors and assistant behavior
analysts can also deliver this service. CPT 0364T and 0365T are
timed codes reimbursed at $62.50 per in 30-minute increments ($125.00/hour)
for authorized ABA supervisors, $37.50 per 30 minutes ($75.00/hour) per
assistant behavior analysts, and $25.00 per 30 minutes ($50.00/hour)
for BTs.
• CPT
0360T and 0361T. Observational Behavioral Follow-Up Assessment for
Supervised Field Work of assistant behavior analysts and BTs by
the authorized ABA supervisor. These are timed codes reimbursed
at $62.50 for each per 30 minutes ($125.00/hour) for authorized
ABA supervisors and $37.50 per 30 minutes ($75.00/hour) for assistant behavior
analysts delegated supervision responsibility.
• CPT 0368T and 0369T.
Adaptive Behavior Treatment by Protocol Modification for team meetings
by the authorized ABA supervisor reimbursed at $62.50 per 30 minutes ($125.00/hour) and
$37.50 per 30 minutes ($75.00/hour) for the assistant behavior analyst
delegated this responsibility.
• CPT 0370T. Family
Adaptive Behavior Treatment Guidance. Authorized ABA supervisor (or
as delegated to an assistant behavior analyst) treatment guidance
to the parents/caregivers is a single unit of service CPT code reimbursed
at $125.00.
13.4 For claims with a date of service between April
1, 2016 and December 22, 2016, the GPCI–adjusted reimbursement rates,
with the no greater than 15% reduction cap, apply.
13.5 NDAA FY 2017, Section 716, signed December
23, 2016, directed that “in furnishing applied behavior analysis
under the TRICARE program to individuals during the period beginning
on December 23, 2016 and ending on December 31, 2018, the reimbursement
rates for providers of applied behavior analysis will not be less
than the rates that were in effect on March 31, 2016.” To comply,
claims for ABA services with a date of service on or after December
23, 2016 through December 31, 2018, will be reimbursed the greater
of:
• The
reimbursement rates for the covered ABA CPT codes:
• CPT 0359T. The Initial
ABA assessment and ABA TP and every six month ABA reassessment and
TP update by the authorized ABA supervisor (or as delegated to an assistant
behavior analyst). CPT 0359T is a single unit of service code reimbursed
at $500.00.
• CPT
0360T and 0361T. Observational Behavioral Follow-Up Assessment for
Supervised Field Work of assistant behavior analysts and BTs by
the authorized ABA supervisor. These are timed codes reimbursed
at $62.50 per 30 minutes ($125.00/ hour) for authorized ABA supervisors
and $37.50 per 30 minutes ($75.00/hour) for assistant behavior analysts
delegated supervision responsibility.
• CPT 0364T and 0365T.
Adaptive Behavior Treatment by Protocol. These codes are generally
used by the BT for one-on-one ABA services with the beneficiary.
Authorized ABA supervisors and assistant behavior analysts can also
deliver this service. CPT 0364T and 0365T are timed codes reimbursed
at $62.50 per 30-minute increments ($125.00/hour) for authorized
ABA supervisors, $37.50 per 30 minutes ($75.00/hour) per assistant behavior
analysts, and $25.00 per 30 minutes ($50.00/ hour) for BTs.
• CPT 0368T and 0369T.
Adaptive Behavior Treatment by Protocol Modification for team meetings
by the authorized ABA supervisor or for the authorized ABA supervisor treatment
protocol modification, with or without the BT or parent/caregiver
present, is reimbursed at $62.50 per 30 minutes ($125.00/hour) and
$37.50 per 30 minutes ($75.00/hour) for the assistant behavior analyst
delegated this responsibility.
• CPT 0370T. Family
Adaptive Behavior Treatment Guidance. Authorized ABA supervisor (or
as delegated to an assistant behavior analyst) treatment guidance
to the parents/caregivers is a single unit of service CPT code reimbursed
at $125.00.
Note: Negotiated provider
rates lower than those directed in this paragraph are not allowed.
• The provisions of
paragraph 13.2 apply
for annual GPCI rate adjustments.
13.6 For claims submitted
beginning January 1, 2019, ABA services under the ACD will be reimbursed
the greater of:
• The
reimbursement rates for the covered ACD CPT codes (rates are also
listed at https://health.mil/Military-Health-Topics/Conditions-and-Treatments/Autism-Care-Demonstration):
• CPT
97151. Behavior Identification Assessment is authorized for only
the authorized ABA supervisor (or as delegated to an assistant behavior
analyst). CPT 97151 is authorized for up to 16 units (four hours)
of service code reimbursed for up to a total of $500.00 at the initial
assessment prior to rendering any other CPT code. Additionally, CPT
97151 shall be authorized for up to 16 units (four hours) for every
authorization period and shall be conducted over no more than a
14 calendar day period. An exception to the 14-day
rule can be granted by the Contractors in situations out of the provider’s
control. Additionally, for authorizations that crossover, if CPT
0359T was already billed and reimbursed, if CPT 97151 units are
submitted, they will be denied.
• CPT
97153. Adaptive Behavior Treatment by Protocol. CPT 97153 is a timed
codes reimbursed at $31.25 per 15-minute increments ($125.00/ hour)
for authorized ABA supervisors, $18.75 per 15-minute increment ($75.00/hour)
for assistant behavior analysts, and $12.50 per 15-minute increment
($50.00/hour) for BTs.
• CPT
97155. Adaptive Behavior Treatment by Protocol Modification is rendered
by an authorized ABA supervisor for treatment protocol modification
with the beneficiary present. CPT 97155 is reimbursed at $31.25
per 15-minute increment ($125.00/hour) for the authorized ABA supervisor
and $18.75 per 15-minute increment ($75.00/hour) for the assistant
behavior analyst delegated this responsibility.
• CPT
97156. Family Adaptive Behavior Treatment Guidance. Authorized ABA
supervisor (or as delegated to an assistant behavior analyst) treatment
guidance to the parents/caregivers (with or without the beneficiary
present) is reimbursed at $31.25 per 15-minute increment ($125.00/hour)
for the authorized ABA supervisor.
Note: Concurrent
billing is excluded for all ACD Category I CPT codes except when
the family and the beneficiary are receiving separate services and
the beneficiary is not present in the family session. For
example, CPT 97153 and 97156 could be billed concurrently if services
were being provided to the beneficiary and family in two separate
locations. Documentation must indicate two separate rendering providers
and locations for the services. If CPT 97153 and 97155 are billed
concurrently, the higher rate will be paid and the other will be
denied.
Note: Negotiated provider rates lower
than those directed in this paragraph are not allowed.
• The
provisions of paragraph 13.2 apply for annual GPCI rate
adjustments.
13.7 For
BCBAs submitting claims for T1023
for services through
May 1, 2019, reimbursement shall be the geographically
adjusted reimbursement methodology for CPT code 96102.
For
claims submitted for services on or after May 1, 2019. The reimbursement
shall be the geographically adjusted reimbursement methodology for
the previous CPT 96102 and updated with the CMS Medicare Economic
Index (MEI) annually. The reimbursement for T1023 will be posted
with the other ABA reimbursement rates at https://www.health.mil/Military-Health-Topics/Conditions-and-Treatments/Autism-Care-Demonstration. Reimbursement
is limited to one unit per
outcome measure
(PDDBI: [Parent and Teacher form]:
if initial authorization,
the Contractor may authorize up to two units solely for the purpose
of the PDDBI at baseline and then at reauthorization. Vineland-3/SRS-2:
one unit each per two year period).
14.0
Cost-Sharing
14.1 Effective
October 1, 2015, all beneficiary cost-sharing and deductibles and
enrollment fees will be the same as the TRICARE Basic Program: TRICARE
Standard, as defined in
32 CFR 199.4 (through December
31, 2017), TRICARE Extra Program as defined in
32 CFR 199.17 (through December 31, 2017), TRICARE
Select as defined in
32 CFR 199.17 (starting
January 1, 2018), and TRICARE Prime Program enrollment fees and
copayments as defined under the Uniform Health Maintenance Organization (HMO)
Benefit Schedule of Charges in
32 CFR 199.18.
For information on fees for Prime enrollees choosing to receive
care under the Point of Service (POS) option, refer to
32 CFR 199.17. Also, refer to TRM,
Chapter 2, Section 1. These cost-sharing provisions
are not retroactive. There is no maximum Government payment or annual cap
specifically for ABA services. Established TRICARE deductibles, enrollment
fees, copayments, cost-shares, and the annual catastrophic cap protections
apply to beneficiaries in the ACD.
14.2 Effective January 1, 2018,
all beneficiary cost-sharing and deductibles and enrollment fees
will be those applicable to the specific category of the eligible
beneficiary receiving services under this demonstration; e.g., TRICARE
Prime, TRICARE Select; and TRICARE for Life (TFL). For information
on fees for Prime enrollees choosing to receive care under the Point
of Service (POS) option, refer to
32 CFR 199.17.
Also, refer to TRM,
Chapter 2, Section 1. There is no maximum
Government payment or annual cap specifically for ABA services;
TRICARE deductibles, enrollment fees, copayments, cost-shares, and the
annual catastrophic cap protections implemented pursuant to 32 CFR
199 apply to beneficiaries.
14.3 For
CPT code 97151, all assessment services rendered within a 14 day calendar period
using this CPT code shall be subject to one copayment. If CPT code
97151 is billed with other ABA services, only one copay applies.
14.4 For all other CPT codes rendered
on or after January 1, 2019, all ABA services rendered on the same
day shall be subject to only one copayment per day. Other (non-ABA)
services rendered on the same day as ABA services shall follow normal
TRICARE cost-share/copayment rules.
15.0 Additional
Contractor Responsibilities
The contractor
shall:
15.1 Ensure all requirements outlined in this section
are met when authorizing ABA services under the ACD.
15.2 Maintain
all documents related to the ACD in accordance with
Chapter 9.
15.3 Forward to the “gaining” contractor
all ACD related documents within 10 calendar days of being notified
that a beneficiary is transferring to a location under the jurisdiction
of another contractor.
15.4 Conduct annual audits on at
least 20% of each authorized ABA supervisor’s assistant behavior analysts
and BTs for compliance with the requirements governing ABA providers
as specified in
paragraph 6.0. Auditors shall include assessment
of compliance with the requirement for BT supervision for a minimum
of 5% and a maximum or 20% of the hours spent providing one-on-one ABA services per
30 consecutive day period per beneficiary as per
paragraph 4.13. Upon determining non-compliance
with one or more assistant behavior analyst or BT qualification
requirements, the contractor shall immediately initiate a compliance
audit of all assistant behavior analysts and BTs employed by or
contracted with that authorized ABA supervisor.
This
requirement applies to all ABA services rendered through December
31, 2018. This supervision audit requirement is no longer required
as of January 1, 2019.
15.5 Conduct semi-annual audits
on 20% of beneficiaries receiving ABA services for compliance with
paragraphs 8.1 through
8.4.
Audits shall include evaluation of the six month progress measurement
using the same tool throughout the episode of care and shall include
a breakdown of measures used. The annual audit cycle shall also
include compliance with the requirement to complete the outcome
evaluations (see
paragraph 8.2) and shall include analysis
of number of hours of supervision expressed as a percentage per
month.
This supervision audit requirement is no longer required
as of January 1, 2019.
15.6 Complete and timely submit
the monthly, quarterly, and semi-annual reports. Details for reporting
are identified by DD Forms 1423, Contract Data Requirements Lists (CDRLs),
located in Section J of the applicable contract.
15.7 Ensure
all TRICARE Encounter Data (TED) requirements outlined in the TRICARE
Systems Manual (TSM),
Chapter 2 are
met including appropriate use of Special Processing Code “
AS Comprehensive
Autism Care Demonstration”.
15.8 The contractor shall ensure
timely processing of referrals and authorization of ABA services. Case
management services shall be offered to those NADFMs (retirees and
other eligible beneficiaries of Reserve and National Guard sponsors)
who meet contractor criteria for case management. ADFMs registered
in ECHO are assigned a contractor ECHO case manager and shall receive
care coordination from that contractor ECHO case manager. Additional
case management services may be provided by the contractor, if needed.
15.9 After December 31, 2016, the contractor shall
deny claims for all BTs who do not meet certification requirements
of
paragraph 6.3.1.
15.10 After December 31, 2016, the contractor shall
deny claims for all ABA providers that do not have BLS/CPR certification
per
paragraphs 6.1.12,
6.2.7, and
6.3.2.
15.11 After December 31, 2016, the contractor shall
deny supervision claims for all providers who have not completed
the BACB eight-hour, competency-based training for Supervising Training Curriculum
Outline and three hours of continuing education related to supervision
during each BACB certification cycle or possession of the QASP Supervisor
(QASP-S) designation for QABA providers per
paragraphs 6.1.12 and
6.2.7.
This
requirement applies to all ABA services rendered through December 31,
2018.
16.0 Quality
Assurance
16.1 ABA services involves the provision of care
to a vulnerable patient population. The contractor shall have a
process in place for evaluating and resolving family member/caregiver
concerns regarding ABA services provided by the authorized ABA supervisor,
and the assistant behavior analysts, and/or BTs they supervise.
16.2 The contractor
shall designate an ACD complaint officer to receive and address
beneficiary family member/caregiver complaints. Contact information
shall be provided to all family members/caregivers of beneficiaries
receiving ABA services under this demonstration.
16.3 Allegations
of risk to patient safety shall be immediately reported to the contractor’s
Program Integrity (PI) unit and DHA PI Division. The contractor’s
PI unit shall take action in accordance with
Chapter 13,
developing for potential patient harm, fraud, and abuse issues.
16.4 Potential
complaints shall be ranked by severity categories. Allegations involving
risk to patient safety shall be considered the most severe, shall
be addressed immediately, and shall be reported to other agencies
in accordance with applicable law. For example, allegations of physical,
psychological, or sexual abuse require immediate reporting to state
Child Protective Services, or appropriate officials, to the BACB,
BICC, and/or QABA, and to state license or certification boards
as indicated in accordance with applicable laws, regulations, and
policies concerning mandated reporting requirements.
16.5 Claims
shall be denied for services of an authorized ABA supervisor who
has any restriction on their certification imposed by the BACB, BICC,
or QABA, or any restriction on their state license or certification
for those having a state license or certification.
16.6 Risk Management
policies and processes shall be established by the contractor for
the authorized ABA supervisor.
17.0 Quality
Monitoring And Oversight
17.1 Potential categories requiring
quality monitoring and oversight by the contractor include, but are
not limited to:
• Fraudulent billing
practices (to include concurrent billing, i.e., billing for two
services at the same time).
• Lack of ASD diagnosis
from a provider qualified to provide such per
paragraph 5.0.
• Lack of an ABA referral
from a TRICARE authorized ASD referring provider as per
paragraph 5.0.
• Lack of maintenance
of the required medical record documentation.
• Billing for office
supplies to include therapeutic supplies.
• Billing for ABA services using
aversive techniques.
• Group ABA services that are billed
as authorized one-on-one ABA services.
• Billing
for educational or vocational ABA services, and other non-medical services
such as changing of diapers or billing for services while the beneficiary
is sleeping.
17.2 Documentation requirements
shall address the requirements for
all session
progress notes and the ABA TP (to include the initial ABA TP and
ABA TP updates) that identify the specific ABA services used for
each behavior target. Progress notes shall contain the following
documentation elements in accordance with TPM,
Chapter 1, Section 5.1, “Requirements for
Documentation of Treatment in Medical Records”:
• The date and time
of session;
• Length
of therapy session;
• A legible name of
the rendering provider, to include provider type/level;
• A
signature of the rendering provider;
• A
notation of the patient’s current clinical status evidenced by the
patient’s signs and symptoms;
• Content of the session;
• A statement summarizing
the techniques attempted during the session;
• Description of the
response to treatment, the outcome of the treatment, and the response to
significant others;
• A statement summarizing
the patient’s degree of progress towards the treatment goals (when
present); and
• Progress notes should
intermittently (at least monthly) include reference to progress regarding
the periodic ABA program review established early on in the patient’s
treatment.
17.3 ABA Initial TP and TP updates:
• Initial
ABA TP documentation identifies short-term objectives, and short and
long-term treatment goals to include specified treatment interventions
for each identified target in each domain.
• ABA TP update assessment
notes address progress toward short and long-term treatment goals
for the identified targets in each domain utilizing either graphic
representation of ABA TP progress or an objective measurement tool
consistent with the baseline assessment. Documentation should note
interventions that were ineffective and required modification of
the TP. TP updates shall document TP modifications that were the
result of the outcome evaluations.
• The ABA TP and TP
updates must include the ASD diagnosing and referring provider’s
ASD diagnosis, to include symptom severity level/level of support
required according to DSM-5 ASD criteria. Documentation on the initial
ABA TP and the ABA TP updates shall reflect the authorized ABA supervisor’s
determination of the level of support required for the beneficiary
to demonstrate progress toward short and long-term goals (Note:
The level of support required to demonstrate progress is important
because it is directly associated with severity of the diagnosis
of ASD and is an important factor in determining the number of hours
of ABA services per week to authorize).
• Documentation of family
member/caregiver engagement and implementation of the ABA TP at
home shall be included as a required TP goal that is reassessed
every six months during the ABA TP update. Reasons for lack of/inability
for parental involvement must be documented.
• Effective
January 1, 2019, the final product for CPT 97151 will be in the
format of a treatment plan. However, all encounters using CPT 97151
must document a session note. This session note will include:
• The
date and time of session;
• Length
of assessment session;
• A
legible name of the rendering provider, to include provider type/level;
• A
signature of the rendering provider;
• Content
of the session to include what activity, measures, observations
were administered during the assessment.
17.4 To conduct proper oversight
for the potential of improper payments,
including
but not limited to improper concurrent billing practices, and
to verify that ABA services are appropriately performed as reflected
on submitted claims, the following monitoring activities will be
accomplished:
17.4.1 Conduct
comprehensive medical reviews on a statistically valid number of
applied behavior analysis providers’ claims (for CPT codes listed
in
paragraphs 12.1 through
12.2.5)
to ensure an adequate number of claims are reviewed.
17.4.2 Reviews
shall compare the beneficiaries’ session notes to the provider’s
claims to determine whether all required documentation exists and
is adequate to support the charges.
17.4.3 The contractor
shall take corrective action on claims which indicate improper payments, including,
but not limited to, payment recoupment. Contractors shall refer
cases to DHA PI, as appropriate.
18.0 Applicability
The ACD is limited to TRICARE beneficiaries
who meet the requirements specified in
paragraph 7.0. The ACD applies
to the managed care support contractors, the TOP contractor, and
the Uniformed Services Family Health Plan (USFHP) designated providers.
19.0 Exclusions
• Training
of BTs.
• ABA services for
all other diagnoses that are not ASD.
• Billing for e-mails
and phone calls.
• Billing
for driving to and from ABA services appointments.
• Billing for report
writing outside of what is included in the assessment code (CPT
0359T and 97151).
• Billing for office
supplies or therapeutic supplies (i.e., binders, building blocks,
stickers, crayons, etc.).
• Billing for ABA services provided
remotely through Internet technology or through telemedicine/telehealth (except
as allowed under
paragraph 4.18, Remote Supervision, and outcome
measures as allowed under
paragraph 8.2.2).
• Billing for ABA services involving
aversive techniques or rewards that can be construed as abuse.
• Billing for multiple
ABA providers time during one ABA session with a child when more than
one ABA provider is present.
• Educational/academic and
vocational rehabilitation.
• Educational
ABA services.
• ABA services for a
beneficiary that are written in a beneficiary’s Individualized Education Program
(IEP) and that are required to be provided without charge by the
local public education facility in accordance with the Individuals
with Disabilities Act. In order for ABA services to be authorized
within a school setting, the parent/caregiver must voluntarily provide
the IEP (or equivalent for non-public school placement) in order
for the contractor to make an appropriate determination.
• Billing
the ACD for school tuition that includes educational ABA services
and non-ABA services.
• Use and billing of
restraints.
• Respite
care (except as authorized under ECHO).
• Custodian, personal
care, and/or child care.
• Group ABA services (defined
as multiple beneficiaries with fewer providers, i.e., three plus children
and one to two providers).
• Indirect supervision.
• Direct
supervision of BTs and assistant behavior analysts (for services
provided on or after January 1, 2019.).
• Concurrent
billing is excluded for all ACD Category I CPT codes except when
the family and the beneficiary are receiving separate services and
the beneficiary is not present in the family session.
20.0 Effective
Date And Duration
Requirements for coverage
under the ACD are effective as of July 25, 2014. The ACD will terminate
December 31, 2023.