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.