3.0 DEMONSTRATION
GOALS3.1 Analyzing
and evaluating the appropriateness of the ACD under TRICARE in light
of current and future Behavior Analyst Certification Board (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 Behavior Technicians (BTs) beyond
ABA provided by Board Certified Behavior Analysts (BCBAs);
3.3 Assessing,
across the TRICARE regions and overseas locations, 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 Speech-Language Pathology (SLP) services, Occupational Therapy
(OT), Physical Therapy (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.
6.0 AUTISM
SERVICES COORDINATIONThe
TRICARE Overseas Program (TOP) contractor, U.S. Family Health Plan
Designated Providers (USFHP DPs), and TRICARE For Life (TFL) are
excluded from paragraphs 6.0 through 6.9.
Case management services in accordance with the contracts are otherwise
not affected.
6.1 The
contractor shall assign an autism-specific care manager, known as
the ASN (see paragraph 11.11), to all new beneficiaries
entering the ACD for ABA services on or after October 1, 2021, who
will serve as the primary advocate for the beneficiary.Note: “New
beneficiaries” is defined as any beneficiary not currently receiving
ABA services under the ACD as of the date of publication of this
manual change. Current beneficiaries in the ACD who are transferring
regions and continuing ABA services are not considered new. Additionally,
any beneficiary requesting ABA services after a gap in ABA services
for any reason, for a period of 12 months or more, is considered
a “new beneficiary” and all referral and authorization requirements,
including the assigning of an ASN, apply.
6.1.1 The contractor shall
provide the name and contact information of the assigned ASN in writing
to the family.
6.1.2 The ASN shall make
contact with the family to describe the ASN services prior to any
ABA services being authorized.
6.1.3 The
contractor may utilize a non-clinical outreach coordinator to assist
families with identifying providers, support groups, and local level
resources.
6.1.4 The ASN shall: 6.1.4.1 Take
the lead role and coordinate with other Case Management (CM) activities
when the beneficiary has a CM and an ASN.
6.1.4.2 Be
assigned and serve as the primary point of contact for the beneficiary/family
even when the beneficiary is eligible for services from the TRICARE
Select Navigator.
6.1.4.3 Coordinate
with the TRICARE Select Navigator.
6.2 Comprehensive
Care Plan (CCP)6.2.1 The ASN shall conduct
an initial care management assessment, to develop a written CCP (see paragraph 11.20)
in order to identify the needs of the beneficiary and family. Discharge/transition planning
shall be addressed in the CCP upon a beneficiary’s enrollment into
the ACD.
6.2.2 The ASN shall complete
the CCP within 90 calendar days of the family being assigned an ASN.
• The contractor
shall, for CCPs not completed within 90 calendar days as a result
of family/beneficiary noncompliance, suspend ABA services through
the duration of the existing authorization or until the CCP is complete,
whichever occurs first.
6.2.3 The ASN shall review
and incorporate the results of all outcome measures into the CCP.
6.2.4 The ASN shall notify
the medical home, PCM, and/or referring provider and parent/caregivers
that the CCP has been established.
• The ASN
shall share the CCP with the respective providers prior to the beneficiary receiving
ABA services under the ACD.
6.2.5 The ASN shall update
the CCP at least every six months to include updated outcome measures.
6.3 The ASN shall serve
as a single Point of Contact (POC), in coordination with Military
Medical Treatment Facility (MTF) CM (when applicable), readily accessible
by phone or email (based on beneficiary preference), during regular
business hours for the respective geographic time zone in which
the beneficiary resides, to assist the beneficiary/family with all
questions from the beneficiary’s family related to autism care and
shall:6.3.1 Coordinate medical
and behavioral health services (PT, OT, SLP, etc.), MTF services (including
coordination with the MTF CM), ECHO services (for ADFMs), Network
PCM (if applicable), specialty providers, ABA services, EFMP coordinators,
and other clinical services based on the CCP for the beneficiary
and the family.6.3.1.1 Ensure
parent-mediated programs work in collaboration with other identified
treatment goals as part of a CCP (paragraph 11.20) to ensure
that program goals do not contradict one another.
6.3.1.2 Coordinate
and participate in medical team conference meetings and document
in the contractor online system a summary of the medical team conference
calls. The ASN notes shall be available to the PCM and/or referring
provider, and the government. Any provider may request a medical
team conference, however, the ASN, or non-clinical outreach coordinator,
shall coordinate the meeting.
6.3.2 Work
with the family to coordinate services, treatments, and hours appropriate
for the family and beneficiary and document all types of care in
the CCP.
6.3.3 Facilitate continuity
of care when a beneficiary in the ACD moves, their sponsor retires,
or a provider becomes unavailable.6.3.3.1 The incoming and outgoing ASNs shall
be assigned concurrently for at least one month prior to and after
transferring regions/markets.
Note: Assignment
of a new ASN is dependent on the family or provider notifying the
contractor of the pending move/transition.
6.3.3.2 The
outgoing ASN shall actively communicate with the incoming ASN to
ensure direct ASN to ASN case transfer occurs via telephone and
secure e-mail, and shall include, but not limited to, ensuring that
the current referrals transfer without requiring a new ASD diagnosing/referring
provider appointment.
• The incoming
ASN shall work with the family to ensure all ACD program requirements are
met if there is missing information in the case transfer.
Note: Voluntary
case management services are available upon request for beneficiaries registered
in ECHO. These case managers can assist with continuity of care
issues with current ACD beneficiaries who do not have an ASN.
6.3.3.3 The
outgoing ASN shall forward to the incoming ASN all ACD related documentation, including,
but not limited to, the CCP and outcomes measures within 10 calendar
days of being notified that a beneficiary is transferring to a location
under the jurisdiction of another contractor.
6.3.3.4 The
incoming ASN or non-clinical outreach coordinator shall identify
providers for care and services for the diagnosis of ASD at the
new location prior to a move.
• The incoming
ASN or non-clinical outreach coordinator shall assist with identifying available
appointments with needed providers no more than two weeks prior
to arrival as the contractor cannot guarantee provider availability
for extended periods of time.
6.3.3.5 The
contractor shall coordinate with the MTF or appointing center for
appointments that are required or available within the MTF.
6.4 The
ASN or non-clinical outreach coordinator shall identify and facilitate
connections with local level resources that may benefit TRICARE
eligible beneficiaries in the ACD to include, but not limited to, access
to state Medicaid services, community services, respite care, support
groups, etc.6.4.1 The
ASN or non-clinical outreach coordinator shall assist the family
in accessing available respite service options, as well as assist
in identifying necessary documents for the respective options.
6.4.2 All
beneficiaries may be eligible for state and/or local level services.
6.4.3 ADFMs
may also be eligible for Service/EFMP respite or TRICARE ECHO respite
services, see TPM,
Chapter 9, Section 12.1.
6.5 The ASN or non-clinical
outreach coordinator shall provide educational resources about ASD
to the beneficiary and/or family, including but not limited to,
appropriate treatments and services, contractor provided parental
education modules, available resources (both military and civilian), potential
impact of the diagnosis of ASD on the family, and the potential
long-term care required to support the beneficiary and help them
reach their maximum potential. 6.5.1 The ASN or non-clinical outreach
coordinator shall document that materials were received via acknowledgment
by the family.
6.5.2 The contractor
shall make resources available electronically on the contractor’s
website no later than October 1, 2021.
• The
contractor shall also make this information available by mail or
email if requested by the family.
6.6 The ASN shall provide
beneficiary-specific outcome measures data to the respective TRICARE authorized
rendering providers.
6.7 The
contractor may employ or subcontract the ASN role.
Note: If
subcontracted, the ASN must not provide any ASN services (see paragraph 6.0 through 6.9)
to beneficiaries for whom they are rendering treatment services.
The ASN role must be external to the agency rendering services to
the beneficiary.
6.8 If a new beneficiary
or the family, on or after October 1, 2021, declines the ASN for
any reason, they are no longer eligible for the ACD.6.8.1 The contractor shall
document in the beneficiary file of any declination of ASN and coordinated
ACD services.
6.8.2 Declining
ACD services does not preclude Basic benefit services, just the
coordinated ASN and ABA services. However, the beneficiary or family
member can request to reengage in the ACD at any point provided
all criteria are met. The beneficiary is considered a new beneficiary
for purposes of the ACD if they reengage.
6.9 The
contractor shall document ASN notes in the contractor’s case management
system that is visible to government designated authorities.
8.0 ABA
SERVICESUnder
the demonstration authority, TRICARE covers clinically necessary
and appropriate ABA services for the diagnosis of ASD only. ABA
services are one component of a comprehensive array of services.
Additionally, ABA providers are authorized to render only ABA services
under the demonstration authority. The following paragraphs identify
approved ABA services under the demonstration:
8.1 ABA
Services BenefitABA
services for the diagnosis of ASD may be provided solely by a master’s
level or above authorized ABA supervisor and/or under the tiered
delivery model, where an authorized ABA supervisor will plan, deliver,
and supervise an ABA program. Both models are authorized and the
model selected is based on the needs of the beneficiary. The Treatment
Plan (TP) is based on which model is being implemented. See paragraphs 11.4 and 11.5 for
definitions of sole and tiered delivery models.
8.2 ABA
Provider RequirementsThe
contractor shall ensure that all TRICARE ABA provider requirements
are met, and subsequently certified, prior to reimbursement of claims
for any ABA services. All TRICARE ABA providers authorized under
the ACD only (master’s level and above, assistant, and BT level)
must:
8.2.1 Obtain a National
Provider Identifier (NPI) number (all claims must have the rendering provider’s
name and NPI for processing). For ABA providers who do not possess
an NPI prior to July 1, 2021, these providers shall have until August
1, 2021 to obtain and submit an NPI. For ABA providers new to the
ACD on or after July 1, 2021, providers must already possess an
NPI at the time of certification application submission.
8.2.2 Complete
the training for 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. Any course that is done entirely
in person is also acceptable. This certification must be maintained
and current.
8.2.3 The contractor shall
obtain respective documents from the authorized ABA supervisor:8.2.3.1 A
copy of a Criminal History Review, as specified in Chapter 4, Section 1, paragraph 8.0, for all
authorized ABA supervisors with whom the contractor enters into
a Participation Agreement.
8.2.3.2 A
copy of a Criminal History Background Check (CHBC) of assistant
behavior analysts and BTs new to the demonstration on or after July
1, 2021.
8.2.3.3 The CHBC of assistant
behavior analysts and BTs shall Include current Federal, State,
and County Criminal and Sex Offender reports for all locations the
assistant behavior analyst or BT has resided or worked during the
previous 10 years new to the demonstration on or after July 1, 2021;
8.2.3.4 The TOP contractor
shall obtain criminal history reviews and criminal history background checks
in accordance with host nation laws and policies from the authorized
ABA supervisor; and
8.2.4 Any
provider who is convicted of any felony of any kind, or a misdemeanor
involving crimes against a child or domestic violence is ineligible,
to become a TRICARE authorized provider.
8.2.5 The contractor shall
issue a provider certification after the review of a complete application packet
that meets the requirements set forth in this section.
8.3 ACD-Corporate
Services Providers (ACSPs) And Sole ProvidersACSPs include autism
centers, autism clinics, and Sole Providers (regardless of setting
of rendered ABA services, i.e., home or clinic). In many cases,
ACSPs will have contractual agreements with individual assistant
behavior analysts and BTs under their supervision to render ABA
services. Autism schools are not authorized providers under the
ACD. The ACSP including Sole Providers must:
8.3.1 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/Sole Provider’s name, unless state requirements
specify greater amounts;
• TOP
contractor shall ensure professional liability insurance is in accordance
with the TOP contract.
8.3.2 Submit
to the contractor all documents necessary to support an application
for designation as a TRICARE ACSP/Sole Provider;
8.3.3 Enter into a Participation
Agreement, Addendum A, approved by the Director, DHA
or designee (i.e., the contractor). All ACSPs/Sole Provider practices
prior to July 1, 2021 must re-sign all of their Participation Agreements
no later than August 1, 2021 or risk terminating their TRICARE authorized
status.
• The contractor shall
submit a list of non-compliant providers. The Government retains final
decision making for provider termination;
8.3.4 Employ
directly or contract with qualified authorized ABA supervisors,
assistant behavior analysts, and/or BTs, if applicable;
8.3.5 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 in this section;
8.3.6 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;
8.3.7 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.
8.3.8 Report to the contractor
within 30 calendar days of notification of a state sanction or BACB sanction
issued to the BCBA or BCBA-Doctoral level (BCBA-D) for violation
of BACB Professional and Ethical Compliance Code for Behavior Analysts
(http://www.bacb.com/ethics-code)
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 12.
While the Participation Agreement is with the ACSP/Sole provider,
failure to remove the sanctioned provider will result in the termination
of the entire ACSP or Sole provider group from the ACD.
8.3.9 Familiarize
themselves with, and comply with program requirements as stated
in 32 CFR 199.6 and 32 CFR 199.9. This information
is available online and is accessible to the public. TRICARE Manuals
and CFRs can be found online at https://manuals.health.mil/.
All authorized ABA providers agree to abide by all rules and regulations
of the TRICARE Program, but additionally agree to bill for services
that are only deemed clinically necessary and appropriate.
8.3.10 Attend
a contractor-hosted “provider education” training, no less than
annually, beginning no later than October 1, 2021.
8.3.11 Comply
with all applicable requirements of the Government designated utilization
and clinical quality management organization.
8.4 Provider
Requirements8.4.1 Authorized
ABA Supervisors (BCBA, BCBA-D, or Clinical Psychologist)8.4.1.1 Have
a master’s degree or above in a qualifying field as defined by the
state licensure/ certification where defined or in the absence of
state licensure/certification, a graduate degree from an accredited
institution (per TPM, Chapter 11, Section 3.3) in
behavior analysis, psychology, special education, or a related field;
and
8.4.1.2 Have
a current:8.4.1.2.1 Unrestricted
state-issued license or state certification for full clinical practice
if practicing in a state that offers state licensure or state certification
in behavior analysis or psychology; or
8.4.1.2.2 Certification
from the BACB where such state-issued license or certification is
not available.
8.4.2 Assistant
Behavior Analysts8.4.2.1 Have
a bachelor’s degree or above in a qualifying field as defined by
the state licensure/ certification where defined or in the absence
of state licensure/certification, a degree in a field accepted by
a certification body approved by the Director, DHA; and
8.4.2.2 Have
a current:8.4.2.2.1 Unrestricted
state issued license or state certification if they practice in
a state that offers state licensure or state certification; or
8.4.2.2.2 Certification
from the BACB or the Qualified Applied Behavior Analysis (QABA) certification
board.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 once the state licensure language becomes
effective. A certification as an ABA provider must be maintained.
8.4.2.3 Assistant
behavior analysts must receive supervision in compliance with their
certification board. Assistant behavior analysts must work under
the supervision of an authorized ABA supervisor who meets the requirements
specified in paragraph 8.4.1.
8.4.2.4 Assistant
behavior analysts who conduct supervision of BTs must be in compliance
with their certification board for supervisory activities.
8.4.3 Behavior
Technicians (BTs)8.4.3.1 All
BTs must possess a current Registered Behavior Technician (RBT),
Applied Behavior Analysis Technician (ABAT), or Board Certified
Autism Technician (BCAT) certification, or state certification,
before applying for TRICARE-authorized provider status.Note: Should
a state licensure or state certification specify a BT certification
type, that state designation must be followed.
8.4.3.2 The
contractor shall certify a BT as a TRICARE provider within 10 business
days from the receipt of a complete application that meets all requirements
for certification.
8.4.3.3 BTs
must receive ongoing supervision in compliance with their certification
board.
8.5 ABA
Provided Under The TRICARE Overseas Program (TOP)8.5.1 The contractor shall
ensure ABA services provided overseas shall follow all the requirements
in this manual. While U.S. territories fall under TOP, tiered services
(the use of assistants and BTs) may be authorized in U.S. territories
only, and must follow all requirements laid out in this manual,
including reimbursement rates (see http://www.health.mil/rates)
for all ABA providers. The tiered model is not authorized outside
of the U.S. and U.S. territories.
8.5.2 The TOP contractor
shall verify compliance with all requirements outlined in the ACD.
8.5.3 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.
8.5.4 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. See Chapter 24, Section 9, paragraph 1.6 for additional
guidance.
8.5.5 The contractor shall
ensure the reimbursement of TOP claims for ABA services obtained overseas
shall be based upon the lesser of billed charges, the negotiated
reimbursement rate, usual and customary charges, or the Government-directed
reimbursement rate foreign fee schedule. (See Chapter 24, Section 9 and the TRICARE Reimbursement
Manual (TRM), Chapter 1, Section 35 for additional guidance).
8.6 ABA
Policy8.6.1 Referral
for ABA ServicesA
complete referral for ABA services under the ACD is required for
all TRICARE eligible beneficiaries in accordance with paragraph 4.0.
Referral processing requirements are located in Chapter 1, Section 3. A retroactive referral
will not be accepted.
8.6.1.1 A
referral must specify ABA services are being requested.
8.6.1.2 For
beneficiaries first diagnosed with ASD at age eight years or older,
and requesting ABA services, on or after October 1, 2021, a specialized
ASD diagnosing provider evaluation (not a PCM), meeting all diagnosis
requirements set forth in paragraph 4.2, is required as part of the
referral for ABA services.
8.6.1.3 The contractor shall
collect an updated evaluation to determine the current level of supports
needed, to include diagnostic criteria and a validated assessment
tool, by an ASD diagnosing provider, if the initial diagnosis was
made greater than two years prior to a referral for ABA services effective
October 1, 2021.
8.6.1.4 The contractor shall
align all new and existing beneficiaries to a chronological two
year referral timeline, no later than July 1, 2021, from initial
or most current verified referral, and notify the beneficiary/family
of this date.
• The
contractor shall use the referral receipt date confirmed by the
contractor’s system of the verified referral as the start date of
the two-year referral timeline.
8.6.2 Authorization
for ABA Services8.6.2.1 The contractor shall,
upon receipt of the completed referral for ABA services, issue an evaluation
authorization for an initial assessment and TP development. The
authorized ABA supervisor then completes and submits the initial
documentation (assessment and TP) including recommended Adaptive
Behavior Services (ABS) CPT codes and number of units to the contractor
for review and subsequent appropriate approval for a six month treatment
and reassessment/TP update authorization for active delivery of
ABA services in accordance with Chapter 1, Section 3.8.6.2.1.1 The
contractor shall issue the treatment authorization identifying approved
units in accordance with the guidance defined in paragraph 8.11.6.2.
8.6.2.1.2 The contractor shall issue an initial
six-month treatment authorization only when all initial outcome
measures are complete.
8.6.2.1.3 The contractor shall
ensure all ABA services are preauthorized.
8.6.2.2 The
contractor shall, no later than August 1, 2021:8.6.2.2.1 Complete
a clinical necessity review on every TP’s recommended goals, targets, progress,
and hours (see paragraph 8.7.1 for TP requirements) prior to
issuing any six month treatment authorization for ABA services.
8.6.2.2.2 .Deny
and return TPs containing exclusions as defined in paragraph 8.10.
8.6.2.2.3 Work
with the ABA provider to revise the TP to address any findings requiring resolution
prior to authorization of that TP.
8.6.2.3 Authorizations
issued prior to August 1, 2021, and their associated claims remain
active until the next authorization period. Revisions to the existing
authorizations are not permitted.
8.6.2.4 The
contractor shall complete 100% clinical necessity reviews of ABA
services for all compliant TPs within the five business days for
authorization processing standards.
8.6.3 Subsequent
Referrals and Authorizations8.6.3.1 If ongoing services
are clinically indicated, prior to the expiration of each six-month treatment
authorization period, as early as 60 calendar days in advance and
no later than 30 calendar days in advance, a re-authorization for
ABA services should be requested by the ABA provider for the next
six months from the contractor. Should the ABA provider submit the
reauthorization request less than 30 calendar days in advance of
the expiring authorization, the ABA provider is at risk for non-reimbursable
ABA services until the new authorization is issued if the existing
authorization expires prior to the approval of the next authorization.8.6.3.1.1 The
contractor shall not back date late submissions.
8.6.3.1.2 The
request for re-authorization must be supported by submission of
the every six month ABA reassessment and TP update that includes
documentation of progress. Outcome measures must be completed/submitted
prior to issuing the next six-month treatment authorization.
8.6.3.1.3 The
contractor shall complete a clinical necessity review of the documentation submitted
every six months, including Pervasive Developmental Disorder Behavior
Inventory (PDDBI) results and other treatment services the beneficiary
is receiving.
8.6.3.1.4 The contractor shall
work with the ABA provider to revise the ABA TP if the beneficiary is
not making clinically sufficient progress as shown on the outcome
measures prior to authorization.
8.6.3.1.5 The
contractor shall issue subsequent treatment authorizations that
meet the requirements set forth in this Section.
8.6.3.2 Every
two years from the initial verified referral date, a new referral,
with level of support, is required and
must be submitted for ongoing ABA services. The new referral is
not a new diagnostic evaluation, but rather a review of the beneficiary’s
progress, and update to the DSM criteria to include an update for
the level of supports required. These subsequent referrals may be
accepted up to six months in advance.
8.6.4 Outcome
MeasuresFor
all TRICARE eligible beneficiaries receiving ABA services, all outcome
measures must be completed and reported, using norm-referenced,
valid, and reliable evaluation tools prior to issuing the treatment
authorization. For the purpose of the ACD, all outcome measures
completed by ABA providers are considered an indirect service and
to be completed under CPT code 97151 (see paragraph 8.11.6.2.1). Submission
of all outcome measure results must include the full publisher print report
or hand-scored protocol and summary score sheet(s). Imbedding scores
within the treatment plan or other clinical documents is insufficient
to meet the submission requirements.
8.6.4.1 PDDBI,
Current Edition8.6.4.1.1 This
outcome measure must be completed using the standard or extended
form at baseline and every six-months thereafter by the authorized
ABA supervisor. The name of the respondent and relation to the beneficiary
is required on all forms. Only the Parent Form is required at baseline.
The Parent Form and the Teacher Form must be completed and submitted
every six-months thereafter to align with the TP submission and
reauthorization. The PDDBI must be completed and submitted by their
respective deadlines. The Teacher Form must be completed by only
the BCBA/BCBA-D. Responsibility for the completion of the Teacher
Form by the BCBA/BCBA-D cannot be delegated. The Domain/Composite
Score Summary Table, including all domain and composite scores,
must be submitted to the contractor.
8.6.4.1.2 The
contractor shall ensure all Domain and Composite scores are received,
valid, and reported in the corresponding DD Form 1423, Contract
Data Requirements List (CDRL) located in Section J of the applicable
contract.
8.6.4.2 Vineland
Adaptive Behavior Scales-3 (Vineland-3) (or Current Edition)The
Parent Form, the Interview Form (if completed by a TRICARE-authorized
provider), or the Teacher Form are required. The name of the respondent
and relation to the beneficiary is required on all forms. This measure
is required at baseline and every year thereafter. See definition, paragraph 11.32.
8.6.4.3 Social
Responsiveness Scale, 2nd Edition (SRS-2) (or Current Edition)The
Parent Form is required. The name of the respondent and relation
to the beneficiary is required on all forms. This measure is required
at baseline and every year thereafter. See definition, paragraph 11.29.
8.6.4.4 Parenting
Stress Index, Fourth Edition (PSI-4) (or Current Edition) Required
as of August 1, 2021The
Short Form is required. The name of the respondent and relation
to the beneficiary is required. This measure is required at baseline
and every six-months thereafter. See definition, paragraph 11.25.
8.6.4.5 Stress
Index for Parents of Adolescents (SIPA) Required as of August 1,
2021The Profile Form is required.
The name of the respondent and relation to the beneficiary is required.
This measure is required at baseline and every six-months thereafter.
See definition, paragraph 11.30.
8.6.4.6 The
contractor shall make available to treating providers of ACD beneficiaries
all available outcome measures scores.
8.6.5 Medical
Team Conference8.6.5.1 Medical
team conferences include face-to-face participation (in-person or
via a compliant telehealth platform) by a minimum of three Qualified
Health Care Professionals (QHPs) from different specialties or disciplines
(each of whom provides direct services to the beneficiary), with
or without the presence of the beneficiary/family member(s), who
convene to collaborate or discuss a specific beneficiary case. The
participants are actively involved in the development, revision,
coordination, and implementation of health care services clinically
necessary for the beneficiary. See paragraph 8.11.6.2.7 for requirements
for using this CPT code. Though not required, family member/beneficiary participation,
as appropriate, is recommended.
8.6.5.2 The
ASN shall participate in these medical team conference discussions
when an ASN is assigned per paragraph 6.0.
8.6.5.3 Participants
must document their participation in the team conference as well
as their contributed information and subsequent treatment recommendations
in their medical documentation records.
8.6.5.4 No
more than one individual from the same specialty may report this
code at the same encounter.
8.6.5.5 Non-health
care providers, i.e., school officials or an IEP meeting, are not
counted as participants for this team conference. These individuals
may be invited to participate in the medical team conference; however,
these individuals are ineligible for reimbursement. Non-health care providers
do not count toward the minimum of three QHPs for utilization of
this service.
8.7 ABA
Service DocumentationAll
ABA documentation must be completed according to the following:
8.7.1 ABA
assessments and TP documentation (completed by the authorized ABA
supervisor) must include:8.7.1.1 Identifying
InformationThe
beneficiary’s name, date of birth, date the initial ABA assessment
and initial ABA TP were completed, the beneficiary’s DoD Benefit
Number (DBN) or sponsor’s Social Security Number (SSN), and the
name of the referring provider;
8.7.1.2 Reason
for ReferralThe
ABA TP and TP updates must include the ASD diagnosing/referring
provider’s ASD diagnosis, to include symptom severity level/level
of support required according to DSM-5 ASD criteria.
8.7.1.3 Background
InformationBackground
and history to include, but is not limited to, information that
clearly reports the beneficiary’s condition, diagnoses, medical
co-morbidities (to include over-the-counter (OTC) medications),
family history, school enrollment status, number of hours enrolled
in school, the number of hours receiving other support services
such as OT, PT, and SLP, documentation of the age of the child and
year of the initial ASD diagnosis, and how long the beneficiary
has been receiving ABA services.
8.7.1.4 Summary
of Assessment ActivitiesThe
TP must include 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 clinical adaptive behavior skills). This assessment may indicate
a need for a behavior intervention plan (paragraph 11.6)
for each target behavior excess and deficit. The TP shall include
the list of assessments administered. The initial ABA assessment
must include the PDDBI Parent Form Domain/Composite Score Summary
Table.
8.7.1.5 TP
GoalsThe ABA TP must clearly define
measurable targets in all relevant DSM-5 (or most current edition)
symptom domains, including parent/caregiver goals 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. The ABA TP goals must address core symptoms
of ASD:
• Social
Communication and Social Interaction Behavior (to include restricted,
repetitive, and/or stereotypical patterns of behavior, interests,
and/or activities);
• Restrictive/Repetitive/Stereotypical
Patterns of Behavior (i.e., stereotyped/ repetitive motor movements,
insistence on sameness, inflexible adherence to routines, highly fixated
interests, hyper/hypo-activity to sensory input).
8.7.1.5.1 Goals
must be measurable, objective, achievable, developmentally appropriate,
and clinically significant.
8.7.1.5.2 Goals
must be described as follows:
• Objective,
baseline and ongoing measurement levels for each target behavior/symptom
in terms of frequency, intensity, and duration;
• A
description of treatment interventions and techniques specific to
each of the targeted behaviors/symptoms;
• Identify
the objective measures of assessment for each goal specified; and
• Functional
goals must be specific to the beneficiary, objectively measurable
within a specified time frame, attainable in relation to the beneficiary’s
prognosis and developmental status, relevant to the beneficiary
and family, and directly related to the core symptoms of ASD as
defined by the DSM.
8.7.1.5.3 The
ASN, when assigned, shall ensure goals typically treated by specialty
providers are identified and addressed in the CCP. When
developing goals for beneficiaries with suspected or diagnosed co-morbid
medical or behavioral health conditions, the authorized ABA supervisor
must coordinate with the appropriate skilled and licensed professionals
in order to assess the most appropriate treatment intervention.
In order for the authorized ABA provider to address co-morbid condition
targets, documentation on the TP must demonstrate coordination with
the appropriate medical specialty services, to include the name
of the consulting provider. For example:8.7.1.5.3.1 A
beneficiary with a co-morbid diagnosis of a motor disorder who has
TP goals addressing speech or motor skill development would require
coordination with SLP, OT, or PT as appropriate.
8.7.1.5.3.2 A
beneficiary with a co-morbid diagnosis of anxiety disorder would
require coordination with the appropriate behavioral health provider.
8.7.1.5.3.3 A
beneficiary with a feeding disorder would require coordination with
the appropriate medical provider to include but not limited to:
physician, dietitian, OT, or SLP.
8.7.1.6 TP
ABA Services RecommendationsTP
recommendations of units of ABA services are based on a combination
of: the DSM-5 (or most current edition) symptom domains and levels
of support required per DSM-5 ASD criteria, results of outcome measures
(for TP updates), and the capability of the beneficiary to participate
actively in ABA services. A recommendation for the number of hours,
submitted as units, of all relevant ABA services (see CPT codes
for all covered services) under the ACD must be included. If recommended units
(hours) are not being rendered, then an explanation (i.e., family
availability, family preference, BT turnover, etc.) is required
to be documented in the subsequent TP.
8.7.1.6.1 A
recommendation for the number of monthly hours, submitted as units,
and measurable objectives and goals for parent/caregiver treatment
guidance on implementation of selected treatment protocols with
the beneficiary at home and in other settings where applicable is required.
Participation by the parent(s)/caregiver(s) is required, and re-authorization
for ABA services is contingent upon their involvement. If parent(s)/caregiver(s)
participation is not possible, the TP must document the reasons
for non-participation (i.e., the parent/caregiver is deployed, is
physically unable to deliver the ABA services, etc.). All attempts
to mitigate the lack of involvement/participation must be documented
by the ABA provider. Implementation of the TP should begin with
parent guidance sessions (CPT code 97156 or 97157), especially if
other ABA services are delayed because the authorized ABA supervisor
is hiring a new BT for the TP.
8.7.1.6.2 TP
must identify recommended units for each requested CPT code including
the location of rendered services.
8.7.1.6.3 Documentation
of parent/caregiver engagement and implementation of the ABA TP must
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.
8.7.1.6.4 Recommendation
for continued ABA services (if continuation is indicated) to include
a recommendation for the number of weekly units of one-on-one ABA
services, including documentation of clinical necessity if additional
units are required.
8.7.1.7 TP
ProgressABA
reassessments and TP updates must document the evaluation of progress
for each current behavior target identified on the initial ABA TP
and prior TP updates. Documentation of the ABA reassessment and
TP update must 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):
8.7.1.7.1 Date
and time the reassessment and TP update was completed.
8.7.1.7.2 ABA
provider conducting the reassessment and TP update.
8.7.1.7.3 Evaluation
of progress on each treatment target (i.e., Met, Not Met, Discontinued).
8.7.1.7.4 Description
of 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 identify interventions that were
ineffective and required modification of the TP. TP updates must
document TP modifications that were the result of the outcome evaluations.
8.7.1.7.5 Revisions
to the ABA TP must include identification of new behavior targets,
objectives, and goals, to include TP modifications based on the
cumulative six month assessment of the PDDBI and other outcome measures
evaluation.
8.7.1.7.6 The
contractor shall engage the authorized ABA supervisor to review
the TP if no progress has been made and the provider must incorporate
revisions to the individual TP to address the lack of progress.
8.7.1.8 SignaturesThe
ABA TP and TP updates must 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.
8.7.1.9 The
reassessments, to include the completion of the PDDBI, and TP updates
are required every six months (one assessment for each authorization
period) and must be dated as being conducted during that time frame.
Reassessments must be completed and submitted no later than 30 calendar
days prior to the end of the current authorization for review for
re-authorization. Any delay in submission of the ABA reassessment
and TP updates may delay the subsequent authorization for ABA services.
8.7.2 Progress
Note DocumentationIn
addition to TPM, Chapter 1, Section 5.1, “Requirements for
Documentation of Treatment in Medical Records,” progress note documentation
must contain the following documentation elements for each CPT code
session:
8.7.2.1 Beneficiary’s
full name (not initials);
8.7.2.2 The
date and time of session to include start and end time;
8.7.2.3 Location
of rendered services;
8.7.2.4 Length
of session;
8.7.2.5 A
legible name of the rendering provider, to include provider type/level;
8.7.2.6 A
signature of the rendering provider with the date signed;
8.7.2.7 Name
of authorized ABA supervisor;
8.7.2.8 Name
of all session participants (excluding other beneficiaries in CPT
codes 97157 and 97158);
8.7.2.9 A
notation of the patient’s current clinical status evidenced by the
patient’s signs and symptoms;
8.7.2.11 A
statement summarizing the techniques attempted during the session;
8.7.2.12 Narrative
description of the response to treatment, the outcome of the treatment,
and the response to significant others (group session notes must
contain individualized responses to treatment);
8.7.2.13 A
narrative statement summarizing the patient’s degree of progress
towards the treatment goals;
8.7.2.14 Each
section of the progress note documentation must be individualized
to the beneficiary and each session, and
8.7.2.15 Effective
January 1, 2019, the final product for CPT code 97151 must be in
the format of a TP. However, all encounters using CPT code 97151
must document a progress note. This progress note must include,
but is not limited to:
• The
date and time of session to include start and end time;
• 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.
8.8 Discharge
Planning8.8.1 The
following discharge criteria are established to determine if/when
ABA services are no longer appropriate:8.8.1.1 Loss
of eligibility for TRICARE benefits as defined in 32 CFR 199.3.
8.8.1.2 The
authorized ABA supervisor, the contractor, or the family 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.
• Recommended
by the contractor through the clinical necessity review process.
• The
patient can no longer participate in ABA services (due to medical
problems, family problems, or other factors that prohibit participation).
8.8.1.3 Termination
of services if the diagnosing/referring provider or PCM either changes
the diagnosis, or does not believe continued ABA services are clinically
necessary.
8.8.2 Termination of ABA
services under any circumstance must not occur abruptly by the authorized
ABA supervisor. All termination plans must be at least 45 calendar
days prior to the termination of services.8.8.2.1 The
contractor shall work with the ABA provider to ensure a smooth transition
when services are determined to no longer be clinically necessary
or otherwise need to be terminated on short notice.
8.8.2.2 The
contractor shall, should ABA services be terminated abruptly by
the authorized ABA supervisor, report the authorized ABA supervisor
to the appropriate credentialing/licensure board.
8.8.3 The contractor shall,
if the clinical necessity review determines direct ABA services,
either one to one or group, are no longer clinically necessary,
approve parent training services to fade an ABA service program
for one six-month authorization.
8.8.4 Discharge
planning must be documented in every initial TP, every updated TP,
and at termination of services.
8.8.5 A
discharge summary from the treating authorized ABA supervisor is
required for all beneficiaries whose ABA services are terminated
to include the reason for termination. Discharge summary writing
is not a reimbursable service as this is an indirect activity (report/summary
writing).
8.9 ABA
Quality Monitoring and Oversight8.9.1 This
demonstration is subject to existing program requirements for quality
monitoring and oversight.
8.9.2 The contractor shall
conduct, on an annual basis, an audit, which must include a minimum of
30 records for each ASCP/Sole provider group that include a combination
of administrative records (paragraph 8.9.7) and medical documentation
(paragraph 8.9.8) reviews and one medical team conference
progress note.
8.9.3 The TOP and USFHP
contractor shall conduct, on an annual basis, an audit, which must include
a minimum of 10% of records for each ASCP/Sole provider group that
include a combination of administrative records (paragraph 8.9.7)
and medical documentation (paragraph 8.9.8) reviews and one medical team
conference progress note.
8.9.4 The contractor shall
conduct outreach and education to ACSP/Sole Provider groups with inconsistencies
or errors identified in the annual audits.
8.9.5 The contractor shall
initiate progressively more severe administrative action, commensurate
with the seriousness of the identified problems, and consistent
with Chapter 13 and 32 CFR 199.9.
8.9.6 The contractor shall
recoup all claims determined to be insufficient for claims payment.
8.9.7 Administrative
Claims Review8.9.7.1 The contractor shall
target detection and prevention efforts of services that pose the greatest
risk of fraud and abuse to the TRICARE program and beneficiaries,
to include a review of suspect billing practices and document risks
to determine improper payments in the ACD program.
8.9.7.2 The
contractor shall review ACD claims which may include at a minimum,
but are not limited to:
• High-dollar,
erratic, or inconsistent billing and coding patterns.
• Changes
in billing frequency.
• Concurrent
billing (i.e., billing for two services at the same time).
• Misrepresentation
of provider (i.e., filing for a non-rendering provider or non-authorized
provider).
• Claims
patterns of “impossible days” (provider’s total claims exceed 12
hours per any given calendar day).
• Patterns
of high claim error rates.
8.9.7.3 The
contractor shall provide education to each ACSP/Sole provider groups
if suspect billing patterns are identified to address the findings
and corresponding program requirements.8.9.7.3.1 The
contractor shall, no later than 180 calendar days following education,
conduct a post-payment review of the Sole Provider or ACSP provider
groups to determine if suspect billing patterns have improved.
8.9.7.3.2 The
contractor shall, if suspect billing has not improved, refer the
Sole Provider or ACSP provider group to the contractor’s Program
Integrity department for review.
8.9.8 Medical
Records Documentation Review - Clinical and Non-Clinical Documentation8.9.8.1 The
contractor shall review ABA session documentation notes to ensure,
include at a minimum, but not limited to:
• Compliance
with the requirements set forth in paragraph 8.7.2.
• Compliance
with ABS approved CPT codes per paragraph 8.11.6.
• Sufficient
documentation to justify a medical record.
• No
billing for office supplies to include therapeutic supplies.
• No
billing for ABA services using aversive techniques to include restraints
(even if billed using a covered CPT code).
• Group
ABA services are not billed as authorized one-on-one ABA services.
• No
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.
• See
exclusions (paragraph 8.10) for additional activities
that are prohibited.
8.9.8.2 Clinical
content reviews shall be completed by clinical staff.
8.9.8.3 The
contractor shall educate and monitor providers with identified insufficiencies
in clinical documentation for a minimum of six months but not later
than 12 months.
8.9.8.5 The contractor shall
place any ABA provider who has not improved after a minimum of six months,
but no later than 12 months of education and monitoring on pre-payment
review.
8.9.9 New
ACSP/Sole Provider Review8.9.9.1 The contractor shall
monitor all new ACSP/Sole providers entering the ACD program after July
1, 2021 for administrative and medical records documentation review.
8.9.9.2 The
contractor shall conduct a probe audit sample (see Chapter 13, Section 3, paragraph 3.2.1) following
180 days of participation in the program to review clinical documentation
and claims submission for consistency with program requirements.
8.9.9.3 The
contractor shall share results of the probe audit with the new ACSP/Sole
Provider, and provide education to address inconsistencies with
program requirements.
8.9.10 Annual
ReviewsThe contractor shall
conduct an annual audit of a statistically valid number of providers,
to include collecting proof of documentation (either through source
verification or actual document), to ensure ABA providers meet the
requirements set forth in paragraphs 8.2 through 8.4.
8.10 ExclusionsThe contractor shall
not reimburse for, to include but not limited to:
8.10.1 Training
of BTs.
8.10.2 ABA
Services for any other diagnoses other than ASD.
8.10.3 ABA
services are not covered for symptoms and/or behaviors that are
not part of the core symptoms of ASD (i.e., impulsivity due to ADHD,
reading difficulties due to learning disability, excessive worry
due to anxiety disorder, etc.).
8.10.4 Billing
for e-mails and phone calls.
8.10.5 Billing
for driving to and from ABA services appointments (i.e., beneficiary’s
house, clinic, or other locations). Mileage/time traveling is not
to be billed to the TRICARE program.
8.10.6 Billing
for report writing outside of what is included in the assessment
code (CPT code 97151).
8.10.7 Billing
for office supplies or therapeutic supplies (i.e., binders, building
blocks, stickers, crayons, etc.).
8.10.8 Billing
for ABA services provided remotely through Internet technology or
through telemedicine/telehealth (except as allowed under paragraph 8.11.6.2.4.9).
8.10.9 Billing
for asynchronous telehealth services.
8.10.10 Rendering
and billing for ABA services involving any aversive techniques or
restraints.
8.10.11 Billing
for services outside of the home, clinic, office, school, or telehealth.
Certain community settings such as sporting events, camps, and other
setting as determined by the contractor are also excluded. Any location
not listed must be reviewed and approved by the contractor.
8.10.12 Billing
for ABA services while the beneficiary is at another medical appointment
to include another family member’s appointment.
8.10.13 Educational/academic
and vocational rehabilitation. All educational/academic and vocational
goals must be removed from the TP prior to approval by the contractor.
8.10.14 Educational
ABA services, such as services typically provided through a school
curriculum.
8.10.15 TRICARE ABA services
are not authorized in the school setting as a shadow, aid, or support to
the beneficiary. ABA services in the school setting are limited
to the role of the BCBA who is targeting a specific behavior excess
or deficit and is for a limited duration. Any ABA services requested
for the school setting must be specifically preauthorized in the
TP for use in the school setting.8.10.15.1 The contractor shall
authorize and reimburse only CPT code 97153 rendered by the authorized
ABA supervisor (not delegated to the assistant or BT) in the school
setting.
8.10.15.2 After May 1, 2021, authorizations
with approved BT services in the school setting will run through
the end of the current authorization. However, no new authorizations
for BTs in school setting will be approved after May 1, 2021.
8.10.16 ABA
services for a beneficiary that are written in a beneficiary’s IEP
and required to be provided without charge by the local public education
facility in accordance with the Individuals with Disabilities Act
or other applicable laws and regulations. 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.
8.10.17 Billing
for school tuition.
8.10.18 Autism
schools are not TRICARE authorized providers. If an Autism school
has a clinic setting as part of their offered services, the clinic
must have a separate tax ID number.
8.10.19 Goals
targeting functional/activities of daily living (ADLs) skills (see 32 CFR 199.2 definitions of ADLs) are excluded.
However, the principles of ABA (i.e., backward chaining, schedules
of reinforcement, etc.) may be targeted as a goal of parent/caregiver
guidance to introduce how the parent should teach ADLs outside of
ABA services rendered by an ABA provider.
8.10.20 Rendering
or billing for custodian, personal care, and/or child care.
8.10.21 Durable
Equipment (DE) whose safety and efficacy have not been established
as described in 32 CFR 199.4.
8.10.22 Billing
of direct and indirect supervision of BTs and assistant behavior
analysts.
8.10.23 Billing
of ABA evaluation or intervention services provided by a clinic
or agency owned by the beneficiary’s immediate family member (e.g.,
biological, adoptive, or foster parents, guardians, court-appointed
managing conservators, other family members by birth or marriage).
8.10.24 Billing
an ABA evaluation or intervention services provided directly by
the beneficiary’s responsible adult (e.g., biological, adoptive,
or foster parents, guardians, court-appointed managing conservators,
other family members by birth or marriage). Billing for rendered
ABA services by family members is considered a conflict of interest
and therefore may be subject to the Civil Money Penalties Law (CMPL).
8.10.25 Under
the ACD, concurrent billing is excluded for all ABS 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.
8.10.26 Rendering
or billing for any two ABA providers at the same time.
8.10.27 Rendering
or billing any interventions considered psychotherapy to include
but not limited to: Cognitive Behavior Therapy, Acceptance and Commitment
Therapy, Prolonged Exposure, group psychotherapy, etc.
8.10.28 ABA
providers rendering and billing for non-ABA services.
8.11 Reimbursement8.11.1 Network
and non-network provider claims for ABS CPT codes must be submitted electronically.
8.11.2 The contractor shall
pay all claims by electronic funds transfer.
8.11.3 The contractor shall
reimburse claims using the ABS CPT codes. These codes apply to the provision
of ABA services rendered by ACD approved providers in all authorized
settings (clinic, school, home, TH, or certain community setting).
8.11.4 The contractor shall
ensure paid claims identify the name of the rendering provider for each
ABA service delivered, to include the NPI (see paragraph 8.2.1 for
NPI requirements) of the rendering provider per unique claim line
(i.e., every session must be identified as its own unique line on any
claim submitted).
8.11.5 Application
of Health Insurance Portability and Accountability Act (HIPAA) taxonomy designation.
All claims for ABS CPT codes must 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; or
• Other
appropriate HIPAA taxonomy based on license/certification
8.11.6 ABS
Approved CPT CodesThe
contractor shall only authorize ABS codes for only ABA providers
under the demonstration authority using a special processing code.
8.11.6.1 Healthcare
Common Procedure Coding System (HCPCS) T1023 - Outcome Measures Submitted
By BCBA/BCBA-D (For authorizations issued prior to August 1, 2021)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 paragraphs 8.6.4.2 and 8.6.4.3 for
submission requirements and required data elements. For outcome measures
administered via telehealth, claims must include the modifier GT or 95.
Additionally, all approved ABA services provided via telehealth
must adhere to state laws governing telehealth services.
8.11.6.2 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. Existing authorization
prior to August 1, 2021, run through the end of their current authorization period
end date. The next authorization must incorporate the changes set
forth below.
8.11.6.2.1 CPT
Code 97151 - Behavior Identification Assessment8.11.6.2.1.1 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,
must be coded using CPT code 97151, “Behavior Identification Assessment.”
8.11.6.2.1.2 Elements
of ABA assessment include:
• One-on-one
observation of the beneficiary (must be completed in person, face-to-face).
• 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, to include the administration of the PDDBI.
• 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.
8.11.6.2.1.3 This
code is intended for reporting initial assessments and reassessments
by the authorized ABA supervisor once every six months.
8.11.6.2.1.4 CPT
code 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).
8.11.6.2.1.5 CPT
code 97151 may not be conducted via telehealth.
8.11.6.2.1.6 The
contractor shall, for services rendered prior to August 1, 2021,
authorize CPT code 97151 for 16 units (four hours) for the initial
request of ABA services to complete an initial ABA assessment and
TP development.
8.11.6.2.1.7 The contractor shall,
for services rendered on a new or approved TP on or after August 1,
2021, authorize CPT code 97151 for up to 32 units (eight hours)
for the initial request of ABA services to complete an initial ABA
assessment and TP development (to include administration, scoring,
and review of the PDDBI). CPT code 97151 must be used within 14
calendar days of the first date of service for CPT code 97151 and
is a use or lose concept.
8.11.6.2.1.8 The contractor shall,
after the initial assessment, authorize CPT code 97151 for up to
24 units (six hours) for reassessments and TP updates for every
subsequent authorization.
8.11.6.2.1.9 The
contractor may authorize one additional unit of indirect CPT code
97151 per measure for providers that complete the Vineland, the
SRS, and the PSI/SIPA, when prior authorized.
8.11.6.2.1.10 A
second opinion authorization (for 32 units of CPT code 97151) may
be permitted to overlap with another approved authorization. Two
“ongoing” treatment authorizations of direct service (CPT codes
97153, 97155, 97156, 97157, and 97158) are not permitted.
8.11.6.2.2 CPT
Code 97153 - Adaptive Behavior Treatment by Protocol8.11.6.2.2.1 The
code, CPT code 97153, must 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.
8.11.6.2.2.2 CPT
code 97153 is a timed, 15 minutes, increment code.
8.11.6.2.2.3 The
contractor shall not, for new and approved TPs on or after August
1, 2021, authorize CPT code 97153 for greater than 32 units (eight
hours) per day or 160 units (40 hours) per week without a clinical
necessity review for determination.
8.11.6.2.2.4 CPT
code 97153 may not be conducted via telehealth.
8.11.6.2.3 CPT
Code 97155 - Adaptive Behavior Treatment by Protocol Modification8.11.6.2.3.1 The
code, CPT code 97155, 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 with the beneficiary present. The focus of this code is
the addition or change to the protocol.
8.11.6.2.3.2 CPT
code 97155 is a timed, 15-minute, increment code.
8.11.6.2.3.3 CPT
code 97155 must be completed at least one time per month by the
authorized ABA supervisor.
• The contractor
shall complete a post-claims payment review, and if this requirement
is not met, a 10% penalty on all ABA claims for that beneficiary
shall be recouped for the entire six-month authorization.
8.11.6.2.3.4 The
contractor shall not authorize for greater than eight units (two
hours) per day.
Note: Team
meetings and supervision of any type are not reimbursable under
CPT code 97155.
8.11.6.2.4 CPT
Code 97156 - Family Adaptive Behavior Treatment Guidance8.11.6.2.4.1 It
is important that family members or caregivers learn to apply the
same treatment protocols to reduce maladaptive behaviors and reinforce
appropriate behavior. It is expected that as families become more
capable of providing treatment protocols or as beneficiary symptoms
improve, the amount of one-on-one ABA services provided by an ABA
provider will decrease. Unless therapeutically contraindicated,
the family and/or guardian must actively participate in the continuing care
of the beneficiary. Documentation of contraindication must be documented
in the TP for continued eligibility for the ACD.
8.11.6.2.4.2 The
code, CPT code 97156, is used by the authorized ABA supervisor for
guiding the parents/caregivers to utilize the ABA TP protocols to
reinforce adaptive behaviors. Authorized ABA supervisors may delegate
family/caregiver guidance to assistant behavior analysts working
under their supervision but only the authorized ABA supervisor may
bill for this service using this code.
8.11.6.2.4.3 The
beneficiary is not required to be present for the parent/caregiver
sessions; however, presence of the beneficiary is encouraged.
8.11.6.2.4.4 CPT
code 97156 is a timed, 15-minute, increment code.
8.11.6.2.4.5 The
contractor shall not authorize CPT code 97156 for greater than eight
units (two hours) per day.
8.11.6.2.4.6 CPT
code 97156 may be used only in a home or clinic/office-based setting.
School settings are prohibited.
8.11.6.2.4.7 For
new and approved TPs on or after August 1, 2021, a minimum of six
parent/caregiver sessions are required every six months. These six
sessions may include CPT codes 97156, 97157, or a combination of
the two.8.11.6.2.4.7.1 The
contractor shall work with the family and the provider to resolve
barriers for parent/caregiver sessions. The first session shall
be within the first 30 calendar days of the treatment authorization.
8.11.6.2.4.7.2 The
contractor shall not, if this requirement is not met for two consecutive authorization
periods, renew ABA services for a subsequent authorization period
for that beneficiary.
8.11.6.2.4.8 For
new and approved TPs on or after August 1, 2021, parent/caregiver
sessions for CPT code 97156 may be conducted via telehealth only
after the first six-month authorization period per authorized provider.
Additionally, all services provided via telehealth must adhere to
state laws governing telehealth services.
8.11.6.2.4.9 For
new and approved TPs on or after August 1, 2021, parent/caregiver
sessions conducted remotely must include the GT and 95 modifier
when submitting claims. Remote Family Adaptive Behavior sessions
must be in compliance with TPM, Chapter 7, Section 22.1.
8.11.6.2.5 CPT
Code 97157 - Multiple-Family Group Adaptive Behavior Treatment Guidance (Beginning
August 1, 2021)8.11.6.2.5.1 It
is important that parents or caregivers learn to apply the same
treatment protocols to reduce maladaptive behaviors and reinforce
appropriate behavior. 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. This code is
to be used for identifying behavior excesses and deficits, and teaching
parent(s)/caregiver(s) to utilize treatment protocols designed to
reduce maladaptive behaviors and/or skill deficits in a group setting.
This code is not authorized for a support group or group psychotherapy.
The beneficiary should not be present for the multi-family parent/caregiver sessions.
8.11.6.2.5.2 Groups
must not exceed eight participants (i.e., each individual parent/caregiver,
or pair of parents/caregivers, counts as one participant and only
one claim may be filed per beneficiary).
8.11.6.2.5.3 The
contractor shall recoup all claims for groups that exceed eight
participants.
8.11.6.2.5.4 CPT
code 97157 may only be used in a clinic/office-based setting.
8.11.6.2.5.5 CPT
code 97157 may not be conducted via telehealth.
8.11.6.2.5.6 CPT
code 97157 is a timed, 15-minute, increment code.
8.11.6.2.5.7 The
contractor shall not authorize CPT code 97157 for greater than six,
15-minute units (1.5 hours) per day.
8.11.6.2.6 CPT
Code 97158 - Group Adaptive Behavior Treatment by Protocol Modification (Beginning
August 1, 2021)8.11.6.2.6.1 The code, CPT code 97158,
is used by the authorized ABA supervisor to beneficiaries in a group
setting. The focus of the skills group will be to address specific
measurable goals to address targeted social deficits and problem
behaviors utilizing various techniques (e.g., modeling, rehearsing, corrective
feedback). The authorized ABA supervisor must adjust the level of
assistance (e.g., prompts) given to each member based on their skill
level and ongoing progress in the group.
8.11.6.2.6.2 CPT
code 97158 must only be used when the beneficiary’s TP identifies
goals targeted for generalization of mastered skills. As beneficiaries
demonstrate generalized skills, it would be expected that one to
one services decrease as group services increase, then ABA services
fade altogether.
8.11.6.2.6.3 Groups
must not exceed eight participants.
8.11.6.2.6.4 The
contractor shall recoup all claims for groups that exceed eight
participants.
8.11.6.2.6.5 CPT
code 97158 may not be conducted via telehealth.
8.11.6.2.6.6 CPT
code 97158 is a timed, 15-minute, increment code.
8.11.6.2.6.7 The
contractor shall not authorize CPT code 97158 for greater than six,
15-minutes units (1.5 hours) per day.
8.11.6.2.7 CPT
Codes 99366 and 99368 Medical Team Conference (Beginning August
1, 2021)8.11.6.2.7.1 CPT
codes 99366 and 99368 are permitted only via face-to-face either
in person or through the telehealth platform. Telephone-only is
not permitted for providers.
8.11.6.2.7.2 CPT
code 99366 Medical team conference with patient by healthcare professional.
8.11.6.2.7.3 CPT
code 99368 Medical team conference without patient by health care
professional.
8.11.6.2.7.4 The
following criteria must be met to report and be reimbursed for the
medical team conference codes:
• A
minimum of three QHPs from different specialties or disciplines
who provide direct care to the patient must participate in the reported
team conference.
• No
more than one individual from the same specialty may report CPT
codes 99366 and 99368 at the same encounter.
• Reporting
participants must be present for the entire medical team conference.
• Reporting
participants must have performed face-to face evaluations or treatments of
the patient, independent of any medical team conference, within
the previous 60 calendar days.
Note: Additionally,
the ASN must be present, when assigned, via TH or telephone, for
provider reimbursement of the medical team conference.
8.11.6.2.7.5 Reporting
participants should record and document their role in the conference, contributed
information, and subsequent treatment recommendations. The time
for the medical team conference starts at the beginning of the case
review and ends at the conclusion of the review. Record keeping
or report generation time is not included.
8.11.6.2.7.6 The
contractor shall issue one unit of CPT code 99366 and one unit of
CPT code 99368 on each six-month treatment authorization for the
ABA provider to participate in a medical team conference.
8.11.6.2.7.7 ABA
providers must use the ACD Special Processing Code AS when
submitting claims for this CPT code.
8.11.7 Reimbursement
Rates for ABS Services8.11.7.1 Reimbursement of claims
in accordance with the guidance in paragraph 8.11.6 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).
8.11.7.2 ABA reimbursement
rates will be updated at the same time as the annual CHAMPUS Maximum
Allowable Charge (CMAC) Update, and will be effective May 1st. The
rates will also be posted at http://www.health.mil/rates.
• The
contractor shall update their reimbursement systems, once the rates
are posted on the website, to reflect the annually updated rates
in compliance with
Chapter 1, Section 4, paragraph 2.4.
8.11.7.3 The
contractor shall, for claims submitted beginning January 1, 2019,
reimburse ABA services under the ACD in accordance with 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-Demonstration8.11.7.3.1 CPT
code 97151.8.11.7.3.1.1 Behavior
Identification Assessment is authorized for only the authorized
ABA supervisor (or as delegated to an assistant behavior analyst).
For dates of services prior to August 1, 2021, CPT code 97151 is
authorized for up to 16 units (four hours) of service code reimbursed
for up to a total of $500.00 ($125/hour) at the initial assessment
prior to rendering any other CPT code. For dates of services on
or after August 1, 2021, CPT code 97151 is authorized for up to
32 units (eight hours) at $125/hour of services for the initial
assessment only. Subsequent authorization periods shall be authorized
for up to 24 units (six hours) of services at $125/hour. CPT code
97151 shall be conducted over no more than a 14 calendar-day period.
8.11.7.3.1.2 The
contractor may authorize one additional unit of CPT code 97151 per
outcome measure for providers that complete the Vineland, the SRS,
the PSI/SIPA, when prior authorized.
8.11.7.3.2 CPT
code 97153. Adaptive Behavior Treatment by Protocol. CPT code 97153
is a timed code reimbursed no lower than $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.
8.11.7.3.3 CPT
code 97155. Adaptive Behavior Treatment by Protocol Modification
is rendered by an authorized ABA supervisor for treatment protocol
modification with the beneficiary present. CPT code 97155 is reimbursed
no lower than $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.
8.11.7.3.4 CPT
code 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 no lower than $31.25 per 15-minute increment
($125.00/hour) for the authorized ABA supervisor.
8.11.7.3.5 CPT
code 97157 (authorized beginning August 1, 2021). Multiple-Family
Group Adaptive Behavior Treatment Guidance. Authorized ABA supervisor
treatment guidance in a group setting to the parents/caregivers
(without the beneficiary present) is reimbursed at the geographically adjusted
reimbursement methodology for CPT code 90853 (group psychotherapy)
for each participant.
8.11.7.3.6 CPT
code 97158 (authorized beginning August 1, 2021). Group Adaptive
Behavior Treatment with Protocol Modification. Authorized ABA supervisor
treatment guidance in a group setting to the beneficiaries is reimbursed
at the geographically adjusted reimbursement methodology for CPT
code 90853 (group psychotherapy) for each participant.
8.11.7.3.7 For
CPT codes 99366 and99368 (authorized beginning August 1, 2021),
see https://health.mil/.
Reimbursement rates can be found using the search word “CMAC”.
8.11.7.3.8 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. Documentation
must indicate two separate rendering providers and locations for
the services.
• The contractor
shall pay the higher rate and deny the other if CPT codes 97153
and 97155 are billed concurrently.
|
CPT
Codes
|
97151
|
97153
|
97155
|
97156
|
97157
|
97158
|
|
97151
|
N/A
|
|
|
|
|
|
|
97153
|
Y
|
N/A
|
|
|
|
|
|
97155
|
N
|
N
|
N/A
|
|
|
|
|
97156
|
Y
|
Y
|
Y
|
N/A
|
|
|
|
97157
|
Y
|
Y
|
Y
|
N
|
N/A
|
|
|
97158
|
Y
|
N
|
N
|
Y
|
Y
|
N/A
|
8.11.7.4 For
BCBAs submitting claims for T1023 for services on or after May 1,
2019, the reimbursement rate shall be the geographically adjusted
reimbursement methodology for the previous CPT code 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 until July 31, 2021.
(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 one year period). As of August 1, 2021, all outcome
measures will no longer be reimbursed by T1023, meaning current
authorizations will be effective until their expiration at which
time, the subsequent treatment authorization will follow paragraph 8.11.6.2.1 (CPT code
97151- see this paragraph for details on reimbursement for the authorized
outcome measures for new authorizations).
8.11.7.6 Negotiated
provider rates lower than those directed in this paragraph are not
allowed.
8.11.7.7 Policies
in this section must be adhered to or claims may be recouped.
8.11.8 Cost-Sharing8.11.8.1 Effective
January 1, 2018, all beneficiary cost-sharing, deductibles, and
enrollment fees will be those applicable to the specific category
of the TRICARE eligible beneficiary receiving services under this
demonstration; e.g., TRICARE Prime, TRICARE Select; and 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 and 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.
8.11.8.2 The
contractor shall, for services rendered on or after January 1, 2019,
apply only one copay for all ABA services rendered on the same day.
Other (non-ABA) services rendered on the same day as ABA services
will follow normal TRICARE cost-share/copayment rules.
8.11.8.3 The
contractor shall, for CPT code 97151, apply one copayment for all
assessment services rendered within a 14 calendar day period using
this CPT code. If CPT code 97151 is billed on the same day as other
ABA service, only one copay applies.
8.11.8.4 For
Other Health Insurance (OHI), beneficiaries receiving ABA services
are required to obtain a referral and prior authorization. ABA services
under OHI will be reimbursed for only the covered services listed
in this manual section.
9.0 ACD
REQUIREMENTS9.1 Utilization
Management (UM)9.1.1 The contractor shall
implement UM tools, no later than August 1, 2021, to assist in guiding clinical
decision making for all clinical necessity reviews that shall occur
when approving all TPs; i.e., for the initial authorization and
every six months thereafter.
9.1.2 The contractor’s UM
tools shall provide a set of evidence-based standards on TPs for beneficiaries
diagnosed with ASD. UM tools/criteria are used to guide reviewers
to consider the severity of behaviors in the context of patient-specific
variables that help place a patient in the most appropriate level
of care. Standardized decision paths provide UM reviewers with a
common language that enables consistent, objective decision-making.
UM addresses treatment needs of individuals diagnosed with ASD who
frequently receive treatments by providers from several different
disciplines--such as ABA services, PT, OT, and SLP--that target
the same core symptoms or functional deficits.9.1.2.1 The
basis of the UM tool shall integrate the comprehensive picture of
treatment and progress to evaluate the extent to which skill domains
are clinically necessary and appropriate.
9.1.2.2 The
contractor shall select a UM tool that includes, at a minimum, the
criteria to evaluate:
• Level
of clinical support/need;
• TP
programming;
• Dose
response (intensity, frequency, duration);
• Progress
towards improved symptom presentation, to include baseline functioning and
cumulative periodic assessments (every six months) using, at a minimum,
the identified outcome measures;
• Duration
of services; and
• Other
rendered/recommended services.
9.1.2.3 The
contractor shall use the UM tool to determine clinical necessity
determinations for all ABS CPT codes.
9.1.3 The contractor shall
ensure that all clinical necessity reviews include an assessment
of progress towards treatment goals. The TP and corresponding outcome
measures must demonstrate progress towards symptom improvements.
9.1.4 The contractor shall,
if no progress is made in the previous six months, engage the ABA provider
to address the TP and goals prior to issuing another treatment authorization
or transition services to more appropriate treatment (see paragraph 8.8 for
discharge planning).
9.1.5 In
general, ABA treatment hours should gradually decrease over time,
as beneficiaries reach treatment goals and parents/caregivers gain
skills and proficiency effectively managing behaviors related to
the diagnosis of ASD.
9.1.6 The contractor shall
employ a BCBA or a master’s/doctoral level professional in a like-specialty
to complete clinical necessity reviews.
• The contractor’s
UM person shall be different from the ASN.
9.1.7 The contractor shall
submit, as part of the annual UM/Medical Management (MM) plan, a comprehensive
UM plan that incorporates all services for the diagnosis of ASD
to DHA. For plan submission requirements refer to DD Form 1423,
CDRL located in Section J of the applicable contract.
9.2 Program
Integrity (PI)9.2.1 The contractor shall
leverage existing Program Integrity actions in accordance with Chapter 13, unless otherwise noted in this
section.
9.2.2 The contractor shall,
in addition to the requirement set forth in Chapter 13, Section 1 have an
ACD PI Subject Matter Expert (SME) knowledgeable about the ACD.
9.2.3 The contractor’s PI
unit shall take action in accordance with Chapter 13,
developing for potential patient harm, fraud, and abuse issues.
9.3 Additional
Contractor Responsibilities9.3.1 The contractor shall
develop an ACD-specific webpage within the existing TRICARE website requirement,
that provides ACD information and resources, designed for use by
families, beneficiaries (when appropriate), and providers to include,
but not limited to:
• Online
directory for ACD providers no later than January 1, 2022, including
but not limited to ABA provider, parent-mediated programs, ASD diagnosing
providers, respite care, SLP, OT, PT, etc. (the online ACD provider
directory may be part of the contractor’s main online provider directory);
• ACD
Education and Resources link no later than October 1, 2021as identified
in this policy updated on at least a semi-annual basis. Existing
databases may be incorporated into the contractor platform;
• Link
to the Contractor Provider Portals no later than January 1, 2022,
accessible to all TRICARE authorized providers and ACD providers
serving a beneficiary with a diagnosis of ASD including direct and
private sector care that serves as a platform for providers to communicate
directly with the contractor for: secure messaging; beneficiary
referral and authorization timeline information; TP submissions,
certification, and directory changes.
• Contact
information or link for submitting beneficiary or family member/caregiver complaints
no later than October 1, 2021.
9.3.2 The contractor shall,
for beneficiaries without an ASN, 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.
9.3.3 The contractor shall
designate an ACD complaint officer to receive and address beneficiary family
member/caregiver complaints. Contact information shall be provided
to all parents/caregivers of beneficiaries receiving services under
this demonstration on the contractor ACD specific website.
9.3.4 The
contractor shall develop a provider education training, to be implemented
no later than January 1, 2022, that includes at a minimum: ACD requirements
(to include ABA provider requirements, correct billing practices/claims
filing, authorizations, exclusions, medical records documentation,
provider responsibilities, program requirements), Basic TRICARE
rules, and 32 CFR 199.9.3.4.1 The
TOP and USFHP contractors may use other provider education strategies
to achieve the requirement set forth in paragraph 9.3.4.
9.3.4.2 The contractor shall
submit the ABA provider training curriculum for DHA review and approval
per CDRL requirements prior to executing the training.
9.3.4.3 The contractor shall
ensure compliance with paragraph 8.3.10 by retaining evidence of attendance/completion.
9.3.4.4 The contractor shall
impose a 10% claims penalty for all rendered services during the
non-compliant period for any ABA provider who is non-compliant with
this requirement.
9.3.5 The contractor shall
submit a notice of disciplinary action for any provider including,
but not limited to, ABA providers to their respective certifying/licensing
body, with appropriate documentation, after a failed attempt to
resolve the matter with the provider. The contractor may submit
such notice prior to attempting to resolve the matter with the provider
in cases involving the safety of the beneficiary.
9.3.6 The contractor shall
deny services and/or recoup claims of an authorized ABA supervisor who
has any restriction on their certification imposed by the BACB,
Behavioral Intervention Certification Council (BICC), or QABA, or
any restriction on their state license or certification for those having
a state license or certification.
9.3.7 The contractor shall
recoup claims and/or deny services for session notes that describe
the rendering of non-ABA services.
9.3.8 The contractor shall
authorize all CPT code units in the six-month authorization and monitor
to ensure TP recommendations (per week/month respectively; see paragraph 8.11.6.2) are maintained and not
exceeded.
• The contractor shall
deny claims containing units (hours) over the approved authorization
and the MUEs set for each CPT Code.
9.3.9 The contractor shall
report allegations of abuse to authorities responsible for child protective
services, military and family advocacy programs, and to state and
national license or certification boards as appropriate, and to
the Director, DHA, or designee.
9.3.10 Outcome
Measures Oversight9.3.10.1 The contractor shall
ensure completion of the Vineland, the SRS, PDDBI, PSI/SIPA (current edition)
at baseline and every six months or year thereafter for each beneficiary
participating in the ACD.9.3.10.1.1 The
non-clinical support person may assist in the administrative tasks
of completing this requirement.
9.3.10.1.2 The
contractor may utilize other sources for collection of these measures,
such as a provider (TRICARE-authorized or otherwise) submitting
the measures as part of their standard assessment process.
9.3.10.2 The
contractor shall transition all beneficiaries participating in the
ACD prior to April 1, 2021 to a one-year timeline at the next earliest
interval. For example, if the beneficiary is in their seventh month
of ABA services, the Vineland and the SRS shall be completed by
the twelfth month (five months later) and prior to the issuing of
the next authorization.
9.3.10.3 The contractor shall
use the date of receipt of the specific measure to determine the
next chronological interval (six months or one year) for outcome
measures due dates.
9.3.10.4 The
outcome measures timeline does not change when changing regions,
provider, or beneficiary category. If the beneficiary or family
elects to pause services from the ACD, ASN and/or ABA services for
more than 180 calendar days, the timeline resets to collect outcome
measures.
9.3.10.5 The contractor shall
accept and report only complete and valid outcome measures.
9.3.10.6 The
contractor shall accept valid measures for baseline data with dates
up to one year prior to initiation of services.
9.3.10.7 The
contractor shall terminate ASN services and not issue a subsequent
ABA treatment authorizations for failure to complete
any and all outcome measures.
9.3.10.8 The
contractor shall transition to the new edition within one year of
its release, should the outcome measure edition update.
9.3.11 Provider
NetworksThis
paragraph applies only to the 50 U.S., District of Columbia, and
U.S. territories. See paragraph 8.5 for
TOP.
9.3.11.1 The contractor shall
establish network contracting targets sufficient to support the
ACD program IAW access standards and network expansion prescribed
in Chapter 5, Section 1 and apply existing network
requirements and access standards to providers under the ACD program.
9.3.11.2 The
contractor shall ensure that the beneficiary shall begin ABA treatment
services within 28 calendar days from the completed ABA assessment
date.
9.3.11.3 The contractor shall
certify all BTs within 10 business days of a complete application package
that meets all requirements.
9.3.11.4 The
contractor shall include the provider’s work address, work fax number,
work telephone number, and hours of operation in their directory.
9.3.11.5 The
contractor shall include information regarding ages served, telehealth
capabilities, and available session settings (in-home, clinic-based,
both) in their directory.
9.3.11.6 The contractor shall
engage in an active provider placement process, no later than August 1,
2021, to ensure access to care standards are met.9.3.11.6.1 The
contractor shall have up to 15 business days to complete the active
provider placement process.
9.3.11.6.2 The contractor shall
have a process that confirms when a beneficiary is referred to a new
ABA provider, that the provider can provide an assessment (CPT code
97151) within 28 calendar days of the verified referral (this 28
day period includes the 15 business day provider placement), and that
the provider will be able to provide the ABA services (CPT codes
97153, 97156, or 97157) within 28 calendar days of the completion
of the assessment.
9.3.11.6.3 The contractor shall
document that the provider was able to accept and see the beneficiary
within access to care standards.
9.3.11.6.4 The
contractor shall also document in the beneficiary’s file when a
family declines access to an available provider who can meet the
access to care standards.Note: MTF
directed referrals or family requests for a specific provider do
not ensure access to care standards. Therefore, these recommendations
will be taken into consideration, but do not guarantee timely placement.
The contractor is not required to comply with directed referrals
for ABA providers if doing so will exceed access to care standards.
Should the family specify a specific provider, access to care is
also not guaranteed.
9.3.12 ABA
Provider Steerage ModelThe
TOP and USFHP DPs contractors are exempt from paragraphs 9.3.11 through 9.3.11.3.
9.3.12.1 The
contractor shall develop an ABA provider steerage model, to be implemented
no later than January 1, 2022, for individual authorized ABA supervisors
which shall take into account, at a minimum:9.3.12.1.1 Compliance
with access standards.
9.3.12.1.2 Include at least one
other determinant into their ABA provider steerage model. Any additional
determinants shall be submitted to DHA for approval prior to implementation.
This additional determinant shall be an objective, verifiable measure
that has a direct impact on beneficiaries or their families.
9.3.12.2 The
contractor shall assign beneficiaries to ABA providers who rank
highest in the steerage model when possible consistent with access
to care standards.
9.3.12.3 The contractor shall
list ABA providers who rank highest in the steerage model first
in the online provider directories and shall give priority to those
who rank highest when assigning patients to a provider.
9.3.13 The contractor shall
complete and timely submit quarterly and annual Comprehensive Autism
Care Reports. For reporting requirements, refer to DD Form 1423,
CDRL, located in Section J of the applicable contract.
• The
TOP contractor shall submit ad hoc reports in accordance with the
TOP contract.
9.3.14 The contractor shall
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
ACD).
9.3.15 The contractor shall
maintain one toll-free telephone number, specific to the ACD, to answer
all provider and beneficiary questions. All ACD-specific customer
service staff shall be knowledgeable of the most up to date ACD
policy and provide consistently accurate information.
• The
TOP, USFHP DPs, and TFL contractors shall use their existing telephone
number for provide and beneficiary questions.
9.3.16 The
authority for all aspects of the ACD, which is administered separate
and apart from the general regulations and Manual sections governing
the TRICARE Basic Program, and also separate and apart from ECHO,
is defined per statute (10 United States Code (USC) 1092 as further
implemented by 32 CFR 199.1(o)).
The ACD is specifically implemented by Federal Register notice as
required by 32 CFR 199.1(o) and
DoD AI-102.
9.3.17 The contractor shall
not, unless specifically identified in this Manual and if the contractor identifies
a gap in the ACD policy, automatically default to normal TRICARE
policy, but shall contact DHA for clarification.
11.0 DEFINITIONS11.1 Adaptive
Behavioral Services (ABS)According
to the American Medical Association (AMA) CPT coding guidance, ABS
address deficient adaptive behaviors (e.g., instruction-following,
verbal and nonverbal communication, imitation, play and leisure,
social interactions, self-care, daily living, and personal safety
skills) or maladaptive behaviors (e.g., repetitive and stereotypic
behaviors, and behaviors that risk physical harm to the patient,
others, and/or property).
11.2 Applied
Behavior Analysis (ABA) AssessmentA
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 may be required
to address problematic behaviors. Data gathered from a parent/caregiver
interview and parent report rating scales are also required. The
ABA assessment will also include standardized outcome measures at
appropriate intervals as noted above.
11.3 ABA
ServicesABA
methods designed to improve the functioning of a specific ASD target
deficit in a core area affected by 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).
11.4 ABA
Sole Provider ModelA
service delivery model that includes only the use of the authorized
ABA supervisor to implement a TP designed by the authorized ABA
supervisor. The ABA sole provider delivery model is authorized in
the Continental United States (CONUS), U.S. territories, and TOP.
11.5 ABA
Tiered Delivery ModelA
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.
Supervised assistant behavior analysts may assist the authorized
ABA supervisor in clinical support to include the supervision of
BTs and the provision of parent(s)/caregiver(s) treatment guidance.
Tiered delivery models are only authorized in the CONUS and U.S
territories.
11.6 ABA
TP11.6.1 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.
11.6.2 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. The ABA TP shall also include a discharge plan.
11.7 ABA
TP GoalsThese
are the broad spectrum, complex short-term and long-term desired
outcomes of ABA services.
11.8 ABA
TP ObjectivesThe
short, simple, measurable steps that must be accomplished in order
to reach the short-term and long-term goals of ABA services.
11.9 Assistant
Behavior AnalystThe
term “assistant behavior analyst” refers to supervised Licensed
Assistant Behavior Analyst (LABA), Board Certified Assistant Behavior
Analyst (BCaBA), and Qualified Autism Service Practitioner (QASP).
11.10 Authorized
ABA SupervisorAn
authorized ABA supervisor, whether or not currently supervising,
is defined as a Licensed Behavior Analyst (LBA), BCBA, BCBA-Doctorate
(BCBA-D), or a clinical psychologist practicing within the scope
of their state licensure or state certification.
11.11 Autism
Services Navigator (ASN)The
ASN collaborates and oversees the assessment, planning, facilitation,
care coordination, evaluation, and advocacy for options and services
to meet an individual’s comprehensive health needs through communication
and available resources to promote quality, cost-effective outcomes.
An ASN must hold a current, valid, unrestricted license which include:
a Registered Nurse (RN) with CM experience, clinical psychologist,
LCSW, or other licensed mental health professionals who possess
a certification in CM. The ASN must have clinical experience in:
pediatrics, behavioral health, and/or ASD; a healthcare environment;
and proven care management experience. This definition specifically excludes
both BCBAs and assistant behavior analysts.
11.12 Autism
Spectrum Disorder (ASD)For
ACD eligibility, the covered diagnosis is ASD (F84.0) according
to the DSM-5/Autistic Disorder according to the International Classification
of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM).
The ASD diagnosis must specify the level of support according to
the DSM-5 criteria (Level 1 = mild, Level 2 = moderate, or Level
3 = severe).
11.13 ASD
Diagnosing and Referring Providers11.13.1 ASD
diagnosing and referring providers include: TRICARE-authorized PCMs
and specialized ASD diagnosing providers. TRICARE authorized PCMs
for the purposes of the diagnosis and referral include: TRICARE
authorized pediatric physicians, pediatric family medicine, and
pediatric Nurse Practitioners (NPs). Authorized specialty ASD diagnosing
providers include: TRICARE-authorized physicians board-certified
or board-eligible in developmental-behavioral pediatrics, neurodevelopmental
pediatrics, child neurology, 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:
• Either
a pediatric NP or a family NP; and
• Either
(Family, or Child/Adolescent) Psychiatric Mental Health Nurse Practitioner (PMHNP)
or a (Child/ Adolescent) Psychiatric and Mental Health Clinical
Nurse Specialist (PMHCNS).
11.13.2 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.
11.13.3 Diagnoses
and referrals from Physician Assistants (PAs) or other providers
not having the above qualifications shall not be accepted.
11.14 Behavior
AnalysisBehavior
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
TP developed by the behavior analyst.
11.15 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 RBT credential for BTs with
a minimum of a high school education.
11.16 Behavior
Intervention PlanBehavior
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.
11.17 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.
11.18 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.”
11.19 Clinical
NecessityClinical
necessity refers to services that are clinically indicated and appropriate
to address a beneficiary’s diagnosed condition and not in excess
of the beneficiary’s needs. The services must be individualized,
specific, and consistent with the confirmed diagnosis of the beneficiary.
11.20 Comprehensive
Care Plan (CCP)The
CCP refers to a plan that is developed and maintained by the ASN.
The CCP shall identify all care and services for the diagnosis of
ASD, as well as, transition timelines to include, but not limited,
to Permanent Change of Station (PCS) orders. The CCP will allow
for a more consistent and beneficiary-centric approach to care.
11.21 Family/Caregiver11.21.1 Family/Caregiver
follows the definition for “immediate family” in 32 CFR 199.2(b): [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
as appropriate. For the purposes of the ACD, a “nanny” may be considered
an eligible caregiver pending the following requirements are met:
• At
least 18 years of age.
• Employed
full-time by the family or an agency on behalf of the family (but
must work full-time with the child).
• The
nanny is documented in the Service family care plan. Documentation
must be submitted to the contractor.
• Has
medical Power of Attorney.
• The
approved TP must identify the level of the nanny’s participation
to include specific goals.
• Caregiver
(nanny) training cannot exceed parent training (CPT codes 97156
and 97157).
11.21.2 No
other individual is considered “family” or “caregiver” under the
ACD.
11.22 Functional
Behavior AnalysisThe
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.
11.23 Medical
Team ConferencesMedical
team conferences are for the purpose of the treating providers to
periodically meet to discuss the beneficiary and the overall program
and progress towards goals. All CPT coding guidance and ACD requirements
must be met for reimbursement of this code.
11.24 Parent-Mediated
ProgramsParent-mediated
interventions often focus on social reciprocity. In these programs, professionals
train parents one-on-one or in group formats in home or community
settings with methods that may include didactic instruction, discussion,
modeling, coaching, or performance feedback. Once trained, parents
implement all or part of the intervention(s) with their child.
11.25 Parenting
Stress Index, Fourth Edition (PSI-4) or current edition (Abidin)The
PSI is a measure used for screening/triaging, and evaluating the
parenting system and identifying issues that may lead to problems
in the child’s or parent’s behavior. The PSI focuses on three major
domains of stress: child characteristics, parent characteristics,
and situational/demographic life stress. Additionally, the PSI is
useful in designing a TP, for setting priorities for intervention
or for follow-up evaluation. The PSI is commonly administered in
medical centers, outpatient therapy settings, and pediatric practices.
The PSI is not intended to diagnose dysfunction in the parent-child
relationship, or to be a screening tool of parental mental health
problems. This outcome measure must be completed at baseline and
every six months thereafter for beneficiaries ages 0 through 12
years only. Only the short form is required.
11.26 Pervasive
Developmental Disorder 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 through 18.5 years.
Note: Per
guidance interpreted from the PDDBI manual and the publisher, the
teacher form may be completed by the authorized ABA supervisor.
11.27 Qualified
Applied Behavior Analysis (QABA) Certification BoardQABA
“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 BTs with a minimum of a high school education or equivalent.
11.28 Qualified
Health Care Professional (QHP)A
QHP is an individual who is qualified by education, training, licensure/regulation
(when applicable) and facility privileging (when applicable) who
performs a professional service within his/her scope of practice
and independently reports that professional service.
11.29 Social
Responsiveness Scale, Second Edition (SRS-2) or current edition
(Constantino)The
SRS-2 identifies social impairment associated with ASD and quantifies
its severity. Applicable for ages 2-1/2 through 99 years.
11.30 Stress
Index for Parents of Adolescents (SIPA) or current edition (Sheras
and Abidin)The
SIPA is a screening and diagnostic instrument that identifies areas
of stress in parent-adolescent interactions, allowing examination
of the relationship of parenting stress to adolescent characteristics,
parent characteristics, the quality of the adolescent-parent interactions,
and stressful life circumstances. Areas of parent-focused inspection
include life restrictions, relationship with spouse/partner, social
alienation, and incompetence/guilt. Areas of adolescent-focused
inspection include moodiness/emotional liability, social isolation/withdrawal,
delinquency/antisocial, and failure to achieve or persevere. The
SIPA is the upward age extension of the PSI-Third edition (PSI-3). Applicable
for ages 11-19 years.
11.32 Vineland
Adaptive Behavior Scale, Third Edition (Vineland-3) or current edition
(Sparrow, S.S. et.al)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.