3.0 DEMONSTRATION GOALS
3.1 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 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 COORDINATION
6.1 The contractor
shall assign an autism-specific care manager known as the ASN (see
paragraph 11.11)
to each beneficiary participating in the ACD who will serve as the
primary advocate for the beneficiary and family.
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 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 (POC) 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.
6.2.1.1 The ASN shall incorporate in
the CCP the results of all respective outcome measures (see
paragraph 6.2).
6.2.1.2 The ASN shall include discharge/transition
planning 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.
6.2.3 The contractor shall, for CCPs
not completed within 90 calendar days as a result of family/beneficiary noncompliance,
suspend ASN and applicable ABA services through the duration of
the existing authorization or until the CCP is complete whichever
occurs first.
6.2.4 The ASN
shall notify the medical home, PCM, and/or referring provider, and
parent/caregivers that the CCP is complete and has been established.
6.2.5 The ASN shall share the CCP
and CCP updates with the respective providers prior to the beneficiary receiving
services under the ACD.
6.2.6 The ASN
shall update the CCP at least every six months.
6.3 Outcome Measures
6.3.1 All TRICARE eligible beneficiaries
participating in the ACD must complete respective outcome measures
that are norm-referenced, valid, and reliable evaluation tools.
6.3.1.1 The ASN shall ensure the following
measures are completed and submitted at baseline and by the respective
repeated intervals:
|
Outcome Measure
(current edition)
|
Repeated Due Date
|
Applicable for ASN Services
|
Applicable for ABA Services
|
Completed by:
|
|
Note: See definitions
sections for descriptions of outcome measure.
|
|
Parenting Stress Index (PSI)
|
Every Six Months
|
X
|
X
|
ASN
|
|
Stress Index for Parents of
Adolescents (SIPA)
|
Every Six Months
|
X
|
X
|
ASN
|
|
Vineland Adaptive Behavior
Scales (Vineland)
|
Annually
|
|
X
|
ASN
|
|
Social Responsiveness Scale
(SRS)
|
Annually
|
|
X
|
ASN
|
|
Pervasive Developmental Disorder
Behavior Inventory (PDDBI)
|
Every Six Months
|
|
X
|
Authorized ABA Supervisor
|
6.3.1.2 The non-clinical support person
may assist in the administration tasks of completing this requirement.
6.3.1.3 The contractor may utilize
other sources for collection of these measures, such as a provider (TRICARE-authorized
or equivalent) submitting the measures as part of their standard
assessment process.
6.3.1.4 The ASN shall accept and report
only complete and valid outcome measures.
6.3.1.5 The contractor shall accept
valid outcome measures for baseline data with dates up to one year
prior to initiation of both ASN and ABA services.
6.3.2 The contractor shall deny ASN
services and authorization/reauthorization for ABA services for
failure to complete outcome measures at baseline and repeated interval
due dates for outcome measures.
6.3.2.1 The ASN shall identify any
beneficiary, parent/caregiver, or authorized ABA supervisor who
is unable or unwilling to meet this requirement and assist the family
in resolving the lack of completion of outcome measures.
6.3.2.2 The ASN shall document non-compliance
in the beneficiary’s ASN record.
6.3.3 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.
6.3.4 The contractor shall transition
to the new edition within one year of its release, should the outcome measure
edition update.
6.3.5 The contractor
shall ensure all outcome measures scores are reported in the corresponding
DD Form 1423, Contract Data Requirements List (CDRL), located in
Section J of the applicable contract.
6.4 The ASN shall serve as a single
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:
6.4.1 Coordinate medical and behavioral
health services (PT, OT, SLP, etc.), MTF services, 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.
6.4.1.1 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.
6.4.1.2 Coordinate and participate
in medical team conference meetings and document in the contractor on-line
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 outreach coordinator, shall coordinate the
meeting.
6.4.2 Work with
the family to coordinate services, treatments, and hours appropriate
for the family and beneficiary and document all types of care in
a CCP.
6.4.3 Facilitate
continuity of care when a beneficiary in the ACD moves, their sponsor
retires, or a provider becomes unavailable.
6.4.3.1 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.
6.4.3.2 The outgoing ASN shall actively
communicate with the incoming ASN to ensure direct ASN to ASN case
transfer occurs via telephone and secure email, and shall include,
but not be limited to, ensuring that the current referrals transfer
without requiring a new ASD diagnosing/referring provider appointment.
6.4.3.3 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.
6.4.3.4 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.
6.4.3.5 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 at
the new location as the contractors cannot guarantee provider availability
for extended periods of time.
6.4.3.6 The ASN shall coordinate with
the MTF or appointing center for appointments that are required within
the MTF.
6.5 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.
6.6 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. All beneficiaries may be eligible for
state and/or local level services. ADFMs may also be eligible for
Service/EFMP respite or TRICARE ECHO Respite services (see TPM,
Chapter 9, Section 12.1).
6.7 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.
6.7.1 The ASN
or non-clinical outreach coordinator shall document that materials
were received via acknowledgment by the family.
6.7.2 The contractor shall make resources
available electronically on the contractor’s website and by mailing/emailing
if requested.
6.8 The contractor
may employ or subcontract the ASN role.
Note: If subcontracted, the ASN must
not provide any ASN services (see
paragraph 6.0) to beneficiaries
for whom they are rendering treatment services. The ASN role must
be external to any agency rendering services to the beneficiary.
6.9 The contractor shall analyze
data on a monthly basis, through the referral, authorization, claims
process, and other data elements relevant to identifying beneficiaries
diagnosed with ASD to identify potentially eligible beneficiaries
with a diagnosis of ASD (DSM-5 F84.0) and offer ASN services to
these beneficiaries.
6.9.1 If a beneficiary
or the family declines the ASN for any reason (i.e., declines at
outset, meets ABA services goals, takes a break from services, etc.),
they are no longer eligible for the ACD.
6.9.2 The contractor shall document
in the beneficiary file of any declination of ASN and coordinated
ACD services.
6.9.3 Declining
ACD services does not preclude TRICARE 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 pending all
criteria are met.
6.10 The contractor
shall document ASN notes in the contractor’s CM system that is visible
to Government designated authorities.
7.0 PARENTAL AND FAMILY SUPPORT
The contractor shall make publicly
available on the contractor website (see
paragraph 9.3.1), and the
ASN shall notify the family, information and resources related to
ASD that include, but are not limited to:
7.1 Support groups and resources
in the local area.
7.2 Support
groups and services on military installations when available.
Note: Support groups are a community
resource, not a TRICARE covered benefit.
7.3 A “New to the ACD information
toolkit” (approved by DHA prior to use) that shall provide new beneficiaries
and their families with information about the ACD, including but
not limited to ECHO enrollment, description of all services available
to the beneficiary, the role of the ASN, what to expect every six
months, one year, and two years if receiving services.
7.4 Mental health services (i.e.,
individual, family, and group) and non-clinical services (i.e.,
Military OneSource, etc.), in each local area (based on the Prime
Service Area (PSA)/market if located in a PSA/market) that offer
specialized services for family members of a beneficiary with a
diagnosis of ASD (in accordance with
paragraphs 6.4.1 and
6.5).
Telehealth (TH) services may be leveraged for accessing appropriate
mental health services (see TPM,
Chapter 7, Section 22.1 regarding TH services).
7.5 Parent-mediated programs (see
paragraph 11.24),
rendered by TRICARE authorized individual providers under the TRICARE
Basic Program, where available. The ASN shall identify these resources
to each family. Parent-mediated programs shall be reimbursed based
on the TRICARE authorized individual provider’s discipline for treatment
(i.e., Licensed Clinical Social Workers (LCSWs) shall use Current
Procedural Terminology (CPT) codes for individual/group/family psychotherapy
sessions).
8.0 ABA SERVICES
Under 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 Benefit
ABA 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/or supervise
an ABA program. Both models are authorized and the model selected
shall be 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 Requirements
The 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).
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 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.
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;
and
8.2.4 Any provider
who is convicted for any felony of any kind, or a misdemeanor involving
crimes against a child or domestic violence is ineligible to become
a TRICARE authorized provider.
8.3 ACD-Corporate Services Providers
(ACSPs) And Sole Providers
ACSPs include autism centers,
autism clinics, and Sole Providers (regardless of setting of rendered
ABA services, i.e., home or clinic). In many cases, ACSPs may have
contractual agreements with individual assistant behavior analysts and
BTs under their supervision to render ABA services. 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;
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 must re-sign all of their participation
agreements within 120 calendar days of the implementation of this
manual change;
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 or state licensure.
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 on-line and is accessible
to the public. TRICARE Manuals and the Code of Federal Regulation
(CFR) can be found on-line 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. The provider education
training include at a minimum: ACD requirements (to include ABA
provider requirements, correct billing practices/claims filing,
authorizations, exclusions, medical records documentation, provider
responsibilities, and program requirements), basic TRICARE rules,
and 32 CFR 199.
8.3.11 Comply with all applicable
requirements of the Government designated utilization and clinical
quality management organization.
8.4 Provider
Requirements
8.4.1 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 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 Analysts
8.4.2.1 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 follow all the requirements in this
manual. While US territories fall under TOP, tiered services (the
use of assistants and BTs) may be authorized in US 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 US and US 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.
8.5.5 The contractor shall ensure
the reimbursement of TOP claims for ABA services obtained overseas
are based upon the lesser of billed charges, the negotiated reimbursement
rate, or the Government-directed reimbursement rate foreign fee
schedule. (See
Chapter 24, Section 9 and
the TRICARE Reimbursement Manual (TRM),
Chapter 1, Section 35 for additional guidance).
8.6 ABA Policy
8.6.1 Referral for ABA Services
A 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
shall 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,
a specialized ASD diagnosing provider evaluation, meeting all requirements
set forth in
paragraph 4.3, is required as part of the
referral for ABA services.
8.6.1.3 If the initial diagnosis of
ASD was made greater than two years prior to a referral for ABA
services, an updated evaluation, to include diagnostic criteria
and a validated assessment tool, by an ASD diagnosing provider is
required to determine the current level of supports needed.
8.6.1.4 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 Services
8.6.2.1 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.
8.6.2.1.2 The contractor shall issue
an initial six-month treatment authorization only when all initial outcomes
measures are complete.
8.6.2.1.3 The contractor shall ensure
all ABA services are preauthorized.
8.6.2.2 The contractor shall:
8.6.2.2.1 Complete a clinical necessity
review on every TPs 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 Authorize TPs containing clinically
necessary and appropriate services in accordance with the Section
(exclusions as defined in
paragraph 8.10 shall not be authorized).
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 The contractor shall complete
100% clinical necessity reviews for ABA services for all compliant
TPs within five business days for authorization processing standards.
8.6.3 Subsequent Referrals and Authorizations
8.6.3.1 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
authorization.
8.6.3.1.3 The contractor shall complete
a clinical necessity review of the documentation submitted every
six months, including Pervasive Developmental Disabilities 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 authorization that meet the requirements set forth
in this Section.
8.6.3.2 Every two years from the initial
authorization, a new referral with level of support 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 Medical
Team Conference
8.6.4.1 Medical team conferences include
face-to-face participation (in-person or via a compliant TH 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 8.11.6.1.7 for requirements for
using this CPT code. Though not required, family member/beneficiary
participation as appropriate is recommended.
8.6.4.2 The ASN shall participate in
these discussions.
8.6.4.3 Participants must document
their participation in the team conference as well as their contributed information
and subsequent treatment recommendations in their documentation
records.
8.6.4.4 No more than one individual
from the same specialty may report this code at the same encounter.
8.6.4.5 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 Documentation
All ABA documentation must
be completed by the authorized ABA provider 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 Information: The
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 Referral: The ABA
TP and TP updates must include the ASD diagnosing/referring provider’s ASD
diagnosis, to include the level of support required according to
DSM-5 ASD criteria.
8.7.1.3 Background Information: Background
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 Activities:
The 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 targeted 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 Goals: The 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 child, objectively measurable within a specified time frame,
attainable in relation to the child’s prognosis and developmental
status, relevant to child and family, and directly related to the
core symptoms of ASD as defined by the DSM.
8.7.1.5.3 The ASN shall ensure goals
typically treated by specialty providers are identified and addressed
in the CCP. When developing goals for children with suspected or
diagnosed co-morbid medical or behavioral health conditions, the
ABA supervisor must coordinate with the appropriate skilled and
licensed professionals in order to assess the most appropriate treatment
intervention. In order for the ABA provider to address co-morbid
condition targets, documentation on the TP must demonstrate coordination
with the appropriate medical specialty service, to include the name
of the consulting provider. For example:
8.7.1.5.3.1 A child 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 child with a co-morbid diagnosis
of anxiety disorder would require coordination with the appropriate
behavioral health provider.
8.7.1.5.3.3 A child 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 Recommendations:
TP recommendation 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 the 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 weekly 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 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 Progress: ABA 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 Signatures: The 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 Documentation
In 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
session note. This session note must include, but is not limited
to:
8.7.2.15.1 The date and time of session,
to include start and end time;
8.7.2.15.2 Length of assessment session;
8.7.2.15.3 A legible name of the rendering
provider, to include provider type/level;
8.7.2.15.4 A signature of the rendering
provider;
8.7.2.15.5 Content of the session to include
what activity, measures, observations were administered during the
assessment.
8.8 Discharge Planning
8.8.1 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:
8.8.1.2.1 The patient has met ABA TP
goals and is no longer in need of ABA services.
8.8.1.2.2 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.
8.8.1.2.3 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.
8.8.1.2.4 Recommended by the contractor
through the clinical necessity review process.
8.8.1.2.5 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 submitted 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,
use 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 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
Oversight
8.9.1 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 8.9.6) and medical documentation
(
paragraph 8.9.7) reviews and one medical team
conference session note.
8.9.3 The contractor
shall conduct outreach and education to ACSP/Sole Provider groups
with inconsistencies or errors identified in the annual audits.
8.9.4 The contractor shall initiate
progressively more severe administration action, commensurate with
the seriousness of the identified problems, and consistent with
Chapter
13 and
32 CFR 199.9.
8.9.5 The contractor shall recoup
all claims determined to be insufficient for claims payment.
8.9.6 Administrative
Claims Review
8.9.6.1 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.
8.9.6.2 The contractor shall review
ACD claims 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.
8.9.6.3 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.
8.9.6.3.1 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.
8.9.6.3.2 The contractor shall, if suspect
billing has not improved, refer the Sole Provider or ACSP provider group
to the contractor’s Program Integrity (PI) department for review.
8.9.7 Medical
Records Documentation Review - Clinical and Non-Clinical Documentation
8.9.7.1 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.
8.9.7.2 Clinical content reviews shall
be completed by clinical staff.
8.9.7.3 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.
8.9.7.5 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.
8.9.8 New
ACSP/Sole Provider Review
8.9.8.1 The contractor shall monitor
all new ACSP/Sole Providers entering the ACD program for administrative
and medical records documentation review.
8.9.8.2 The contractor shall conduct
a probe audit sample (see
Chapter 13, Section 3, paragraph 3.2.1) following
180 calendar days of participation in the program to review clinical
documentation and claims submission for consistency with program
requirements.
8.9.8.3 The contractor shall share
results of the probe audit with the new ACSP/Sole Provider, and
provide education to address inconsistencies with program requirements.
8.9.9 Annual Reviews
The 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 Exclusions
The contractor shall not reimburse
for:
8.10.1 Training of BTs.
8.10.2 ABA Services for any 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 emails 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 any administrative
tasks (i.e., filing, telephone, appointment scheduling), or supplies
or items to include 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/TH (except
as allowed under
paragraph 8.11.6.1.4.9).
8.10.9 Billing for asynchronous TH
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 TH. 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.
8.10.16 The contractor shall authorize
and reimburse only CPT code 97153 rendered by the authorized ABA supervisor
(not delegated to the assistant) in the school setting.
8.10.17 ABA services for a beneficiary
that are written in a beneficiary’s IEP and are 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.
8.10.18 Billing for school tuition.
8.10.19 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.
8.10.20 Goals targeting a 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.
8.10.21 Rendering or billing for custodian,
personal care, and/or child care.
8.10.22 Durable Equipment (DE) whose
safety and efficacy have not been established as described in
32
CFR 199.4.
8.10.23 Billing of direct and indirect
supervision of BTs and assistant behavior analysts.
8.10.24 Billing of ABA evaluation or
intervention services provided by a clinic or agency owned by the
child’s responsible adult (e.g., biological, adoptive, or foster
parents, guardians, court-appointed managing conservators, other
family members by birth or marriage).
8.10.25 Billing for an ABA evaluation
or intervention services provided directly by the child’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 to family members
is considered a conflict of interest and therefore may be subject
to the Civil Money Penalties Law (CMPL).
8.10.26 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.
8.10.27 Rendering or billing for any
two ABA providers at the same time under one CPT code.
8.10.28 Rendering and billing for any
interventions considered psychotherapy to include, but not limited
to: Cognitive behavior therapy, Acceptance and Commitment Therapy,
Prolonged Exposure, group psychotherapy, etc.
8.10.29 ABA providers rendering and
billing for non-ABA-services.
8.11 Reimbursement
8.11.1 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 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 only:
8.11.5.1 103K00000X Behavior Analyst
for master’s level and above;
8.11.5.2 106E00000X Assistant Behavior
Analyst;
8.11.5.3 106S00000X Behavior Technician;
or
8.11.5.4 Other appropriate HIPAA taxonomy
based on license/certification.
8.11.6 ACD
Approved CPT Codes
The contractor
shall only authorize ABS codes for only ABA providers under the
demonstration authority using the Special Processing Code (SPC), AS.
8.11.6.1 Category I CPT Codes
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.
8.11.6.1.1 CPT Code 97151 - Behavior Identification
Assessment
8.11.6.1.1.1 The initial ABA assessment,
ABA TP development, and the ABA reassessments and TP updates, conducted
by the authorized ABA supervisor during a one-on-one encounter with
the beneficiary and parents/caregivers, must be coded using CPT
code 97151, “Behavior Identification Assessment.”
8.11.6.1.1.2 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.
8.11.6.1.1.3 This code is intended for reporting
initial assessments and reassessments by the authorized ABA supervisor
once every six months.
8.11.6.1.1.4 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).
8.11.6.1.1.5 CPT code 97151 may not be conducted
via TH.
8.11.6.1.1.6 The contractor shall 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.
8.11.6.1.1.7 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.
8.11.6.1.1.8 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 services (CPT codes 97153, 97155, 97156, 97157, and 97158)
are not permitted.
8.11.6.1.2 CPT
Code 97153 - Adaptive Behavior Treatment by Protocol
8.11.6.1.2.1 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.
8.11.6.1.2.2 CPT code 97153 is a timed,
15 minutes, increment code.
8.11.6.1.2.3 The contractor shall authorize
CPT code 97153 units in a six-month authorization and monitor to ensure
TP recommendations per week are maintained and not exceeded.
8.11.6.1.2.4 The contractor shall deny CPT
code 97153units greater than 32 units (eight hours) per day or 160 units
(40 hours) per week.
8.11.6.1.2.5 CPT code 97153 may not be conducted
via TH.
8.11.6.1.3 CPT
Code 97155 - Adaptive Behavior Treatment by Protocol Modification
8.11.6.1.3.1 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.
8.11.6.1.3.2 CPT code 97155 is a timed,
15-minute, increment code.
8.11.6.1.3.3 CPT code 97155 must be completed
at least one time per month by the authorized ABA supervisor.
8.11.6.1.3.4 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 6-month authorization.
8.11.6.1.3.5 The contractor shall deny CPT
code 97155 units greater than eight units (two hours) per day.
Note: Team meetings and supervision
of any type are not reimbursable under CPT code 97155.
8.11.6.1.4 CPT Code 97156 - Family Adaptive
Behavior Treatment Guidance
8.11.6.1.4.1 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.
8.11.6.1.4.2 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 teaching
to assistant behavior analysts working under their supervision,
but only the authorized ABA supervisor may bill for this service
using this code.
8.11.6.1.4.3 The beneficiary is not required
to be present for the parent/caregiver sessions; however, presence of
the beneficiary is encouraged.
8.11.6.1.4.4 CPT code 97156 is a timed,
15-minute, increment code.
8.11.6.1.4.5 The contractor shall deny CPT
code 97156 units greater than eight units (two hours) per day.
8.11.6.1.4.6 CPT code 97156 may be used
only in a home or clinic/office-based setting. School settings are prohibited.
8.11.6.1.4.7 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.
8.11.6.1.4.7.1 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.
8.11.6.1.4.7.2 The contractor shall deny renewed
ABA services for a subsequent authorization period for that beneficiary
if this requirement is not met for two consecutive authorization
periods.
8.11.6.1.4.8 Parent/caregiver sessions for
CPT code 97156 may be conducted via TH only after the first six-month
authorization period per authorized provider. Additionally, all
services provided via TH must adhere to state laws governing TH
services.
8.11.6.1.4.9 Parent/caregiver sessions conducted
remotely must include the
GT modifier when submitting claims.
Remote Family Adaptive Behavior sessions must be in compliance with
TPM,
Chapter 7, Section 22.1.
8.11.6.1.5 CPT
Code 97157 - Multiple-Family Group Adaptive Behavior Treatment Guidance
8.11.6.1.5.1 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.
8.11.6.1.5.2 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).
8.11.6.1.5.3 The contractor shall recoup
all claims for groups that exceed eight participants.
8.11.6.1.5.4 CPT code 97157 may only be
used in a clinic/office-based setting.
8.11.6.1.5.5 CPT code 97157 may not be conducted
via TH.
8.11.6.1.5.6 CPT code 97157 is a timed,
15-minute, increment code.
8.11.6.1.5.7 The contractor shall only authorize
CPT code 97157 units at a minimum of four, 15-minute units (one
hour) and shall not exceed six, 15-minute units (1.5 hours) per
day.
8.11.6.1.6 CPT
Code 97158 - Group Adaptive Behavior Treatment by Protocol Modification
8.11.6.1.6.1 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.
8.11.6.1.6.2 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.
8.11.6.1.6.3 Groups must not exceed eight
participants.
8.11.6.1.6.4 The contractor shall recoup
all claims for groups that exceed eight participants.
8.11.6.1.6.5 CPT code 97158 may not be conducted
via TH.
8.11.6.1.6.6 CPT code 97158 is a timed,
15-minute, increment code.
8.11.6.1.6.7 The contractor shall only authorize
CPT code 97158 units at a minimum of four, 15-minute units (one
hour) and shall not exceed six, 15-minutes units (1.5 hours) per
day.
8.11.6.1.7 CPT
Codes 99366 and 99368 Medical Team Conference
8.11.6.1.7.1 CPT codes 99366 and 99368 are
permitted only via face-to-face interaction, either in person or through
the TH platform. Telephone-only is not permitted for providers.
8.11.6.1.7.2 CPT code 99366 Medical team
conference with patient by healthcare professional.
8.11.6.1.7.3 CPT code 99368 Medical team
conference without patient by health care professional.
8.11.6.1.7.4 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 or 99368 at the
same encounter.
• The ASN must be present, via
TH or telephone, for provider reimbursement of the medical team
conference.
• 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.
8.11.6.1.7.5 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.
8.11.6.1.7.6 All approved TPs will receive
a minimum of one unit of 99366 and one unit of 99368 on each 6-month
treatment authorization for the ABA provider to participate in a
medical team conference.
8.11.6.1.7.7 ABA providers must use the
ACD SPC, AS, when submitting claims for this CPT code.
8.11.7 Reimbursement Rates for ABS
Services
8.11.7.1 Reimbursement of claims in
accordance with 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 each May 1st. The rates
will also be posted at
http://www.health.mil/rates.
8.11.7.3 The contractor shall update
their reimbursement systems, once posted on the website, to reflect
the annually updated rates in compliance with
Chapter 1, Section 4.
8.11.7.4 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-Demonstration):
• CPT code 97151. Behavior Identification
Assessment is authorized for only the authorized ABA supervisor
(or as delegated to an assistant behavior analyst). 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 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.
• 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.
• 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.
• 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.
• CPT code 97157. 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.
• CPT code 97158. 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.
• For CPT codes 99366 and 99368,
see
https://health.mil.
Reimbursement rates can be found using the search word “CMAC”.
8.11.7.5 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.
8.11.7.6 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
|
8.11.7.7 Negotiated provider rates lower
than those directed in this paragraph are not allowed.
8.11.7.8 The balance billing provisions
for non-participating providers as outlined in the TRM,
Chapter 3, Section 1 do not apply. ABA providers
may not bill the beneficiary more than 100% of the rates posted
at
http://www.health.mil/rates.
8.11.7.9 Policies in this section must
be adhered to or claims may be recouped.
8.11.8 Cost-Sharing
8.11.8.1 There is no maximum Government
payment or annual cap specifically for ABA services. Established TRICARE
deductibles, enrollment fees, copayments, cost-shares, and the annual
catastrophic cap protections apply to beneficiaries participating
in the ACD.
8.11.8.2 All beneficiary cost-sharing,
deductibles, and enrollment fees will be those applicable to the
specific TRICARE plan and beneficiary category of the TRICARE eligible
beneficiary receiving services under this demonstration; e.g., TRICARE
Prime, TRICARE Select; and TRICARE for Life (TFL). For information
on fees for Prime enrollees choosing to receive care under the Point
of Service (POS) option, refer to
32
CFR 199.17 and TRM,
Chapter 2, Section 1.
8.11.8.3 The contractor shall, for services
rendered on or after January 1, 2019, only apply 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.
8.11.8.4 The contractor shall, for CPT
code 97151, apply one copayment for all assessment services rendered within
a 14-day calendar period using this CPT code. If CPT code 97151
is billed on the same day as other ABA service, only one copay applies.
8.11.8.5 For Other Health Insurance
(OHI), beneficiaries receiving ABA services are required to obtain
a referral and prior authorization. ABA services under OHI are reimbursed
for only the covered services listed in this manual section.
9.0 ACD REQUIREMENTS
9.1 Utilization Management (UM)
9.1.1 The contractor shall implement
UM tools 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.
9.1.7 This contractor’s UM person
shall be different from the ASN.
9.1.8 The contractor shall submit,
as part of the annual Medical Management 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 PI 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 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 Responsibilities
9.3.1 The contractor shall develop
an ACD-specific website 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 of ACD providers,
including but not limited to ABA providers, parent-mediated programs,
ASD diagnosing providers, respite care, SLP, OT, PT, etc. (the on-line
ACD provider directory may be part of the contractor’s main on-line
provider directory).
• ACD Education and Resources
link as 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, 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, privileging, certification, directory changes.
• Contact information or link
for submitting beneficiary or family member/caregiver complaints.
9.3.2 The contractor shall designate
an ACD complaint officer to receive and address beneficiary family member/caregiver
complaints. Contact information shall be provided to all parents/caregivers
of beneficiaries receiving services under this demonstration on
the contractor ACD specific website.
9.3.3 The contractor shall submit
the ABA provider training curriculum for DHA review and approval
per CDRL requirements prior to executing the training.
9.3.3.1 The contractor shall ensure
compliance with
paragraph 8.3.9 by retaining evidence of attendance/completion.
9.3.3.2 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.
9.3.4 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.
9.3.5 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.
9.3.6 The contractor
shall recoup claims and/or deny services for session notes that
describe the rendering of non-ABA services.
9.3.7 The contractor shall authorize
all CPT code units (per week/month respectively; see 8.11.6.2) based
on the approved TP in the six-month authorization and monitor the
authorization to ensure paid claims do not exceed what was authorized.
9.3.8 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 ABA Provider Networks
This paragraph applies only
to the 50 US, District of Columbia, and US territories. See
paragraph 8.5 for
TOP.
9.3.10.1 The contractor shall establish
network contracting targets sufficient to support the ACD program
in accordance with 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.
9.3.10.2 The contractor shall ensure
that the beneficiary shall begin ABA treatment services within 28 calendar
days from the completed ABA assessment date.
9.3.10.3 The contractor shall certified
all BTs within 10 business days of a complete application package
that meets all requirements.
9.3.10.4 The contractor shall include
the provider work address, work fax number, work telephone number, and
hours of operation in their directory.
9.3.10.5 The contractor shall include
information regarding ages served, TH capabilities, and settings
for ABA services (i.e., in-home, clinic-based, both) in their directory.
9.3.10.6 The contractor shall engage
in an active provider placement process to ensure access to care standards
are met.
9.3.10.6.1 The contractor shall have up
to 15 business days to complete the active provider placement process.
9.3.10.6.2 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, 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.
9.3.10.6.3 The contractor shall document
that the provider was able to accept and see the beneficiary within access
to care standards.
9.3.10.6.4 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.
9.3.11 ABA Provider Steerage Model
9.3.11.1 The contractor shall develop
an ABA provider steerage model for individual authorized ABA supervisors
which shall take into account, at a minimum:
9.3.11.1.1 Compliance with access standards.
9.3.11.1.2 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.
9.3.11.2 The contractor shall assign
beneficiaries to ABA providers who rank highest in the steerage
model when possible consistent with access to care standards.
9.3.11.3 The contractor shall list ABA
providers who rank highest in the steerage model first in on-line provider
directories and shall give priority to those who rank highest when
assigning patients to a provider.
9.3.12 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.
9.3.13 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 SPC,
AS (Comprehensive
ACD).
9.3.14 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.
9.3.15 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.
9.3.16 The contractor shall contact
DHA for clarification if the contractor identifies a gap in the
ACD policy, and shall not automatically default to normal TRICARE
policy.
11.0 DEFINITIONS
11.1 Adaptive Behavior 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) Assessment
A developmentally appropriate
assessment and reassessment tool must be used for formulating an
individualized ABA TP and is conducted by an authorized ABA supervisor.
For TRICARE purposes, an ABA assessment shall include data obtained
from multiple methods to include direct observation, the measurement,
and recording of behavior. A functional assessment that may include
a functional behavior analysis may be required to address problematic behaviors.
Data gathered from a parent/caregiver interview and a parent report
rating scales are also required. The ABA assessment will also include
required standardized outcomes measures at appropriate intervals
as noted above
11.3 Applied Behavior Analysis (ABA)
Services
ABA 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 Applied Behavior Analysis (ABA)
Sole Provider Model
A 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), US territories, and TOP.
11.5 Applied
Behavior Analysis (ABA) Tiered Delivery Model
A service delivery model that
includes the use of supervised assistant behavior analysts and/or
BTs, in addition to the authorized ABA supervisor, to implement
a TP designed by the authorized ABA supervisor. 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 US territories.
11.6 Applied Behavior Analysis (ABA)
Treatment Plan (TP)
11.6.1 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 Applied Behavior Analysis (ABA)
TP Goals
These
are the broad spectrum, complex short-term and long-term desired
outcomes of ABA services.
11.8 Applied
Behavior Analysis (ABA) TP Objectives
The short, simple, measurable
steps that must be accomplished in order to reach the short-term
and long-term goals of ABA services.
11.9 Assistant Behavior Analyst
The term “assistant behavior
analyst” refers to supervised Licensed Assistant Behavior Analyst
(LABA), BCaBA, and QASP.
11.10 Authorized
ABA Supervisor
An authorized
ABA supervisor, whether or not currently supervising, is defined
as a Licensed Behavior Analyst (LBA), BCBA, BCBA-Doctorate (BCBA-D),
or clinical psychologist TRICARE authorized ABA providers 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 includes:
a Registered Nurse (RN) with CM experience, clinical psychologist,
or Licensed Clinical Social Worker or other licensed mental health
professionals who possess a certification in case management (CCM).
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 Providers
11.13.1 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 pediatrician, family medicine
physicians, and pediatric or family 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: 1) either a pediatric
NP or a family NP; and 2) either (Family, or Child/Adolescent) Psychiatric Mental
Health Nurse Practitioner (PMHNP) or a (Child/Adolescent) Psychiatric
and Mental Health Clinical Nurse Specialist (PMHCNS).
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
Analysis
Behavior
analysis is the scientific study of the principals of learning and
behavior, specifically about how behavior affects, and is affected
by, past and current environmental events in conjunction with biological
variables. ABA is the application of those principles and research
findings to bring about meaningful changes in socially important behaviors
in everyday settings. ABA, by a licensed and/or certified behavior
analyst, focuses on treating behavior difficulties by changing an
individual’s environment (i.e., shaping behavior patterns through
reinforcement and consequences). ABA is delivered optimally when
family members/caregivers actively participate by consistently reinforcing
the ABA interventions in the home setting in accordance with the
prescribed 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 Plan
Behavior
Intervention Plans must include an operational definition of the
target behavior excesses and deficits, prevention and intervention
strategies, schedules of reinforcement, and functional alternative
responses. Behavior Intervention Plans shall be submitted along
with any TP identifying a target behavior excess or deficit.
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
Necessity
Clinical
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 PCS
orders. The CCP will allow for a more consistent and beneficiary-centric
approach to care.
11.21 Family/Caregiver
11.21.1 Family/caregiver follows the
32 CFR 199.2(b) definition: [t]he spouse,
natural parent, child and sibling, adopted child and adoptive parent,
stepparent, stepchild, grandparent, grandchild, stepbrother and
stepsister, father-in-law, mother-in-law of the beneficiary, and
legal guardian as appropriate. 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 Analysis
The process of identifying
the variables that reliably predict and maintain problem behaviors
that typically involve: identifying the problem behavior(s); developing
hypotheses about the antecedents and consequences likely to trigger
or support the problem behavior; and, performing an analysis of
the function of the behavior by testing the hypotheses.
11.23 Medical Team Conferences
Medical 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 Programs
Parent-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 (PSI)
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. 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 Disabilities
Behavior Inventory (PDDBI) (Cohen, I.L. and Sudhalter, V. 2005 or
current edition)
11.26.1 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.
11.26.2 The standard or extended form
must be submitted 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 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.
Note: Per guidance 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 Board
QABA “is an organization established
in 2012 to meet para-professional credentialing needs identified
by behavior analysts, ABA providers, insurance providers, government
departments, and consumers of behavior analysis and behavior health
services.” QABA offers the QASP certification for bachelor’s level
assistant behavior analysts, and the ABAT certification for 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) (Constantino, or current edition)
11.29.1 The SRS-2 identifies social
impairment associated with ASD and quantifies its severity. Applicable
for ages 2-1/2 through 99 years.
11.29.2 The Parent Form is required.
The name of the respondent and relation to the beneficiary is required
on all forms.
11.30 Stress
Index for Parents of Adolescents (SIPA) (Sheras and Abidin, or current
edition)
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 third edition of the Parenting Stress Index (PSI-3).
Applicable for ages 11-19 years.
11.32 Vineland Adaptive Behavior
Scale, Third Edition (Vineland-3) (Sparrow, S.S. et.al, or current edition)
11.32.1 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.
11.32.2 The Parent Form, the Interview
Form (if completed by a TRICARE-authorized provider or ASN), or
the Teacher Form are required. The name of the respondent and relation
to the beneficiary is required on all forms.