3.0 DEMONSTRATION
GOALS3.1 Analyzing and
evaluating the appropriateness of the ACD under TRICARE in light
of current and future Behavior Analyst Certification Board (BACB)
Guidelines for “Applied Behavior Analysis Treatment of Autism Spectrum
Disorder: Practice Guidelines for Healthcare Funders and Managers”
(2014 or current edition);
3.2 Determining the
appropriate provider qualifications for the proper diagnosis of
ASD and for the provision of ABA, and assessing the added value
of assistant behavior analysts and Behavior Technicians (BTs) beyond
ABA provided by Board Certified Behavior Analysts (BCBAs);
3.3 Assessing, across
the TRICARE regions and overseas locations, the ASD beneficiary characteristics
associated with full utilization of the ACD’s tiered delivery model
versus utilization of sole provider BCBA services only, or non-utilization
of any ABA services, and isolating factors contributing to significant
variations across TRICARE regions and overseas locations in delivery
of ABA;
3.4 Determining what
beneficiary age groups utilize and benefit most from ABA interventions;
3.5 Assessing the
relationships between receipt of ABA services and utilization of
established medical interventions for children with ASD, such as
Speech-Language Pathology (SLP) services, Occupational Therapy (OT),
Physical Therapy (PT), and pharmacotherapy; and
3.6 Assessing the
feasibility and advisability of establishing a beneficiary cost-share
for ABA services as a treatment for ASD.
6.0 AUTISM SERVICES
COORDINATIONThe
TRICARE Overseas Program (TOP) contractor, U.S. Family Health Plan
Designated Providers (USFHP DPs), and TRICARE For Life (TFL) are
excluded from paragraphs 6.0 through 6.9.
Case management services in accordance with the contracts are otherwise
not affected.
6.1 The contractor
shall assign an autism-specific care manager, known as the ASN (see paragraph 11.11),
to all new beneficiaries entering the ACD for ABA services on or
after October 1, 2021, who will serve as the primary advocate for
the beneficiary.Note: “New beneficiaries”
is defined as any beneficiary not currently receiving ABA services
under the ACD as of the date of publication of this manual change.
Current beneficiaries in the ACD who are transferring regions and
continuing ABA services are not considered new. Additionally, any
beneficiary requesting ABA services after a gap in ABA services
for any reason, for a period of 12 months or more, is considered
a “new beneficiary” and all referral and authorization requirements,
including the assigning of an ASN, apply.
6.1.1 The contractor
shall provide the name and contact information of the assigned ASN
in writing to the family.
6.1.2 The ASN shall
make contact with the family to describe the ASN services prior
to any ABA services being authorized.
6.1.3 The contractor
may utilize a non-clinical outreach coordinator to assist families
with identifying providers, support groups, and local level resources.
6.1.4 The ASN shall: 6.1.4.1 Take the lead role and coordinate
with other Case Management (CM) activities when the beneficiary
has a CM and an ASN.
6.1.4.2 Be assigned and
serve as the primary point of contact for the beneficiary/family
even when the beneficiary is eligible for services from the TRICARE
Select Navigator.
6.1.4.3 Coordinate with
the TRICARE Select Navigator.
6.2 Comprehensive
Care Plan (CCP)6.2.1 The ASN shall
conduct an initial care management assessment, to develop a written
CCP (see paragraph 11.20) in order to identify the
needs of the beneficiary and family. Discharge/transition planning
shall be addressed in the CCP upon a beneficiary’s enrollment into
the ACD.
6.2.2 The ASN shall
complete the CCP within 90 calendar days of the family being assigned
an ASN.
• The contractor shall, for CCPs
not completed within 90 calendar days as a result of family/beneficiary
noncompliance, suspend ABA services through the duration of the
existing authorization or until the CCP is complete, whichever occurs
first.
6.2.3 The ASN shall
review and incorporate the results of all outcome measures into
the CCP.
6.2.4 The ASN shall
notify the medical home, PCM, and/or referring provider and parent/caregivers
that the CCP has been established.
• The ASN shall share the CCP
with the respective providers prior to the beneficiary receiving
ABA services under the ACD.
6.2.5 The ASN shall
update the CCP at least every six months to include updated outcome measures.
6.3 The ASN shall
serve as a single Point of Contact (POC), in coordination with Military
Medical Treatment Facility (MTF) CM (when applicable), readily accessible
by phone or email (based on beneficiary preference), during regular
business hours for the respective geographic time zone in which
the beneficiary resides, to assist the beneficiary/family with all
questions from the beneficiary’s family related to autism care and
shall:6.3.1 Coordinate medical
and behavioral health services (PT, OT, SLP, etc.), MTF services (including
coordination with the MTF CM), ECHO services (for ADFMs), Network
PCM (if applicable), specialty providers, ABA services, EFMP coordinators,
and other clinical services based on the CCP for the beneficiary
and the family.6.3.1.1 Ensure parent-mediated
programs work in collaboration with other identified treatment goals
as part of a CCP (paragraph 11.20) to ensure that program goals
do not contradict one another.
6.3.1.2 Coordinate and
participate in medical team conference meetings and document in
the contractor online system a summary of the medical team conference
calls. The ASN notes shall be available to the PCM and/or referring
provider, and the government. Any provider may request a medical
team conference, however, the ASN, or non-clinical outreach coordinator,
shall coordinate the meeting.
6.3.2 Work with the
family to coordinate services, treatments, and hours appropriate
for the family and beneficiary and document all types of care in
the CCP.
6.3.3 Facilitate continuity
of care when a beneficiary in the ACD moves, their sponsor retires,
or a provider becomes unavailable.6.3.3.1 The incoming and outgoing ASNs
shall be assigned concurrently for at least one month prior to and
after transferring regions/markets.
Note: Assignment of
a new ASN is dependent on the family or provider notifying the contractor of
the pending move/transition.
6.3.3.2 The outgoing
ASN shall actively communicate with the incoming ASN to ensure direct
ASN to ASN case transfer occurs via telephone and secure e-mail,
and shall include, but not limited to, ensuring that the current
referrals transfer without requiring a new ASD diagnosing/referring
provider appointment.
• The incoming ASN shall work
with the family to ensure all ACD program requirements are met if there
is missing information in the case transfer.
Note: Voluntary case
management services are available upon request for beneficiaries registered
in ECHO. These case managers can assist with continuity of care
issues with current ACD beneficiaries who do not have an ASN.
6.3.3.3 The outgoing
ASN shall forward to the incoming ASN all ACD related documentation, including,
but not limited to, the CCP and outcomes measures within 10 calendar
days of being notified that a beneficiary is transferring to a location
under the jurisdiction of another contractor.
6.3.3.4 The incoming
ASN or non-clinical outreach coordinator shall identify providers
for care and services for the diagnosis of ASD at the new location
prior to a move.
• The incoming ASN or non-clinical
outreach coordinator shall assist with identifying available appointments
with needed providers no more than two weeks prior to arrival as
the contractor cannot guarantee provider availability for extended
periods of time.
6.3.3.5 The contractor
shall coordinate with the MTF or appointing center for appointments
that are required or available within the MTF.
6.4 The ASN or non-clinical
outreach coordinator shall identify and facilitate connections with
local level resources that may benefit TRICARE eligible beneficiaries
in the ACD to include, but not limited to, access to state Medicaid
services, community services, respite care, support groups, etc.6.4.1 The ASN or non-clinical
outreach coordinator shall assist the family in accessing available respite
service options, as well as assist in identifying necessary documents
for the respective options.
6.4.2 All beneficiaries may be eligible
for state and/or local level services.
6.4.3 ADFMs may also be eligible
for Service/EFMP respite or TRICARE ECHO respite services, see TPM,
Chapter 9, Section 12.1.
6.5 The ASN or non-clinical
outreach coordinator shall provide educational resources about ASD
to the beneficiary and/or family, including but not limited to,
appropriate treatments and services, contractor provided parental
education modules, available resources (both military and civilian), potential
impact of the diagnosis of ASD on the family, and the potential
long-term care required to support the beneficiary and help them
reach their maximum potential. 6.5.1 The ASN or non-clinical outreach
coordinator shall document that materials were received via acknowledgment
by the family.
6.5.2 The contractor shall make resources
available electronically on the contractor’s website no later than
October 1, 2021.
• The contractor shall also
make this information available by mail or email if requested by
the family.
6.6 The ASN shall
provide beneficiary-specific outcome measures data to the respective
TRICARE authorized rendering providers.
6.7 The contractor
may employ or subcontract the ASN role.
Note: If
subcontracted, the ASN must not provide any ASN services (see paragraph 6.0 through 6.9)
to beneficiaries for whom they are rendering treatment services.
The ASN role must be external to the agency rendering services to
the beneficiary.
6.8 If a new beneficiary
or the family, on or after October 1, 2021, declines the ASN for
any reason, they are no longer eligible for the ACD.6.8.1 The contractor
shall document in the beneficiary file of any declination of ASN
and coordinated ACD services.
6.8.2 Declining ACD
services does not preclude Basic benefit services, just the coordinated
ASN and ABA services. However, the beneficiary or family member
can request to reengage in the ACD at any point provided all criteria
are met. The beneficiary is considered a new beneficiary for purposes
of the ACD if they reengage.
6.9 The contractor
shall document ASN notes in the contractor’s case management system
that is visible to government designated authorities.
8.0 ABA SERVICESUnder the demonstration
authority, TRICARE covers clinically necessary and appropriate ABA
services for the diagnosis of ASD only. ABA services are one component
of a comprehensive array of services. Additionally, ABA providers
are authorized to render only ABA services under the demonstration authority.
The following paragraphs identify approved ABA services under the
demonstration:
8.1 ABA Services
BenefitABA
services for the diagnosis of ASD may be provided solely by a master’s
level or above authorized ABA supervisor and/or under the tiered
delivery model, where an authorized ABA supervisor will plan, deliver,
and supervise an ABA program. Both models are authorized and the
model selected is based on the needs of the beneficiary. The Treatment
Plan (TP) is based on which model is being implemented. See paragraphs 11.4 and 11.5 for
definitions of sole and tiered delivery models.
8.2 ABA Provider
RequirementsThe contractor
shall ensure that all TRICARE ABA provider requirements are met,
and subsequently certified, prior to reimbursement of claims for
any ABA services. All TRICARE ABA providers authorized under the
ACD only (master’s level and above, assistant, and BT level) must:
8.2.1 Obtain a National
Provider Identifier (NPI) number (all claims must have the rendering provider’s
name and NPI for processing). For ABA providers who do not possess
an NPI prior to July 1, 2021, these providers shall have until August
1, 2021 to obtain and submit an NPI. For ABA providers new to the
ACD on or after July 1, 2021, providers must already possess an
NPI at the time of certification application submission.
8.2.2 Complete the
training for Basic Life Support (BLS) or a Cardiopulmonary Resuscitation (CPR)
equivalent certification, as demonstrated by completion of a hybrid
course comprised of a web-based instruction component and live component
to demonstrate skills on a dummy. Any course that is done entirely
in person is also acceptable. This certification must be maintained
and current.
8.2.3 The contractor
shall obtain respective documents from the authorized ABA supervisor:8.2.3.1 A copy of a Criminal
History Review, as specified in Chapter 4, Section 1, paragraph 8.0, for all
authorized ABA supervisors with whom the contractor enters into
a Participation Agreement.
8.2.3.2 A copy of a Criminal
History Background Check (CHBC) of assistant behavior analysts and BTs
new to the demonstration on or after July 1, 2021.
8.2.3.3 The CHBC of assistant
behavior analysts and BTs shall Include current Federal, State,
and County Criminal and Sex Offender reports for all locations the
assistant behavior analyst or BT has resided or worked during the
previous 10 years new to the demonstration on or after July 1, 2021;
8.2.3.4 The TOP contractor
shall obtain criminal history reviews and criminal history background checks
in accordance with host nation laws and policies from the authorized
ABA supervisor; and
8.2.4 Any provider
who is convicted of any felony of any kind, or a misdemeanor involving
crimes against a child or domestic violence is ineligible, to become
a TRICARE authorized provider.
8.2.5 The contractor
shall issue a provider certification after the review of a complete
application packet that meets the requirements set forth in this
section.
8.3 ACD-Corporate
Services Providers (ACSPs) And Sole ProvidersACSPs include
autism centers, autism clinics, and Sole Providers (regardless of
setting of rendered ABA services, i.e., home or clinic). In many
cases, ACSPs will have contractual agreements with individual assistant
behavior analysts and BTs under their supervision to render ABA
services. Autism schools are not authorized providers under the
ACD. The ACSP including Sole Providers must:
8.3.1 Submit evidence
to the contractor that professional liability insurance in the amounts
of one million dollars per claim and three million dollars in aggregate,
is maintained in the ACSP’s/Sole Provider’s name, unless state requirements
specify greater amounts;
• TOP contractor
shall ensure professional liability insurance is in accordance with
the TOP contract.
8.3.2 Submit to the
contractor all documents necessary to support an application for designation
as a TRICARE ACSP/Sole Provider;
8.3.3 Enter into a
Participation Agreement, Addendum A,
approved by the Director, DHA or designee (i.e., the contractor).
All ACSPs/Sole Provider practices prior to July 1, 2021 must re-sign
all of their Participation Agreements no later than August 1, 2021
or risk terminating their TRICARE authorized status.
• The contractor
shall submit a list of non-compliant providers. The Government retains
final decision making for provider termination;
8.3.4 Employ directly
or contract with qualified authorized ABA supervisors, assistant
behavior analysts, and/or BTs, if applicable;
8.3.5 Certify that
all authorized ABA supervisors, assistant behavior analysts, and
BTs employed by or contracted with the ACSP meet the education,
training, experience, competency, supervision, and ACD requirements
specified in this section;
8.3.6 Comply with all
applicable organizational and individual licensing or certification requirements
that are extant in the State, county, municipality, or other political
jurisdiction in which ABA services are provided under the ACD;
8.3.7 Maintain all
applicable business licenses and employment or contractual documentation
in accordance with Federal, State, and local requirements and the
authorized ABA supervisor’s business policies regarding assistant
behavior analysts and BTs.
8.3.8 Report to the
contractor within 30 calendar days of notification of a state sanction
or BACB sanction issued to the BCBA or BCBA-Doctoral level (BCBA-D)
for violation of BACB Professional and Ethical Compliance Code for
Behavior Analysts (http://www.bacb.com/ethics-code)
or notification of loss of BACB certification. Loss of state licensure
or certification, or loss of BACB certification shall result in
termination of the Participation Agreement with the authorized ABA
supervisor with an effective date of such notification. Termination
of the Participation Agreement by the contractor may be appealed
to DHA in accordance with the requirements of Chapter
12. While the Participation Agreement is
with the ACSP/Sole provider, failure to remove the sanctioned provider
will result in the termination of the entire ACSP or Sole provider
group from the ACD.
8.3.9 Familiarize themselves
with, and comply with program requirements as stated in 32
CFR 199.6 and 32
CFR 199.9. This information is available
online and is accessible to the public. TRICARE Manuals and CFRs
can be found online at https://manuals.health.mil/.
All authorized ABA providers agree to abide by all rules and regulations
of the TRICARE Program, but additionally agree to bill for services
that are only deemed clinically necessary and appropriate.
8.3.10 Attend a contractor-hosted
“provider education” training, no less than annually, beginning no
later than October 1, 2021.
8.3.11 Comply with all
applicable requirements of the Government designated utilization
and clinical quality management organization.
8.4 Provider Requirements8.4.1 Authorized ABA
Supervisors (BCBA, BCBA-D, or Clinical Psychologist)8.4.1.1 Have a master’s
degree or above in a qualifying field as defined by the state licensure/ certification
where defined or in the absence of state licensure/certification,
a graduate degree from an accredited institution (per TPM, Chapter 11, Section 3.3) in
behavior analysis, psychology, special education, or a related field;
and
8.4.1.2 Have a current:8.4.1.2.1 Unrestricted
state-issued license or state certification for full clinical practice
if practicing in a state that offers state licensure or state certification
in behavior analysis or psychology; or
8.4.1.2.2 Certification
from the BACB where such state-issued license or certification is
not available.
8.4.2 Assistant Behavior
Analysts8.4.2.1 Have a bachelor’s
degree or above in a qualifying field as defined by the state licensure/ certification
where defined or in the absence of state licensure/certification,
a degree in a field accepted by a certification body approved by
the Director, DHA; and
8.4.2.2 Have a current:8.4.2.2.1 Unrestricted
state issued license or state certification if they practice in
a state that offers state licensure or state certification; or
8.4.2.2.2 Certification
from the BACB or the Qualified Applied Behavior Analysis (QABA) certification
board.Note: Should a state
licensure or state certification specify criteria for an assistant
behavior analyst that results in a previously authorized TRICARE
assistant behavior analyst not meeting the requirements for state
licensure or state certification, that provider may be recognized
by TRICARE as only a BT without having to obtain the BT certification
(if allowed by state law) and shall be subject to all BT requirements
once the state licensure language becomes effective. A certification
as an ABA provider must be maintained.
8.4.2.3 Assistant behavior
analysts must receive supervision in compliance with their certification board.
Assistant behavior analysts must work under the supervision of an
authorized ABA supervisor who meets the requirements specified in paragraph 8.4.1.
8.4.2.4 Assistant behavior
analysts who conduct supervision of BTs must be in compliance with their
certification board for supervisory activities.
8.4.3 Behavior Technicians
(BTs)8.4.3.1 All BTs must
possess a current Registered Behavior Technician (RBT), Applied
Behavior Analysis Technician (ABAT), or Board Certified Autism Technician
(BCAT) certification, or state certification, before applying for
TRICARE-authorized provider status.Note: Should a state
licensure or state certification specify a BT certification type,
that state designation must be followed.
8.4.3.2 The contractor
shall certify a BT as a TRICARE provider within 10 business days
from the receipt of a complete application that meets all requirements
for certification.
8.4.3.3 BTs must receive
ongoing supervision in compliance with their certification board.
8.5 ABA Provided
Under The TRICARE Overseas Program (TOP)8.5.1 The contractor
shall ensure ABA services provided overseas shall follow all the requirements
in this manual. While U.S. territories fall under TOP, tiered services
(the use of assistants and BTs) may be authorized in U.S. territories
only, and must follow all requirements laid out in this manual,
including reimbursement rates (see http://www.health.mil/rates)
for all ABA providers. The tiered model is not authorized outside
of the U.S. and U.S. territories.
8.5.2 The TOP contractor
shall verify compliance with all requirements outlined in the ACD.
8.5.3 Where there are
no BCBAs or BCBA-Ds certified by the BACB within the TRICARE specialty care
access standards in the host nation, there is no ABA benefit.
8.5.4 The contractor
shall work with the TOP Office to identify the most appropriate
claim form to use depending on the host nation country and the overseas
provider’s willingness to use the Centers for Medicare and Medicaid
Services (CMS) 1500 Claim Form. See Chapter 24, Section 9, paragraph 1.6 for additional
guidance.
8.5.5 The contractor
shall ensure the reimbursement of TOP claims for ABA services obtained overseas
shall be based upon the lesser of billed charges, the negotiated
reimbursement rate, usual and customary charges, or the Government-directed
reimbursement rate foreign fee schedule. (See Chapter 24, Section 9 and the TRICARE Reimbursement
Manual (TRM), Chapter 1, Section 35 for additional guidance).
8.6 ABA Policy8.6.1 Referral for
ABA ServicesA
complete referral for ABA services under the ACD is required for
all TRICARE eligible beneficiaries in accordance with paragraph 4.0.
Referral processing requirements are located in Chapter 1, Section 3. A retroactive referral
will not be accepted.
8.6.1.1 A referral must
specify ABA services are being requested.
8.6.1.2 For beneficiaries
first diagnosed with ASD at age eight years or older, and requesting
ABA services, on or after October 1, 2021, a specialized ASD diagnosing
provider evaluation (not a PCM), meeting all diagnosis requirements
set forth in paragraph 4.2, is required as part of the
referral for ABA services.
8.6.1.3 The contractor
shall collect an updated evaluation to determine the current level
of supports needed, to include diagnostic criteria and a validated
assessment tool, by an ASD diagnosing provider, if the initial diagnosis
was made greater than two years prior to a referral for ABA services effective
October 1, 2021.
8.6.1.4 The contractor
shall align all new and existing beneficiaries to a chronological
two year referral timeline, no later than July 1, 2021, from initial
or most current verified referral, and notify the beneficiary/family
of this date.
• The contractor
shall use the referral receipt date confirmed by the contractor’s
system of the verified referral as the start date of the two-year
referral timeline.
8.6.2 Authorization
for ABA Services8.6.2.1 The contractor
shall, upon receipt of the completed referral for ABA services,
issue an evaluation authorization for an initial assessment and
TP development. The authorized ABA supervisor then completes and
submits the initial documentation (assessment and TP) including
recommended Adaptive Behavior Services (ABS) CPT codes and number
of units to the contractor for review and subsequent appropriate
approval for a six month treatment and reassessment/TP update authorization for
active delivery of ABA services in accordance with Chapter 1, Section 3.8.6.2.1.1 The contractor
shall issue the treatment authorization identifying approved units
in accordance with the guidance defined in paragraph 8.11.6.2.
8.6.2.1.2 The contractor shall issue
an initial six-month treatment authorization only when all initial
outcome measures are complete.
8.6.2.1.3 The contractor
shall ensure all ABA services are preauthorized.
8.6.2.2 The contractor
shall, no later than August 1, 2021:8.6.2.2.1 Complete
a clinical necessity review on every TP’s recommended goals, targets, progress,
and hours (see paragraph 8.7.1 for TP requirements) prior to
issuing any six month treatment authorization for ABA services.
8.6.2.2.2 .Deny and return
TPs containing exclusions as defined in paragraph 8.10.
8.6.2.2.3 Work with the
ABA provider to revise the TP to address any findings requiring resolution
prior to authorization of that TP.
8.6.2.3 Authorizations
issued prior to August 1, 2021, and their associated claims remain
active until the next authorization period. Revisions to the existing
authorizations are not permitted.
8.6.2.4 The contractor
shall complete 100% clinical necessity reviews of ABA services for
all compliant TPs within the five business days for authorization
processing standards.
8.6.3 Subsequent Referrals
and Authorizations8.6.3.1 If ongoing services
are clinically indicated, prior to the expiration of each six-month treatment
authorization period, as early as 60 calendar days in advance and
no later than 30 calendar days in advance, a re-authorization for
ABA services should be requested by the ABA provider for the next
six months from the contractor. Should the ABA provider submit the
reauthorization request less than 30 calendar days in advance of
the expiring authorization, the ABA provider is at risk for non-reimbursable
ABA services until the new authorization is issued if the existing
authorization expires prior to the approval of the next authorization.8.6.3.1.1 The contractor
shall not back date late submissions.
8.6.3.1.2 The request for
re-authorization must be supported by submission of the every six month
ABA reassessment and TP update that includes documentation of progress.
Outcome measures must be completed/submitted prior to issuing the
next six-month treatment authorization.
8.6.3.1.3 The contractor
shall complete a clinical necessity review of the documentation submitted
every six months, including Pervasive Developmental Disorder Behavior
Inventory (PDDBI) results and other treatment services the beneficiary
is receiving.
8.6.3.1.4 The contractor
shall work with the ABA provider to revise the ABA TP if the beneficiary is
not making clinically sufficient progress as shown on the outcome
measures prior to authorization.
8.6.3.1.5 The contractor
shall issue subsequent treatment authorizations that meet the requirements
set forth in this Section.
8.6.3.2 Every two years
from the initial verified referral date, a new referral, with level
of support, is required and must be
submitted for ongoing ABA services. The new referral is not a new
diagnostic evaluation, but rather a review of the beneficiary’s
progress, and update to the DSM criteria to include an update for
the level of supports required. These subsequent referrals may be
accepted up to six months in advance.
8.6.4 Outcome MeasuresFor all TRICARE
eligible beneficiaries receiving ABA services, all outcome measures
must be completed and reported, using norm-referenced, valid, and
reliable evaluation tools prior to issuing the treatment authorization.
For the purpose of the ACD, all outcome measures completed by ABA
providers are considered an indirect service and to be completed
under CPT code 97151 (see paragraph 8.11.6.2.1). Submission of all outcome
measure results must include the full publisher print report or
hand-scored protocol and summary score sheet(s). Imbedding scores
within the treatment plan or other clinical documents is insufficient
to meet the submission requirements.
8.6.4.1 PDDBI, Current
Edition8.6.4.1.1 This outcome
measure must be completed using the standard or extended form at baseline
and every six-months thereafter by the authorized ABA supervisor.
The name of the respondent and relation to the beneficiary is required
on all forms. Only the Parent Form is required at baseline. The
Parent Form and the Teacher Form must be completed and submitted
every six-months thereafter to align with the TP submission and
reauthorization. The PDDBI must be completed and submitted by their
respective deadlines. The Teacher Form must be completed by only
the BCBA/BCBA-D. Responsibility for the completion of the Teacher
Form by the BCBA/BCBA-D cannot be delegated. The Domain/Composite
Score Summary Table, including all domain and composite scores,
must be submitted to the contractor.
8.6.4.1.2 The contractor
shall ensure all Domain and Composite scores are received, valid,
and reported in the corresponding DD Form 1423, Contract Data Requirements
List (CDRL) located in Section J of the applicable contract.
8.6.4.2 Vineland Adaptive
Behavior Scales-3 (Vineland-3) (or Current Edition)The Parent Form,
the Interview Form (if completed by a TRICARE-authorized provider),
or the Teacher Form are required. The name of the respondent and
relation to the beneficiary is required on all forms. This measure
is required at baseline and every year thereafter. See definition, paragraph 11.32.
8.6.4.3 Social Responsiveness
Scale, 2nd Edition (SRS-2) (or Current Edition)The Parent Form
is required. The name of the respondent and relation to the beneficiary
is required on all forms. This measure is required at baseline and
every year thereafter. See definition, paragraph 11.29.
8.6.4.4 Parenting Stress
Index, Fourth Edition (PSI-4) (or Current Edition) Required as of August
1, 2021The
Short Form is required. The name of the respondent and relation
to the beneficiary is required. This measure is required at baseline
and every six-months thereafter. See definition, paragraph 11.25.
8.6.4.5 Stress Index
for Parents of Adolescents (SIPA) Required as of August 1, 2021The Profile Form
is required. The name of the respondent and relation to the beneficiary
is required. This measure is required at baseline and every six-months
thereafter. See definition, paragraph 11.30.
8.6.4.6 The contractor
shall make available to treating providers of ACD beneficiaries
all available outcome measures scores.
8.6.5 Medical Team
Conference8.6.5.1 Medical team
conferences include face-to-face participation (in-person or via
a compliant telehealth platform) by a minimum of three Qualified
Health Care Professionals (QHPs) from different specialties or disciplines
(each of whom provides direct services to the beneficiary), with
or without the presence of the beneficiary/family member(s), who
convene to collaborate or discuss a specific beneficiary case. The
participants are actively involved in the development, revision,
coordination, and implementation of health care services clinically
necessary for the beneficiary. See paragraph 8.11.6.2.7 for requirements
for using this CPT code. Though not required, family member/beneficiary participation,
as appropriate, is recommended.
8.6.5.2 The ASN shall
participate in these medical team conference discussions when an
ASN is assigned per paragraph 6.0.
8.6.5.3 Participants
must document their participation in the team conference as well
as their contributed information and subsequent treatment recommendations
in their medical documentation records.
8.6.5.4 No more than
one individual from the same specialty may report this code at the
same encounter.
8.6.5.5 Non-health care
providers, i.e., school officials or an IEP meeting, are not counted
as participants for this team conference. These individuals may
be invited to participate in the medical team conference; however,
these individuals are ineligible for reimbursement. Non-health care providers
do not count toward the minimum of three QHPs for utilization of
this service.
8.7 ABA Service DocumentationAll ABA documentation
must be completed according to the following:
8.7.1 ABA assessments
and TP documentation (completed by the authorized ABA supervisor) must
include:8.7.1.1 Identifying InformationThe beneficiary’s
name, date of birth, date the initial ABA assessment and initial
ABA TP were completed, the beneficiary’s DoD Benefit Number (DBN)
or sponsor’s Social Security Number (SSN), and the name of the referring
provider;
8.7.1.2 Reason for ReferralThe ABA TP and
TP updates must include the ASD diagnosing/referring provider’s
ASD diagnosis, to include symptom severity level/level of support
required according to DSM-5 ASD criteria.
8.7.1.3 Background InformationBackground and
history to include, but is not limited to, information that clearly
reports the beneficiary’s condition, diagnoses, medical co-morbidities
(to include over-the-counter (OTC) medications), family history,
school enrollment status, number of hours enrolled in school, the
number of hours receiving other support services such as OT, PT,
and SLP, documentation of the age of the child and year of the initial
ASD diagnosis, and how long the beneficiary has been receiving ABA
services.
8.7.1.4 Summary of Assessment
ActivitiesThe
TP must include objectively measured behavioral excesses and deficits
that impede the beneficiary’s safe, healthy, and independent functioning
in all domains applicable (language, development, social communication,
and clinical adaptive behavior skills). This assessment may indicate
a need for a behavior intervention plan (paragraph 11.6)
for each target behavior excess and deficit. The TP shall include
the list of assessments administered. The initial ABA assessment
must include the PDDBI Parent Form Domain/Composite Score Summary
Table.
8.7.1.5 TP GoalsThe ABA TP must
clearly define measurable targets in all relevant DSM-5 (or most
current edition) symptom domains, including parent/caregiver goals
as identified in the initial assessment, and objectives and goals
individualized to the strengths, needs, and preferences of the beneficiary
and his/her family members. The ABA TP goals must address core symptoms
of ASD:
• Social Communication
and Social Interaction Behavior (to include restricted, repetitive,
and/or stereotypical patterns of behavior, interests, and/or activities);
• Restrictive/Repetitive/Stereotypical
Patterns of Behavior (i.e., stereotyped/ repetitive motor movements,
insistence on sameness, inflexible adherence to routines, highly
fixated interests, hyper/hypo-activity to sensory input).
8.7.1.5.1 Goals must be
measurable, objective, achievable, developmentally appropriate,
and clinically significant.
8.7.1.5.2 Goals must be
described as follows:
• Objective, baseline
and ongoing measurement levels for each target behavior/symptom
in terms of frequency, intensity, and duration;
• A description
of treatment interventions and techniques specific to each of the
targeted behaviors/symptoms;
• Identify the
objective measures of assessment for each goal specified; and
• Functional goals
must be specific to the beneficiary, objectively measurable within
a specified time frame, attainable in relation to the beneficiary’s
prognosis and developmental status, relevant to the beneficiary
and family, and directly related to the core symptoms of ASD as
defined by the DSM.
8.7.1.5.3 The
ASN, when assigned, shall ensure goals typically treated by specialty
providers are identified and addressed in the CCP. When
developing goals for beneficiaries with suspected or diagnosed co-morbid
medical or behavioral health conditions, the authorized ABA supervisor
must coordinate with the appropriate skilled and licensed professionals
in order to assess the most appropriate treatment intervention.
In order for the authorized ABA provider to address co-morbid condition
targets, documentation on the TP must demonstrate coordination with
the appropriate medical specialty services, to include the name
of the consulting provider. For example:8.7.1.5.3.1 A beneficiary
with a co-morbid diagnosis of a motor disorder who has TP goals addressing
speech or motor skill development would require coordination with
SLP, OT, or PT as appropriate.
8.7.1.5.3.2 A beneficiary
with a co-morbid diagnosis of anxiety disorder would require coordination
with the appropriate behavioral health provider.
8.7.1.5.3.3 A beneficiary
with a feeding disorder would require coordination with the appropriate medical
provider to include but not limited to: physician, dietitian, OT,
or SLP.
8.7.1.6 TP ABA Services
RecommendationsTP recommendations
of units of ABA services are based on a combination of: the DSM-5
(or most current edition) symptom domains and levels of support
required per DSM-5 ASD criteria, results of outcome measures (for
TP updates), and the capability of the beneficiary to participate
actively in ABA services. A recommendation for the number of hours,
submitted as units, of all relevant ABA services (see CPT codes
for all covered services) under the ACD must be included. If recommended
units (hours) are not being rendered, then an explanation (i.e.,
family availability, family preference, BT turnover, etc.) is required
to be documented in the subsequent TP.
8.7.1.6.1 A recommendation
for the number of monthly hours, submitted as units, and measurable
objectives and goals for parent/caregiver treatment guidance on
implementation of selected treatment protocols with the beneficiary
at home and in other settings where applicable is required. Participation
by the parent(s)/caregiver(s) is required, and re-authorization
for ABA services is contingent upon their involvement. If parent(s)/caregiver(s)
participation is not possible, the TP must document the reasons
for non-participation (i.e., the parent/caregiver is deployed, is
physically unable to deliver the ABA services, etc.). All attempts
to mitigate the lack of involvement/participation must be documented
by the ABA provider. Implementation of the TP should begin with
parent guidance sessions (CPT code 97156 or 97157), especially if
other ABA services are delayed because the authorized ABA supervisor
is hiring a new BT for the TP.
8.7.1.6.2 TP must identify
recommended units for each requested CPT code including the location
of rendered services.
8.7.1.6.3 Documentation
of parent/caregiver engagement and implementation of the ABA TP must
be included as a required TP goal that is reassessed every six months
during the ABA TP update. Reasons for lack of/inability for parental
involvement must be documented.
8.7.1.6.4 Recommendation
for continued ABA services (if continuation is indicated) to include
a recommendation for the number of weekly units of one-on-one ABA
services, including documentation of clinical necessity if additional
units are required.
8.7.1.7 TP ProgressABA reassessments
and TP updates must document the evaluation of progress for each
current behavior target identified on the initial ABA TP and prior
TP updates. Documentation of the ABA reassessment and TP update
must be completed every six months and include all of the following
but not limited to (the contractor may request additional information
based on best practices):
8.7.1.7.1 Date and time
the reassessment and TP update was completed.
8.7.1.7.2 ABA provider
conducting the reassessment and TP update.
8.7.1.7.3 Evaluation of
progress on each treatment target (i.e., Met, Not Met, Discontinued).
8.7.1.7.4 Description of
progress toward short and long-term treatment goals for the identified targets
in each domain utilizing either graphic representation of ABA TP
progress or an objective measurement tool consistent with the baseline
assessment. Documentation should identify interventions that were
ineffective and required modification of the TP. TP updates must
document TP modifications that were the result of the outcome evaluations.
8.7.1.7.5 Revisions to
the ABA TP must include identification of new behavior targets,
objectives, and goals, to include TP modifications based on the
cumulative six month assessment of the PDDBI and other outcome measures
evaluation.
8.7.1.7.6 The contractor
shall engage the authorized ABA supervisor to review the TP if no progress
has been made and the provider must incorporate revisions to the
individual TP to address the lack of progress.
8.7.1.8 SignaturesThe ABA TP and
TP updates must contain signatures by the authorized ABA supervisor,
and the parent/caregiver to ensure the parent/caregiver is fully
cognizant of the care being provided to their child.
8.7.1.9 The reassessments,
to include the completion of the PDDBI, and TP updates are required every
six months (one assessment for each authorization period) and must
be dated as being conducted during that time frame. Reassessments
must be completed and submitted no later than 30 calendar days prior
to the end of the current authorization for review for re-authorization.
Any delay in submission of the ABA reassessment and TP updates may
delay the subsequent authorization for ABA services.
8.7.2 Progress Note
DocumentationIn addition to
TPM, Chapter 1, Section 5.1, “Requirements for
Documentation of Treatment in Medical Records,” progress note documentation
must contain the following documentation elements for each CPT code
session:
8.7.2.1 Beneficiary’s
full name (not initials);
8.7.2.2 The date and
time of session to include start and end time;
8.7.2.3 Location of rendered
services;
8.7.2.4 Length of session;
8.7.2.5 A legible name
of the rendering provider, to include provider type/level;
8.7.2.6 A signature of
the rendering provider with the date signed;
8.7.2.7 Name of authorized
ABA supervisor;
8.7.2.8 Name of all session
participants (excluding other beneficiaries in CPT codes 97157 and 97158);
8.7.2.9 A notation of
the patient’s current clinical status evidenced by the patient’s
signs and symptoms;
8.7.2.11 A statement summarizing
the techniques attempted during the session;
8.7.2.12 Narrative description
of the response to treatment, the outcome of the treatment, and
the response to significant others (group session notes must contain
individualized responses to treatment);
8.7.2.13 A narrative statement
summarizing the patient’s degree of progress towards the treatment goals;
8.7.2.14 Each section
of the progress note documentation must be individualized to the
beneficiary and each session, and
8.7.2.15 Effective January
1, 2019, the final product for CPT code 97151 must be in the format
of a TP. However, all encounters using CPT code 97151 must document
a progress note. This progress note must include, but is not limited
to:
• The date and
time of session to include start and end time;
• Length of assessment
session;
• A legible name
of the rendering provider, to include provider type/level;
• A signature of
the rendering provider;
• Content of the
session to include what activity, measures, observations were administered
during the assessment.
8.8 Discharge Planning8.8.1 The following
discharge criteria are established to determine if/when ABA services
are no longer appropriate:8.8.1.1 Loss of eligibility
for TRICARE benefits as defined in 32
CFR 199.3.
8.8.1.2 The authorized
ABA supervisor, the contractor, or the family has determined one
or more of the following:
• The patient has
met ABA TP goals and is no longer in need of ABA services.
• The patient has
made no measurable progress toward meeting goals identified on the
ABA TP after successive progress review periods and repeated modifications
to the TP.
• ABA TP gains
are not generalizable or durable over time and do not transfer to
the larger community setting after successive progress review periods
and repeated modifications to the TP.
• Recommended by
the contractor through the clinical necessity review process.
• The patient can
no longer participate in ABA services (due to medical problems,
family problems, or other factors that prohibit participation).
8.8.1.3 Termination of
services if the diagnosing/referring provider or PCM either changes
the diagnosis, or does not believe continued ABA services are clinically
necessary.
8.8.2 Termination of
ABA services under any circumstance must not occur abruptly by the authorized
ABA supervisor. All termination plans must be at least 45 calendar
days prior to the termination of services.8.8.2.1 The contractor
shall work with the ABA provider to ensure a smooth transition when services
are determined to no longer be clinically necessary or otherwise
need to be terminated on short notice.
8.8.2.2 The contractor
shall, should ABA services be terminated abruptly by the authorized
ABA supervisor, report the authorized ABA supervisor to the appropriate
credentialing/licensure board.
8.8.3 The contractor
shall, if the clinical necessity review determines direct ABA services,
either one to one or group, are no longer clinically necessary,
approve parent training services to fade an ABA service program
for one six-month authorization.
8.8.4 Discharge planning
must be documented in every initial TP, every updated TP, and at termination
of services.
8.8.5 A discharge summary
from the treating authorized ABA supervisor is required for all beneficiaries
whose ABA services are terminated to include the reason for termination.
Discharge summary writing is not a reimbursable service as this
is an indirect activity (report/summary writing).
8.9 ABA Quality Monitoring
and Oversight8.9.1 This demonstration
is subject to existing program requirements for quality monitoring
and oversight.
8.9.2 The contractor
shall conduct, on an annual basis, an audit, which must include
a minimum of 30 records for each ASCP/Sole provider group that include
a combination of administrative records (paragraph 8.9.7) and medical
documentation (paragraph 8.9.8) reviews and one medical team conference
progress note.
8.9.3 The TOP and USFHP
contractor shall conduct, on an annual basis, an audit, which must include
a minimum of 10% of records for each ASCP/Sole provider group that
include a combination of administrative records (paragraph 8.9.7)
and medical documentation (paragraph 8.9.8) reviews and one medical team
conference progress note.
8.9.4 The contractor
shall conduct outreach and education to ACSP/Sole Provider groups
with inconsistencies or errors identified in the annual audits.
8.9.5 The contractor
shall initiate progressively more severe administrative action, commensurate
with the seriousness of the identified problems, and consistent
with Chapter 13 and 32 CFR
199.9.
8.9.6 The contractor
shall recoup all claims determined to be insufficient for claims
payment.
8.9.7 Administrative
Claims Review8.9.7.1 The contractor
shall target detection and prevention efforts of services that pose
the greatest risk of fraud and abuse to the TRICARE program and
beneficiaries, to include a review of suspect billing practices
and document risks to determine improper payments in the ACD program.
8.9.7.2 The contractor
shall review ACD claims which may include at a minimum, but are
not limited to:
• High-dollar,
erratic, or inconsistent billing and coding patterns.
• Changes in billing
frequency.
• Concurrent billing
(i.e., billing for two services at the same time).
• Misrepresentation
of provider (i.e., filing for a non-rendering provider or non-authorized
provider).
• Claims patterns
of “impossible days” (provider’s total claims exceed 12 hours per
any given calendar day).
• Patterns of high
claim error rates.
8.9.7.3 The contractor
shall provide education to each ACSP/Sole provider groups if suspect
billing patterns are identified to address the findings and corresponding
program requirements.8.9.7.3.1 The contractor
shall, no later than 180 calendar days following education, conduct
a post-payment review of the Sole Provider or ACSP provider groups
to determine if suspect billing patterns have improved.
8.9.7.3.2 The contractor
shall, if suspect billing has not improved, refer the Sole Provider
or ACSP provider group to the contractor’s Program Integrity department
for review.
8.9.8 Medical Records
Documentation Review - Clinical and Non-Clinical Documentation8.9.8.1 The contractor
shall review ABA session documentation notes to ensure, include
at a minimum, but not limited to:
• Compliance with
the requirements set forth in paragraph 8.7.2.
• Compliance with
ABS approved CPT codes per paragraph 8.11.6.
• Sufficient documentation
to justify a medical record.
• No billing for
office supplies to include therapeutic supplies.
• No billing for
ABA services using aversive techniques to include restraints (even
if billed using a covered CPT code).
• Group ABA services
are not billed as authorized one-on-one ABA services.
• No billing for
educational or vocational ABA services, and other non-medical services
such as changing of diapers or billing for services while the beneficiary
is sleeping.
• See exclusions
(paragraph 8.10)
for additional activities that are prohibited.
8.9.8.2 Clinical content
reviews shall be completed by clinical staff.
8.9.8.3 The contractor
shall educate and monitor providers with identified insufficiencies
in clinical documentation for a minimum of six months but not later
than 12 months.
8.9.8.5 The contractor
shall place any ABA provider who has not improved after a minimum
of six months, but no later than 12 months of education and monitoring
on pre-payment review.
8.9.9 New ACSP/Sole
Provider Review8.9.9.1 The contractor
shall monitor all new ACSP/Sole providers entering the ACD program
after July 1, 2021 for administrative and medical records documentation
review.
8.9.9.2 The contractor
shall conduct a probe audit sample (see Chapter 13, Section 3, paragraph 3.2.1) following
180 days of participation in the program to review clinical documentation
and claims submission for consistency with program requirements.
8.9.9.3 The contractor
shall share results of the probe audit with the new ACSP/Sole Provider,
and provide education to address inconsistencies with program requirements.
8.9.10 Annual ReviewsThe contractor
shall conduct an annual audit of a statistically valid number of
providers, to include collecting proof of documentation (either
through source verification or actual document), to ensure ABA providers
meet the requirements set forth in paragraphs 8.2 through 8.4.
8.10 ExclusionsThe contractor
shall not reimburse for, to include but not limited to:
8.10.1 Training of BTs.
8.10.2 ABA Services
for any other diagnoses other than ASD.
8.10.3 ABA services
are not covered for symptoms and/or behaviors that are not part
of the core symptoms of ASD (i.e., impulsivity due to ADHD, reading
difficulties due to learning disability, excessive worry due to
anxiety disorder, etc.).
8.10.4 Billing for e-mails
and phone calls.
8.10.5 Billing for driving
to and from ABA services appointments (i.e., beneficiary’s house,
clinic, or other locations). Mileage/time traveling is not to be
billed to the TRICARE program.
8.10.6 Billing for report
writing outside of what is included in the assessment code (CPT
code 97151).
8.10.7 Billing for office
supplies or therapeutic supplies (i.e., binders, building blocks,
stickers, crayons, etc.).
8.10.8 Billing for ABA
services provided remotely through Internet technology or through telemedicine/telehealth
(except as allowed under paragraph 8.11.6.2.4.9).
8.10.9 Billing for asynchronous
telehealth services.
8.10.10 Rendering and
billing for ABA services involving any aversive techniques or restraints.
8.10.11 Billing for services
outside of the home, clinic, office, school, or telehealth. Certain community
settings such as sporting events, camps, and other setting as determined
by the contractor are also excluded. Any location not listed must
be reviewed and approved by the contractor.
8.10.12 Billing for ABA
services while the beneficiary is at another medical appointment
to include another family member’s appointment.
8.10.13 Educational/academic
and vocational rehabilitation. All educational/academic and vocational
goals must be removed from the TP prior to approval by the contractor.
8.10.14 Educational ABA
services, such as services typically provided through a school curriculum.
8.10.15 TRICARE ABA services
are not authorized in the school setting as a shadow, aid, or support to
the beneficiary. ABA services in the school setting are limited
to the role of the BCBA who is targeting a specific behavior excess
or deficit and is for a limited duration. Any ABA services requested
for the school setting must be specifically preauthorized in the
TP for use in the school setting.8.10.15.1 The contractor
shall authorize and reimburse only CPT code 97153 rendered by the authorized
ABA supervisor (not delegated to the assistant or BT) in the school
setting.
8.10.15.2 After May 1,
2021, authorizations with approved BT services in the school setting
will run through the end of the current authorization. However,
no new authorizations for BTs in school setting will be approved
after May 1, 2021.
8.10.16 ABA services
for a beneficiary that are written in a beneficiary’s IEP and required
to be provided without charge by the local public education facility
in accordance with the Individuals with Disabilities Act or other
applicable laws and regulations. In order for ABA services to be
authorized within a school setting, the parent/caregiver must voluntarily
provide the IEP (or equivalent for non-public school placement)
in order for the contractor to make an appropriate determination.
8.10.17 Billing for school
tuition.
8.10.18 Autism schools
are not TRICARE authorized providers. If an Autism school has a
clinic setting as part of their offered services, the clinic must
have a separate tax ID number.
8.10.19 Goals targeting
functional/activities of daily living (ADLs) skills (see 32
CFR 199.2 definitions of ADLs) are excluded. However,
the principles of ABA (i.e., backward chaining, schedules of reinforcement,
etc.) may be targeted as a goal of parent/caregiver guidance to
introduce how the parent should teach ADLs outside of ABA services
rendered by an ABA provider.
8.10.20 Rendering or
billing for custodian, personal care, and/or child care.
8.10.21 Durable Equipment
(DE) whose safety and efficacy have not been established as described in 32
CFR 199.4.
8.10.22 Billing of direct
and indirect supervision of BTs and assistant behavior analysts.
8.10.23 Billing of ABA
evaluation or intervention services provided by a clinic or agency
owned by the beneficiary’s immediate family member (e.g., biological,
adoptive, or foster parents, guardians, court-appointed managing
conservators, other family members by birth or marriage).
8.10.24 Billing an ABA
evaluation or intervention services provided directly by the beneficiary’s responsible
adult (e.g., biological, adoptive, or foster parents, guardians,
court-appointed managing conservators, other family members by birth
or marriage). Billing for rendered ABA services by family members
is considered a conflict of interest and therefore may be subject
to the Civil Money Penalties Law (CMPL).
8.10.25 Under the ACD,
concurrent billing is excluded for all ABS Category I CPT codes
except when the family and the beneficiary are receiving separate
services and the beneficiary is not present in the family session.
8.10.26 Rendering or
billing for any two ABA providers at the same time.
8.10.27 Rendering or
billing any interventions considered psychotherapy to include but
not limited to: Cognitive Behavior Therapy, Acceptance and Commitment
Therapy, Prolonged Exposure, group psychotherapy, etc.
8.10.28 ABA providers
rendering and billing for non-ABA services.
8.11 Reimbursement8.11.1 Network and non-network
provider claims for ABS CPT codes must be submitted electronically.
8.11.2 The contractor
shall pay all claims by electronic funds transfer.
8.11.3 The contractor
shall reimburse claims using the ABS CPT codes. These codes apply
to the provision of ABA services rendered by ACD approved providers
in all authorized settings (clinic, school, home, TH, or certain
community setting).
8.11.4 The contractor
shall ensure paid claims identify the name of the rendering provider
for each ABA service delivered, to include the NPI (see paragraph 8.2.1 for
NPI requirements) of the rendering provider per unique claim line
(i.e., every session must be identified as its own unique line on any
claim submitted).
8.11.5 Application of
Health Insurance Portability and Accountability Act (HIPAA) taxonomy designation.
All claims for ABS CPT codes must include the HIPAA taxonomy designation
of each provider type. Each provider on a claim form must be identified
by the correct HIPAA taxonomy designation. The designations to be
used are:
• 103K00000X Behavior
Analyst for master’s level and above;
• 106E00000X Assistant
Behavior Analyst;
• 106S00000X Behavior
Technician; or
• Other appropriate
HIPAA taxonomy based on license/certification
8.11.6 ABS Approved
CPT CodesThe
contractor shall only authorize ABS codes for only ABA providers
under the demonstration authority using a special processing code.
8.11.6.1 Healthcare Common
Procedure Coding System (HCPCS) T1023 - Outcome Measures Submitted
By BCBA/BCBA-D (For authorizations issued prior to August 1, 2021)This code is
used by only the BCBA/BCBA-D for the purpose of reimbursement for
submission of required data for the ACD outcomes measures (Vineland-3,
SRS-2, and PDDBI). See paragraphs 8.6.4.2 and 8.6.4.3 for
submission requirements and required data elements. For outcome
measures administered via telehealth, claims must include the modifier GT or 95.
Additionally, all approved ABA services provided via telehealth
must adhere to state laws governing telehealth services.
8.11.6.2 Category I CPT
Codes (For Dates of Service Beginning January 1, 2019)Concurrent billing
is excluded for all ACD Category I CPT codes except when the family
and the beneficiary are receiving separate services and the beneficiary
is not present in the family session. Existing authorization prior
to August 1, 2021, run through the end of their current authorization period
end date. The next authorization must incorporate the changes set
forth below.
8.11.6.2.1 CPT Code 97151
- Behavior Identification Assessment8.11.6.2.1.1 The initial ABA
assessment, ABA TP development, and the ABA reassessments and TP updates,
conducted by the authorized ABA supervisor during a one-on-one encounter
with the beneficiary and parents/caregivers, must be coded using
CPT code 97151, “Behavior Identification Assessment.”
8.11.6.2.1.2 Elements of ABA
assessment include:
• One-on-one observation
of the beneficiary (must be completed in person, face-to-face).
• Obtaining a current
and past behavioral functioning history, to include functional behavior
analysis if appropriate.
• Reviewing previous
assessments and health records.
• Conducting interviews
with parents/caregivers to further identify and define deficient
adaptive behaviors.
• Administering
assessment tools, to include the administration of the PDDBI.
• Interpreting
assessment results.
• Development of
the TP, to include design of instructions to the supervised assistant
behavior analysts and/or BTs (under the ACD).
• Discussing findings
and recommendations with parents/caregivers.
• Preparing the
initial ABA assessment, semi-annual ABA re-assessment (to include
progress measurement reports), initial ABA TP and semi-annual ABA
TP updates.
8.11.6.2.1.3 This code is
intended for reporting initial assessments and reassessments by
the authorized ABA supervisor once every six months.
8.11.6.2.1.4 CPT code 97151
is a timed code (per 15 minutes), meaning this code is reimbursed
per authorized units provided by an authorized ABA supervisor (or
as delegated to an assistant behavior analyst).
8.11.6.2.1.5 CPT code 97151
may not be conducted via telehealth.
8.11.6.2.1.6 The contractor
shall, for services rendered prior to August 1, 2021, authorize
CPT code 97151 for 16 units (four hours) for the initial request
of ABA services to complete an initial ABA assessment and TP development.
8.11.6.2.1.7 The contractor
shall, for services rendered on a new or approved TP on or after
August 1, 2021, authorize CPT code 97151 for up to 32 units (eight
hours) for the initial request of ABA services to complete an initial
ABA assessment and TP development (to include administration, scoring,
and review of the PDDBI). CPT code 97151 must be used within 14
calendar days of the first date of service for CPT code 97151 and
is a use or lose concept.
8.11.6.2.1.8 The contractor
shall, after the initial assessment, authorize CPT code 97151 for
up to 24 units (six hours) for reassessments and TP updates for
every subsequent authorization.
8.11.6.2.1.9 The contractor
may authorize one additional unit of indirect CPT code 97151 per measure
for providers that complete the Vineland, the SRS, and the PSI/SIPA,
when prior authorized.
8.11.6.2.1.10 A second opinion
authorization (for 32 units of CPT code 97151) may be permitted
to overlap with another approved authorization. Two “ongoing” treatment
authorizations of direct service (CPT codes 97153, 97155, 97156,
97157, and 97158) are not permitted.
8.11.6.2.2 CPT Code 97153
- Adaptive Behavior Treatment by Protocol8.11.6.2.2.1 The code, CPT
code 97153, must be used for direct one-on-one ABA services delivered per
ABA TP protocol to the beneficiary. Direct one-on-one ABA services
are most often delivered by the supervised BT or assistant behavior
analyst under the tiered delivery model, but they can also be delivered
by the authorized ABA supervisor under the sole provider or tiered
delivery model.
8.11.6.2.2.2 CPT code 97153
is a timed, 15 minutes, increment code.
8.11.6.2.2.3 The contractor
shall not, for new and approved TPs on or after August 1, 2021, authorize
CPT code 97153 for greater than 32 units (eight hours) per day or
160 units (40 hours) per week without a clinical necessity review
for determination.
8.11.6.2.2.4 CPT code 97153
may not be conducted via telehealth.
8.11.6.2.3 CPT Code 97155
- Adaptive Behavior Treatment by Protocol Modification8.11.6.2.3.1 The code, CPT
code 97155, is used by authorized ABA supervisors (or as delegated
to an assistant behavior analyst) for direct one-on-one time with
one beneficiary to develop a new or modified protocol. This code
may also be used to demonstrate a new or modified protocol to a
BT with the beneficiary present. The focus of this code is the addition
or change to the protocol.
8.11.6.2.3.2 CPT code 97155
is a timed, 15-minute, increment code.
8.11.6.2.3.3 CPT code 97155
must be completed at least one time per month by the authorized
ABA supervisor.
• The contractor shall complete
a post-claims payment review, and if this requirement is not met,
a 10% penalty on all ABA claims for that beneficiary shall be recouped
for the entire six-month authorization.
8.11.6.2.3.4 The contractor
shall not authorize for greater than eight units (two hours) per
day.
Note: Team meetings
and supervision of any type are not reimbursable under CPT code
97155.
8.11.6.2.4 CPT Code 97156
- Family Adaptive Behavior Treatment Guidance8.11.6.2.4.1 It is important
that family members or caregivers learn to apply the same treatment protocols
to reduce maladaptive behaviors and reinforce appropriate behavior.
It is expected that as families become more capable of providing
treatment protocols or as beneficiary symptoms improve, the amount
of one-on-one ABA services provided by an ABA provider will decrease.
Unless therapeutically contraindicated, the family and/or guardian
must actively participate in the continuing care of the beneficiary.
Documentation of contraindication must be documented in the TP for continued
eligibility for the ACD.
8.11.6.2.4.2 The code, CPT
code 97156, is used by the authorized ABA supervisor for guiding
the parents/caregivers to utilize the ABA TP protocols to reinforce
adaptive behaviors. Authorized ABA supervisors may delegate family/caregiver
guidance to assistant behavior analysts working under their supervision
but only the authorized ABA supervisor may bill for this service
using this code.
8.11.6.2.4.3 The beneficiary
is not required to be present for the parent/caregiver sessions; however,
presence of the beneficiary is encouraged.
8.11.6.2.4.4 CPT code 97156
is a timed, 15-minute, increment code.
8.11.6.2.4.5 The contractor
shall not authorize CPT code 97156 for greater than eight units
(two hours) per day.
8.11.6.2.4.6 CPT code 97156
may be used only in a home or clinic/office-based setting. School settings
are prohibited.
8.11.6.2.4.7 For new and approved
TPs on or after August 1, 2021, a minimum of six parent/caregiver
sessions are required every six months. These six sessions may include
CPT codes 97156, 97157, or a combination of the two.8.11.6.2.4.7.1 The contractor
shall work with the family and the provider to resolve barriers
for parent/caregiver sessions. The first session shall be within
the first 30 calendar days of the treatment authorization.
8.11.6.2.4.7.2 The contractor
shall not, if this requirement is not met for two consecutive authorization
periods, renew ABA services for a subsequent authorization period
for that beneficiary.
8.11.6.2.4.8 For new and approved
TPs on or after August 1, 2021, parent/caregiver sessions for CPT code
97156 may be conducted via telehealth only after the first six-month
authorization period per authorized provider. Additionally, all
services provided via telehealth must adhere to state laws governing
telehealth services.
8.11.6.2.4.9 For new and approved
TPs on or after August 1, 2021, parent/caregiver sessions conducted
remotely must include the GT and 95 modifier
when submitting claims. Remote Family Adaptive Behavior sessions
must be in compliance with TPM, Chapter 7, Section 22.1.
8.11.6.2.5 CPT Code 97157
- Multiple-Family Group Adaptive Behavior Treatment Guidance (Beginning
August 1, 2021)8.11.6.2.5.1 It is important
that parents or caregivers learn to apply the same treatment protocols
to reduce maladaptive behaviors and reinforce appropriate behavior.
This code is used by the authorized ABA supervisor (or as delegated
to an assistant behavior analyst) for guiding the parents/caregivers
to utilize the ABA TP protocols. This code is to be used for identifying
behavior excesses and deficits, and teaching parent(s)/caregiver(s)
to utilize treatment protocols designed to reduce maladaptive behaviors
and/or skill deficits in a group setting. This code is not authorized
for a support group or group psychotherapy. The beneficiary should
not be present for the multi-family parent/caregiver sessions.
8.11.6.2.5.2 Groups must not
exceed eight participants (i.e., each individual parent/caregiver,
or pair of parents/caregivers, counts as one participant and only
one claim may be filed per beneficiary).
8.11.6.2.5.3 The contractor
shall recoup all claims for groups that exceed eight participants.
8.11.6.2.5.4 CPT code 97157
may only be used in a clinic/office-based setting.
8.11.6.2.5.5 CPT code 97157
may not be conducted via telehealth.
8.11.6.2.5.6 CPT code 97157
is a timed, 15-minute, increment code.
8.11.6.2.5.7 The contractor
shall not authorize CPT code 97157 for greater than six, 15-minute
units (1.5 hours) per day.
8.11.6.2.6 CPT Code 97158
- Group Adaptive Behavior Treatment by Protocol Modification (Beginning
August 1, 2021)8.11.6.2.6.1 The code, CPT
code 97158, is used by the authorized ABA supervisor to beneficiaries
in a group setting. The focus of the skills group will be to address
specific measurable goals to address targeted social deficits and
problem behaviors utilizing various techniques (e.g., modeling,
rehearsing, corrective feedback). The authorized ABA supervisor
must adjust the level of assistance (e.g., prompts) given to each
member based on their skill level and ongoing progress in the group.
8.11.6.2.6.2 CPT code 97158
must only be used when the beneficiary’s TP identifies goals targeted for
generalization of mastered skills. As beneficiaries demonstrate
generalized skills, it would be expected that one to one services
decrease as group services increase, then ABA services fade altogether.
8.11.6.2.6.3 Groups must not
exceed eight participants.
8.11.6.2.6.4 The contractor
shall recoup all claims for groups that exceed eight participants.
8.11.6.2.6.5 CPT code 97158
may not be conducted via telehealth.
8.11.6.2.6.6 CPT code 97158
is a timed, 15-minute, increment code.
8.11.6.2.6.7 The contractor
shall not authorize CPT code 97158 for greater than six, 15-minutes units
(1.5 hours) per day.
8.11.6.2.7 CPT Codes 99366
and 99368 Medical Team Conference (Beginning August 1, 2021)8.11.6.2.7.1 CPT codes 99366
and 99368 are permitted only via face-to-face either in person or through
the telehealth platform. Telephone-only is not permitted for providers.
8.11.6.2.7.2 CPT code 99366
Medical team conference with patient by healthcare professional.
8.11.6.2.7.3 CPT code 99368
Medical team conference without patient by health care professional.
8.11.6.2.7.4 The following
criteria must be met to report and be reimbursed for the medical
team conference codes:
• A minimum of
three QHPs from different specialties or disciplines who provide
direct care to the patient must participate in the reported team
conference.
• No more than
one individual from the same specialty may report CPT codes 99366
and 99368 at the same encounter.
• Reporting participants
must be present for the entire medical team conference.
• Reporting participants
must have performed face-to face evaluations or treatments of the
patient, independent of any medical team conference, within the
previous 60 calendar days.
Note: Additionally,
the ASN must be present, when assigned, via TH or telephone, for
provider reimbursement of the medical team conference.
8.11.6.2.7.5 Reporting participants
should record and document their role in the conference, contributed
information, and subsequent treatment recommendations. The time
for the medical team conference starts at the beginning of the case
review and ends at the conclusion of the review. Record keeping
or report generation time is not included.
8.11.6.2.7.6 The contractor
shall issue one unit of CPT code 99366 and one unit of CPT code
99368 on each six-month treatment authorization for the ABA provider
to participate in a medical team conference.
8.11.6.2.7.7 ABA providers
must use the ACD Special Processing Code AS when submitting
claims for this CPT code.
8.11.7 Reimbursement
Rates for ABS Services8.11.7.1 Reimbursement
of claims in accordance with the guidance in paragraph 8.11.6 will be established
based on independent analyses of commercial and CMS ABA reimbursement
rates. The national rates for ABA services will then be adjusted
by geographic locality using the Medicare Geographic Practice Cost
Indices (GPCIs).
8.11.7.2 ABA reimbursement
rates will be updated at the same time as the annual CHAMPUS Maximum
Allowable Charge (CMAC) Update, and will be effective May 1st. The
rates will also be posted at http://www.health.mil/rates.
• The contractor shall update
their reimbursement systems, once the rates are posted on the website,
to reflect the annually updated rates in compliance with
Chapter 1, Section 4, paragraph 2.4.
8.11.7.3 The contractor
shall, for claims submitted beginning January 1, 2019, reimburse
ABA services under the ACD in accordance with the reimbursement
rates for the covered ACD CPT codes (rates are also listed at https://health.mil/Military-Health-Topics/Conditions-and-Treatments/Autism-Care-Demonstration8.11.7.3.1 CPT code 97151.8.11.7.3.1.1 Behavior Identification
Assessment is authorized for only the authorized ABA supervisor
(or as delegated to an assistant behavior analyst). For dates of
services prior to August 1, 2021, CPT code 97151 is authorized for
up to 16 units (four hours) of service code reimbursed for up to a
total of $500.00 ($125/hour) at the initial assessment prior to
rendering any other CPT code. For dates of services on or after
August 1, 2021, CPT code 97151 is authorized for up to 32 units
(eight hours) at $125/hour of services for the initial assessment
only. Subsequent authorization periods shall be authorized for up
to 24 units (six hours) of services at $125/hour. CPT code 97151
shall be conducted over no more than a 14 calendar-day period.
8.11.7.3.1.2 The contractor
may authorize one additional unit of CPT code 97151 per outcome measure
for providers that complete the Vineland, the SRS, the PSI/SIPA,
when prior authorized.
8.11.7.3.2 CPT code 97153.
Adaptive Behavior Treatment by Protocol. CPT code 97153 is a timed code
reimbursed no lower than $31.25 per 15-minute increments ($125.00/
hour) for authorized ABA supervisors, $18.75 per 15-minute increment
($75.00/hour) for assistant behavior analysts, and $12.50 per 15-minute
increment ($50.00/hour) for BTs.
8.11.7.3.3 CPT code 97155.
Adaptive Behavior Treatment by Protocol Modification is rendered
by an authorized ABA supervisor for treatment protocol modification
with the beneficiary present. CPT code 97155 is reimbursed no lower
than $31.25 per 15-minute increment ($125.00/hour) for the authorized
ABA supervisor and $18.75 per 15-minute increment ($75.00/hour)
for the assistant behavior analyst delegated this responsibility.
8.11.7.3.4 CPT code 97156.
Family Adaptive Behavior Treatment Guidance. Authorized ABA supervisor
(or as delegated to an assistant behavior analyst) treatment guidance
to the parents/ caregivers (with or without the beneficiary present)
is reimbursed no lower than $31.25 per 15-minute increment ($125.00/hour)
for the authorized ABA supervisor.
8.11.7.3.5 CPT code 97157
(authorized beginning August 1, 2021). Multiple-Family Group Adaptive
Behavior Treatment Guidance. Authorized ABA supervisor treatment
guidance in a group setting to the parents/caregivers (without the
beneficiary present) is reimbursed at the geographically adjusted
reimbursement methodology for CPT code 90853 (group psychotherapy)
for each participant.
8.11.7.3.6 CPT code 97158
(authorized beginning August 1, 2021). Group Adaptive Behavior Treatment
with Protocol Modification. Authorized ABA supervisor treatment
guidance in a group setting to the beneficiaries is reimbursed at
the geographically adjusted reimbursement methodology for CPT code
90853 (group psychotherapy) for each participant.
8.11.7.3.7 For CPT codes
99366 and99368 (authorized beginning August 1, 2021), see https://health.mil/.
Reimbursement rates can be found using the search word “CMAC”.
8.11.7.3.8 Concurrent billing
is excluded for all ACD Category I CPT codes except when the family and
the beneficiary are receiving separate services and the beneficiary
is not present in the family session. Documentation must indicate
two separate rendering providers and locations for the services.
• The contractor shall pay the
higher rate and deny the other if CPT codes 97153 and 97155 are
billed concurrently.
|
CPT Codes
|
97151
|
97153
|
97155
|
97156
|
97157
|
97158
|
|
97151
|
N/A
|
|
|
|
|
|
|
97153
|
Y
|
N/A
|
|
|
|
|
|
97155
|
N
|
N
|
N/A
|
|
|
|
|
97156
|
Y
|
Y
|
Y
|
N/A
|
|
|
|
97157
|
Y
|
Y
|
Y
|
N
|
N/A
|
|
|
97158
|
Y
|
N
|
N
|
Y
|
Y
|
N/A
|
8.11.7.4 For BCBAs submitting
claims for T1023 for services on or after May 1, 2019, the reimbursement
rate shall be the geographically adjusted reimbursement methodology
for the previous CPT code 96102 and updated with the CMS Medicare
Economic Index (MEI) annually. The reimbursement for T1023 will
be posted with the other ABA reimbursement rates at https://www.health.mil/Military-Health-Topics/Conditions-and-Treatments/Autism-Care-Demonstration. Reimbursement
is limited to one unit per outcome measure until July 31, 2021.
(PDDBI: [Parent and Teacher form]: if initial authorization, the
contractor may authorize up to two units solely for the purpose
of the PDDBI at baseline and then at reauthorization. Vineland-3/SRS-2:
one unit each per one year period). As of August 1, 2021, all outcome
measures will no longer be reimbursed by T1023, meaning current
authorizations will be effective until their expiration at which
time, the subsequent treatment authorization will follow paragraph 8.11.6.2.1 (CPT code
97151- see this paragraph for details on reimbursement for the authorized
outcome measures for new authorizations).
8.11.7.6 Negotiated provider
rates lower than those directed in this paragraph are not allowed.
8.11.7.7 Policies in this
section must be adhered to or claims may be recouped.
8.11.8 Cost-Sharing8.11.8.1 Effective January
1, 2018, all beneficiary cost-sharing, deductibles, and enrollment
fees will be those applicable to the specific category of the TRICARE
eligible beneficiary receiving services under this demonstration;
e.g., TRICARE Prime, TRICARE Select; and TFL. For information on
fees for Prime enrollees choosing to receive care under the Point
of Service (POS) option, refer to 32
CFR 199.17 and TRM, Chapter 2, Section 1. There
is no maximum Government payment or annual cap specifically for ABA
services; TRICARE deductibles, enrollment fees, copayments, cost-shares,
and the annual catastrophic cap protections implemented pursuant
to 32 CFR 199 apply.
8.11.8.2 The contractor
shall, for services rendered on or after January 1, 2019, apply
only one copay for all ABA services rendered on the same day. Other
(non-ABA) services rendered on the same day as ABA services will
follow normal TRICARE cost-share/copayment rules.
8.11.8.3 The contractor
shall, for CPT code 97151, apply one copayment for all assessment
services rendered within a 14 calendar day period using this CPT
code. If CPT code 97151 is billed on the same day as other ABA service,
only one copay applies.
8.11.8.4 For Other Health
Insurance (OHI), beneficiaries receiving ABA services are required
to obtain a referral and prior authorization. ABA services under
OHI will be reimbursed for only the covered services listed in this
manual section.
9.0 ACD REQUIREMENTS9.1 Utilization Management
(UM)9.1.1 The contractor
shall implement UM tools, no later than August 1, 2021, to assist
in guiding clinical decision making for all clinical necessity reviews
that shall occur when approving all TPs; i.e., for the initial authorization
and every six months thereafter.
9.1.2 The contractor’s
UM tools shall provide a set of evidence-based standards on TPs
for beneficiaries diagnosed with ASD. UM tools/criteria are used
to guide reviewers to consider the severity of behaviors in the
context of patient-specific variables that help place a patient
in the most appropriate level of care. Standardized decision paths
provide UM reviewers with a common language that enables consistent,
objective decision-making. UM addresses treatment needs of individuals diagnosed
with ASD who frequently receive treatments by providers from several
different disciplines--such as ABA services, PT, OT, and SLP--that
target the same core symptoms or functional deficits.9.1.2.1 The basis of
the UM tool shall integrate the comprehensive picture of treatment
and progress to evaluate the extent to which skill domains are clinically
necessary and appropriate.
9.1.2.2 The contractor
shall select a UM tool that includes, at a minimum, the criteria
to evaluate:
• Level of clinical
support/need;
• TP programming;
• Dose response
(intensity, frequency, duration);
• Progress towards
improved symptom presentation, to include baseline functioning and
cumulative periodic assessments (every six months) using, at a minimum,
the identified outcome measures;
• Duration of services;
and
• Other
rendered/recommended services.
9.1.2.3 The contractor
shall use the UM tool to determine clinical necessity determinations
for all ABS CPT codes.
9.1.3 The contractor
shall ensure that all clinical necessity reviews include an assessment
of progress towards treatment goals. The TP and corresponding outcome
measures must demonstrate progress towards symptom improvements.
9.1.4 The contractor
shall, if no progress is made in the previous six months, engage
the ABA provider to address the TP and goals prior to issuing another
treatment authorization or transition services to more appropriate
treatment (see paragraph 8.8 for discharge planning).
9.1.5 In general, ABA
treatment hours should gradually decrease over time, as beneficiaries
reach treatment goals and parents/caregivers gain skills and proficiency
effectively managing behaviors related to the diagnosis of ASD.
9.1.6 The contractor
shall employ a BCBA or a master’s/doctoral level professional in
a like-specialty to complete clinical necessity reviews.
• The contractor’s UM person
shall be different from the ASN.
9.1.7 The contractor
shall submit, as part of the annual UM/Medical Management (MM) plan,
a comprehensive UM plan that incorporates all services for the diagnosis
of ASD to DHA. For plan submission requirements refer to DD Form
1423, CDRL located in Section J of the applicable contract.
9.2 Program Integrity
(PI)9.2.1 The contractor
shall leverage existing Program Integrity actions in accordance
with Chapter 13, unless
otherwise noted in this section.
9.2.2 The contractor
shall, in addition to the requirement set forth in Chapter 13, Section 1 have an ACD PI Subject
Matter Expert (SME) knowledgeable about the ACD.
9.2.3 The contractor’s
PI unit shall take action in accordance with Chapter
13, developing for potential patient harm, fraud, and
abuse issues.
9.3 Additional Contractor
Responsibilities9.3.1 The contractor
shall develop an ACD-specific webpage within the existing TRICARE
website requirement, that provides ACD information and resources,
designed for use by families, beneficiaries (when appropriate),
and providers to include, but not limited to:
• Online directory
for ACD providers no later than January 1, 2022, including but not
limited to ABA provider, parent-mediated programs, ASD diagnosing
providers, respite care, SLP, OT, PT, etc. (the online ACD provider
directory may be part of the contractor’s main online provider directory);
• ACD Education
and Resources link no later than October 1, 2021as identified in
this policy updated on at least a semi-annual basis. Existing databases
may be incorporated into the contractor platform;
• Link to the Contractor
Provider Portals no later than January 1, 2022, accessible to all
TRICARE authorized providers and ACD providers serving a beneficiary
with a diagnosis of ASD including direct and private sector care
that serves as a platform for providers to communicate directly
with the contractor for: secure messaging; beneficiary referral
and authorization timeline information; TP submissions, certification,
and directory changes.
• Contact information
or link for submitting beneficiary or family member/caregiver complaints
no later than October 1, 2021.
9.3.2 The contractor
shall, for beneficiaries without an ASN, forward to the “gaining”
contractor all ACD related documents within 10 calendar days of
being notified that a beneficiary is transferring to a location
under the jurisdiction of another contractor.
9.3.3 The contractor
shall designate an ACD complaint officer to receive and address
beneficiary family member/caregiver complaints. Contact information
shall be provided to all parents/caregivers of beneficiaries receiving
services under this demonstration on the contractor ACD specific
website.
9.3.4 The contractor
shall develop a provider education training, to be implemented no
later than January 1, 2022, that includes at a minimum: ACD requirements
(to include ABA provider requirements, correct billing practices/claims
filing, authorizations, exclusions, medical records documentation,
provider responsibilities, program requirements), Basic TRICARE
rules, and 32 CFR 199.9.3.4.1 The TOP and USFHP
contractors may use other provider education strategies to achieve
the requirement set forth in paragraph 9.3.4.
9.3.4.2 The contractor
shall submit the ABA provider training curriculum for DHA review
and approval per CDRL requirements prior to executing the training.
9.3.4.3 The contractor
shall ensure compliance with paragraph 8.3.10 by retaining evidence of attendance/completion.
9.3.4.4 The contractor
shall impose a 10% claims penalty for all rendered services during
the non-compliant period for any ABA provider who is non-compliant
with this requirement.
9.3.5 The contractor
shall submit a notice of disciplinary action for any provider including,
but not limited to, ABA providers to their respective certifying/licensing
body, with appropriate documentation, after a failed attempt to
resolve the matter with the provider. The contractor may submit
such notice prior to attempting to resolve the matter with the provider
in cases involving the safety of the beneficiary.
9.3.6 The contractor
shall deny services and/or recoup claims of an authorized ABA supervisor who
has any restriction on their certification imposed by the BACB,
Behavioral Intervention Certification Council (BICC), or QABA, or
any restriction on their state license or certification for those having
a state license or certification.
9.3.7 The contractor
shall recoup claims and/or deny services for session notes that
describe the rendering of non-ABA services.
9.3.8 The contractor
shall authorize all CPT code units in the six-month authorization
and monitor to ensure TP recommendations (per week/month respectively;
see paragraph 8.11.6.2) are maintained and not
exceeded.
• The contractor
shall deny claims containing units (hours) over the approved authorization
and the MUEs set for each CPT Code.
9.3.9 The contractor
shall report allegations of abuse to authorities responsible for
child protective services, military and family advocacy programs,
and to state and national license or certification boards as appropriate,
and to the Director, DHA, or designee.
9.3.10 Outcome Measures
Oversight9.3.10.1 The contractor
shall ensure completion of the Vineland, the SRS, PDDBI, PSI/SIPA
(current edition) at baseline and every six months or year thereafter
for each beneficiary participating in the ACD.9.3.10.1.1 The non-clinical
support person may assist in the administrative tasks of completing this
requirement.
9.3.10.1.2 The contractor
may utilize other sources for collection of these measures, such
as a provider (TRICARE-authorized or otherwise) submitting the measures
as part of their standard assessment process.
9.3.10.2 The contractor
shall transition all beneficiaries participating in the ACD prior
to April 1, 2021 to a one-year timeline at the next earliest interval.
For example, if the beneficiary is in their seventh month of ABA
services, the Vineland and the SRS shall be completed by the twelfth
month (five months later) and prior to the issuing of the next authorization.
9.3.10.3 The contractor
shall use the date of receipt of the specific measure to determine
the next chronological interval (six months or one year) for outcome
measures due dates.
9.3.10.4 The outcome measures
timeline does not change when changing regions, provider, or beneficiary
category. If the beneficiary or family elects to pause services
from the ACD, ASN and/or ABA services for more than 180 calendar
days, the timeline resets to collect outcome measures.
9.3.10.5 The contractor
shall accept and report only complete and valid outcome measures.
9.3.10.6 The contractor
shall accept valid measures for baseline data with dates up to one
year prior to initiation of services.
9.3.10.7 The
contractor shall terminate ASN services and not issue a subsequent
ABA treatment authorizations for failure to complete
any and all outcome measures.
9.3.10.8 The contractor
shall transition to the new edition within one year of its release,
should the outcome measure edition update.
9.3.11 Provider NetworksThis paragraph
applies only to the 50 U.S., District of Columbia, and U.S. territories.
See paragraph 8.5 for TOP.
9.3.11.1 The contractor
shall establish network contracting targets sufficient to support
the ACD program IAW access standards and network expansion prescribed
in Chapter 5, Section 1 and apply existing network
requirements and access standards to providers under the ACD program.
9.3.11.2 The contractor
shall ensure that the beneficiary shall begin ABA treatment services
within 28 calendar days from the completed ABA assessment date.
9.3.11.3 The contractor
shall certify all BTs within 10 business days of a complete application package
that meets all requirements.
9.3.11.4 The contractor
shall include the provider’s work address, work fax number, work
telephone number, and hours of operation in their directory.
9.3.11.5 The contractor
shall include information regarding ages served, telehealth capabilities,
and available session settings (in-home, clinic-based, both) in
their directory.
9.3.11.6 The contractor
shall engage in an active provider placement process, no later than
August 1, 2021, to ensure access to care standards are met.9.3.11.6.1 The contractor
shall have up to 15 business days to complete the active provider placement
process.
9.3.11.6.2 The contractor
shall have a process that confirms when a beneficiary is referred
to a new ABA provider, that the provider can provide an assessment
(CPT code 97151) within 28 calendar days of the verified referral
(this 28 day period includes the 15 business day provider placement),
and that the provider will be able to provide the ABA services (CPT
codes 97153, 97156, or 97157) within 28 calendar days of the completion
of the assessment.
9.3.11.6.3 The contractor
shall document that the provider was able to accept and see the beneficiary
within access to care standards.
9.3.11.6.4 The contractor
shall also document in the beneficiary’s file when a family declines access
to an available provider who can meet the access to care standards.Note: MTF directed
referrals or family requests for a specific provider do not ensure
access to care standards. Therefore, these recommendations will
be taken into consideration, but do not guarantee timely placement.
The contractor is not required to comply with directed referrals
for ABA providers if doing so will exceed access to care standards.
Should the family specify a specific provider, access to care is
also not guaranteed.
9.3.12 ABA Provider
Steerage ModelThe TOP and USFHP
DPs contractors are exempt from paragraphs 9.3.11 through 9.3.11.3.
9.3.12.1 The contractor
shall develop an ABA provider steerage model, to be implemented
no later than January 1, 2022, for individual authorized ABA supervisors
which shall take into account, at a minimum:9.3.12.1.1 Compliance with
access standards.
9.3.12.1.2 Include at least
one other determinant into their ABA provider steerage model. Any additional
determinants shall be submitted to DHA for approval prior to implementation.
This additional determinant shall be an objective, verifiable measure
that has a direct impact on beneficiaries or their families.
9.3.12.2 The contractor
shall assign beneficiaries to ABA providers who rank highest in
the steerage model when possible consistent with access to care
standards.
9.3.12.3 The contractor
shall list ABA providers who rank highest in the steerage model
first in the online provider directories and shall give priority
to those who rank highest when assigning patients to a provider.
9.3.13 The contractor
shall complete and timely submit quarterly and annual Comprehensive Autism
Care Reports. For reporting requirements, refer to DD Form 1423,
CDRL, located in Section J of the applicable contract.
• The TOP contractor
shall submit ad hoc reports in accordance with the TOP contract.
9.3.14 The contractor
shall ensure all TRICARE Encounter Data (TED) requirements outlined
in the TRICARE Systems Manual (TSM), Chapter
2 are met including appropriate use of Special
Processing Code AS (Comprehensive ACD).
9.3.15 The contractor
shall maintain one toll-free telephone number, specific to the ACD,
to answer all provider and beneficiary questions. All ACD-specific
customer service staff shall be knowledgeable of the most up to
date ACD policy and provide consistently accurate information.
• The TOP, USFHP
DPs, and TFL contractors shall use their existing telephone number
for provide and beneficiary questions.
9.3.16 The authority
for all aspects of the ACD, which is administered separate and apart
from the general regulations and Manual sections governing the TRICARE
Basic Program, and also separate and apart from ECHO, is defined
per statute (10 United States Code (USC) 1092 as further implemented
by 32 CFR 199.1(o)).
The ACD is specifically implemented by Federal Register notice as
required by 32 CFR 199.1(o) and
DoD AI-102.
9.3.17 The contractor
shall not, unless specifically identified in this Manual and if
the contractor identifies a gap in the ACD policy, automatically
default to normal TRICARE policy, but shall contact DHA for clarification.
11.0 DEFINITIONS11.1 Adaptive Behavioral
Services (ABS)According to
the American Medical Association (AMA) CPT coding guidance, ABS
address deficient adaptive behaviors (e.g., instruction-following,
verbal and nonverbal communication, imitation, play and leisure,
social interactions, self-care, daily living, and personal safety
skills) or maladaptive behaviors (e.g., repetitive and stereotypic
behaviors, and behaviors that risk physical harm to the patient,
others, and/or property).
11.2 Applied Behavior
Analysis (ABA) AssessmentA developmentally
appropriate assessment and reassessment tool must be used for formulating
an individualized ABA TP and is conducted by an authorized ABA supervisor.
For TRICARE purposes, an ABA assessment shall include data obtained
from multiple methods to include direct observation, the measurement,
and recording of behavior. A functional assessment that may include
a functional behavior analysis may be required to address problematic
behaviors. Data gathered from a parent/caregiver interview and parent
report rating scales are also required. The ABA assessment will
also include standardized outcome measures at appropriate intervals
as noted above.
11.3 ABA ServicesABA methods designed
to improve the functioning of a specific ASD target deficit in a
core area affected by ASD such as social interaction, communication,
or behavior. The ABA provider delivers ABA services to the beneficiary
through direct administration of the ABA specialized interventions
during one-on-one in-person (i.e., face to face) interactions with
the beneficiary. ABA services may be comprehensive (addressing many
treatment targets in multiple domains) or focused (addressing a small
number of treatment targets, such as specific problem behaviors
and/or adaptive behaviors).
11.4 ABA Sole Provider
ModelA
service delivery model that includes only the use of the authorized
ABA supervisor to implement a TP designed by the authorized ABA
supervisor. The ABA sole provider delivery model is authorized in
the Continental United States (CONUS), U.S. territories, and TOP.
11.5 ABA Tiered Delivery
ModelA
service delivery model that includes the use of supervised assistant
behavior analysts and/or BTs, in addition to the authorized ABA
supervisor, to implement a TP designed by the authorized ABA supervisor.
Supervised assistant behavior analysts may assist the authorized
ABA supervisor in clinical support to include the supervision of
BTs and the provision of parent(s)/caregiver(s) treatment guidance.
Tiered delivery models are only authorized in the CONUS and U.S
territories.
11.6 ABA TP11.6.1 A written document
outlining the ABA service plan of care for the individual, including
the expected outcomes of ASD symptoms. For TRICARE purposes, the
ABA TP shall consist of an “initial ABA TP” based on the initial
ABA assessment, and the “ABA TP Update” that is the revised and
updated ABA TP based on periodic reassessments of beneficiary progress
toward the objectives and goals.
11.6.2 Components of
the ABA TP include: the identified behavior targets for improvement,
the ABA specialized interventions to achieve improvement, and the
short-term and long-term ABA TP objectives and goals that are defined
below. The ABA TP shall also include a discharge plan.
11.7 ABA TP GoalsThese are the
broad spectrum, complex short-term and long-term desired outcomes
of ABA services.
11.8 ABA TP ObjectivesThe short, simple,
measurable steps that must be accomplished in order to reach the
short-term and long-term goals of ABA services.
11.9 Assistant Behavior
AnalystThe
term “assistant behavior analyst” refers to supervised Licensed
Assistant Behavior Analyst (LABA), Board Certified Assistant Behavior
Analyst (BCaBA), and Qualified Autism Service Practitioner (QASP).
11.10 Authorized ABA
SupervisorAn
authorized ABA supervisor, whether or not currently supervising,
is defined as a Licensed Behavior Analyst (LBA), BCBA, BCBA-Doctorate
(BCBA-D), or a clinical psychologist practicing within the scope
of their state licensure or state certification.
11.11 Autism Services
Navigator (ASN)The ASN collaborates
and oversees the assessment, planning, facilitation, care coordination,
evaluation, and advocacy for options and services to meet an individual’s
comprehensive health needs through communication and available resources
to promote quality, cost-effective outcomes. An ASN must hold a
current, valid, unrestricted license which include: a Registered
Nurse (RN) with CM experience, clinical psychologist, LCSW, or other
licensed mental health professionals who possess a certification
in CM. The ASN must have clinical experience in: pediatrics, behavioral
health, and/or ASD; a healthcare environment; and proven care management
experience. This definition specifically excludes both BCBAs and
assistant behavior analysts.
11.12 Autism Spectrum
Disorder (ASD)For ACD eligibility,
the covered diagnosis is ASD (F84.0) according to the DSM-5/Autistic
Disorder according to the International Classification of Diseases,
Tenth Revision, Clinical Modification (ICD-10-CM). The ASD diagnosis
must specify the level of support according to the DSM-5 criteria
(Level 1 = mild, Level 2 = moderate, or Level 3 = severe).
11.13 ASD Diagnosing
and Referring Providers11.13.1 ASD diagnosing
and referring providers include: TRICARE-authorized PCMs and specialized ASD
diagnosing providers. TRICARE authorized PCMs for the purposes of
the diagnosis and referral include: TRICARE authorized pediatric
physicians, pediatric family medicine, and pediatric Nurse Practitioners
(NPs). Authorized specialty ASD diagnosing providers include: TRICARE-authorized physicians
board-certified or board-eligible in developmental-behavioral pediatrics, neurodevelopmental
pediatrics, child neurology, child psychiatry; doctoral-level licensed
clinical psychologists, or board certified Doctors Of Nursing Practice
(DNP). For DNPs credentialed as developmental pediatric providers,
dual American Nurses Credentialing Center (ANCC) board certifications
are required as follows:
• Either a pediatric
NP or a family NP; and
• Either (Family,
or Child/Adolescent) Psychiatric Mental Health Nurse Practitioner
(PMHNP) or a (Child/ Adolescent) Psychiatric and Mental Health Clinical
Nurse Specialist (PMHCNS).
11.13.2 For DNPs credentialed
as psychiatric and mental health providers, single ANCC board certification
is required as follows: as either a (Family or Child/Adolescent)
PMHNP or a PMHCNS.
11.13.3 Diagnoses and
referrals from Physician Assistants (PAs) or other providers not
having the above qualifications shall not be accepted.
11.14 Behavior AnalysisBehavior analysis
is the scientific study of the principals of learning and behavior,
specifically about how behavior affects, and is affected by, past
and current environmental events in conjunction with biological
variables. ABA is the application of those principles and research
findings to bring about meaningful changes in socially important
behaviors in everyday settings. ABA, by a licensed and/or certified
behavior analyst, focuses on treating behavior difficulties by changing
an individual’s environment (i.e., shaping behavior patterns through
reinforcement and consequences). ABA is delivered optimally when
family members/caregivers actively participate by consistently reinforcing the
ABA interventions in the home setting in accordance with the prescribed
TP developed by the behavior analyst.
11.15 Behavior Analyst
Certification Board (BACB)The BACB is a
nonprofit 501(c)(3) corporation established to “protect consumers
of behavior analysis services worldwide by systematically establishing,
promoting, and disseminating professional standards.” The BACB certification
offers the BCBA for master’s level and above behavior analysts,
the BCaBA certification for bachelor’s level assistant behavior
analysts, and the RBT credential for BTs with a minimum of a high
school education.
11.16 Behavior Intervention
PlanBehavior
Intervention Plans must include an operational definition of the
target behavior excesses and deficits, prevention and intervention
strategies, schedules of reinforcement, and functional alternative responses.
Behavior Intervention Plans shall be submitted along with any TP
identifying a target behavior excess or deficit.
11.17 Behavior Technician
(BT)The
term “behavior technician” refers to high-school graduate level
paraprofessionals who deliver one-on-one ABA services to beneficiaries
under the supervision of the authorized ABA supervisor, and includes
RBTs, ABATs, and BCATs.
11.18 Behavioral Intervention
Certification Council (BICC)“The BICC was
established in 2013 to promote the highest standards of treatment
for individuals with ASD through the development, implementation,
coordination, and evaluation of all aspects of the certification
and certification renewal processes. BICC is an independent and
autonomous governing body for the BCAT certification program, a
certification for BTs.”
11.19 Clinical NecessityClinical necessity
refers to services that are clinically indicated and appropriate
to address a beneficiary’s diagnosed condition and not in excess
of the beneficiary’s needs. The services must be individualized,
specific, and consistent with the confirmed diagnosis of the beneficiary.
11.20 Comprehensive
Care Plan (CCP)The CCP refers
to a plan that is developed and maintained by the ASN. The CCP shall
identify all care and services for the diagnosis of ASD, as well
as, transition timelines to include, but not limited, to Permanent
Change of Station (PCS) orders. The CCP will allow for a more consistent
and beneficiary-centric approach to care.
11.21 Family/Caregiver11.21.1 Family/Caregiver
follows the definition for “immediate family” in 32 CFR 199.2(b): [t]he spouse, natural parent,
child and sibling, adopted child and adoptive parent, stepparent,
stepchild, grandparent, grandchild, stepbrother and stepsister,
father-in-law, mother-in-law of the beneficiary, legal guardian
as appropriate. For the purposes of the ACD, a “nanny” may be considered
an eligible caregiver pending the following requirements are met:
• At least 18 years
of age.
• Employed full-time
by the family or an agency on behalf of the family (but must work
full-time with the child).
• The nanny is
documented in the Service family care plan. Documentation must be
submitted to the contractor.
• Has medical Power
of Attorney.
• The approved
TP must identify the level of the nanny’s participation to include
specific goals.
• Caregiver (nanny)
training cannot exceed parent training (CPT codes 97156 and 97157).
11.21.2 No other individual
is considered “family” or “caregiver” under the ACD.
11.22 Functional Behavior
AnalysisThe
process of identifying the variables that reliably predict and maintain
problem behaviors that typically involve: identifying the problem
behavior(s); developing hypotheses about the antecedents and consequences
likely to trigger or support the problem behavior; and, performing
an analysis of the function of the behavior by testing the hypotheses.
11.23 Medical Team
ConferencesMedical team
conferences are for the purpose of the treating providers to periodically
meet to discuss the beneficiary and the overall program and progress
towards goals. All CPT coding guidance and ACD requirements must
be met for reimbursement of this code.
11.24 Parent-Mediated
ProgramsParent-mediated
interventions often focus on social reciprocity. In these programs,
professionals train parents one-on-one or in group formats in home
or community settings with methods that may include didactic instruction,
discussion, modeling, coaching, or performance feedback. Once trained, parents
implement all or part of the intervention(s) with their child.
11.25 Parenting Stress
Index, Fourth Edition (PSI-4) or current edition (Abidin)The PSI is a
measure used for screening/triaging, and evaluating the parenting
system and identifying issues that may lead to problems in the child’s
or parent’s behavior. The PSI focuses on three major domains of
stress: child characteristics, parent characteristics, and situational/demographic
life stress. Additionally, the PSI is useful in designing a TP,
for setting priorities for intervention or for follow-up evaluation.
The PSI is commonly administered in medical centers, outpatient
therapy settings, and pediatric practices. The PSI is not intended
to diagnose dysfunction in the parent-child relationship, or to
be a screening tool of parental mental health problems. This outcome
measure must be completed at baseline and every six months thereafter
for beneficiaries ages 0 through 12 years only. Only the short form
is required.
11.26 Pervasive Developmental
Disorder Behavior Inventory (PDDBI) (Cohen, I.L. and Sudhalter,
V. 2005 or current edition)The PDDBI is
an informant-based rating scale that is designed to assist in the
assessment (for problem behaviors, social, language, and learning/memory
skills) of children who have been diagnosed with ASD. The PDDBI
provides age-standardized scores for parent and teacher ratings.
Applicable for ages 2 through 18.5 years.
Note: Per guidance
interpreted from the PDDBI manual and the publisher, the teacher
form may be completed by the authorized ABA supervisor.
11.27 Qualified Applied
Behavior Analysis (QABA) Certification BoardQABA “is an organization
established in 2012 to meet para-professional credentialing needs
identified by behavior analysts, ABA providers, insurance providers,
government departments, and consumers of behavior analysis and behavior
health services.” QABA offers the QASP certification for bachelor’s
level assistant behavior analysts, and the ABAT certification for
BTs with a minimum of a high school education or equivalent.
11.28 Qualified Health
Care Professional (QHP)A QHP is an individual
who is qualified by education, training, licensure/regulation (when
applicable) and facility privileging (when applicable) who performs
a professional service within his/her scope of practice and independently
reports that professional service.
11.29 Social Responsiveness
Scale, Second Edition (SRS-2) or current edition (Constantino)The SRS-2 identifies
social impairment associated with ASD and quantifies its severity.
Applicable for ages 2-1/2 through 99 years.
11.30 Stress Index
for Parents of Adolescents (SIPA) or current edition (Sheras and
Abidin)The
SIPA is a screening and diagnostic instrument that identifies areas
of stress in parent-adolescent interactions, allowing examination
of the relationship of parenting stress to adolescent characteristics, parent
characteristics, the quality of the adolescent-parent interactions,
and stressful life circumstances. Areas of parent-focused inspection
include life restrictions, relationship with spouse/partner, social
alienation, and incompetence/guilt. Areas of adolescent-focused
inspection include moodiness/emotional liability, social isolation/withdrawal,
delinquency/antisocial, and failure to achieve or persevere. The
SIPA is the upward age extension of the PSI-Third edition (PSI-3).
Applicable for ages 11-19 years.
11.32 Vineland Adaptive
Behavior Scale, Third Edition (Vineland-3) or current edition (Sparrow, S.S.
et.al)The
Vineland-3 is a valid and reliable measure of adaptive behavior
for individuals diagnosed with intellectual disabilities and developmental
disabilities (to include ASD). The Vineland-3 consists of an interview,
a parental/caregiver, and teacher rater forms. Applicable for ages
birth to 90 years.