3.0 DEMONSTRATION
GOALS
3.1 Analyzing
and evaluating the appropriateness of the ACD under the TRICARE program 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 COORDINATION
The 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
any beneficiaries entering the ACD
for ABA services on or after October 1, 2021, who serve
s as the
primary advocate for the beneficiary.
Note: For the purpose
of this Demonstration “new
beneficiaries” are any beneficiaries not currently
receiving ABA services under the ACD as of October
1, 2021. Current beneficiaries in the ACD who transfer regions
and continue 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 use 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.
The
ASN shall address discharge/transition planning
in
the CCP upon a beneficiary’s enrollment into the ACD.
6.2.2 The ASN shall complete the CCP
within 90 calendar days of
being assigned to a family
.
• 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,
or referring provider and
parent/caregivers
the CCP
is established.
• The ASN shall share the CCP with
the respective providers, when complete.
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
the Market/Military Medical
Treatment Facility (MTF) CM (when applicable),
and
shall be readily accessible by phone or email (based
upon beneficiary
preference), during regular business hours for the respective geographic time
zone in which the beneficiary resides
. The ASN shall assist
the beneficiary
/beneficiary’s family
with all questions
related to autism
care and shall:
6.3.1 Coordinate medical and behavioral
health services (PT, OT, SLP
),
Market/MTF
services (including coordination with the
Market/MTF
CM), ECHO services (for ADFMs),
network
PCM (if applicable), specialty providers, ABA services, EFMP coordinators,
and other clinical services based
upon 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, 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 contractors
shall ensure the incoming and outgoing ASNs are 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
email. Case
transfer shall include, but
is not limited
to, ensuring
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 shall assist,
upon request, 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 notification that a beneficiary
is transferring to a location under the jurisdiction of another
contractor. The gaining contractor shall accept all
verified ACD documents from the outgoing contractor during the transfer process.
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 Market/MTF or appointing center
for appointments that are required or available within the Market/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, local
level services, or both.
6.4.3 ADFMs may also be eligible for
Uniformed 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 the
family acknowledged receipt of the materials.
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 shall employ
or subcontract the ASN role.
Note: If subcontracted, the ASN
shall not
provide any ASN services (see
paragraph 6.0 through
6.9)
to beneficiaries for whom they are rendering treatment services.
The ASN role
shall 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 any
declination of ASN and coordinated ACD services.
6.8.2 Declining ACD services does not
preclude TRICARE Basic benefit services,
just the coordinated ASN and ABA services. However, the beneficiary
or family member may 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 visible to Government
designated authorities.
8.0 ABA
SERVICES
Under the
demonstration authority, the TRICARE program 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 ABA
services under the demonstration authority. The following paragraphs
identify approved ABA services under the demonstration:
8.1 ABA Services Benefit
The contractor
shall ensure ABA services for the diagnosis of ASD
are provided
by
a master’s level or above authorized ABA supervisor
(a
sole provider model) or under the tiered delivery
model, where an authorized ABA supervisor plan
s,
deliver
s, and supervise
s an
ABA program. Both models are
eligible for authorization and
the model
recommended is based
upon the
needs of the beneficiary. The Treatment Plan (TP) is based
upon
the model
being implemented.
See
paragraphs 11.4 and
11.5 for definitions
of sole and tiered delivery models.
8.2 ABA Provider Requirements
The contractor shall ensure that
all TRICARE ABA provider requirements are met, and subsequently certified,
prior to authorizing care and reimbursement
of claims for any ABA services.
8.2.1 All TRICARE
ABA providers authorized under the ACD
(master’s
level and above, assistant, and BT level) must:
8.2.1.1 Obtain a National Provider
Identifier (NPI) number (all claims must have the rendering provider’s
name and NPI for processing).
ABA providers
who do not possess an NPI prior to July 1, 2021,
have
until August 1, 2021 to obtain and submit an NPI.
ABA
providers new to the ACD on or after July 1, 2021,
must
already possess an NPI at the time of certification application
submission.
8.2.1.2 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.
8.2.2 The contractor shall obtain
respective documents from the authorized ABA supervisor:
8.2.2.1 A copy of a Criminal History
Review, for all authorized ABA supervisors
with whom the contractor enters into a Participation Agreement.
8.2.2.2 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.
8.2.2.3 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;
8.2.2.4 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
8.2.3 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.
8.2.4 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 Providers
8.3.1 ACSPs include autism centers,
autism clinics, and Sole Providers regardless
of setting of rendered ABA services (i.e.,
home or clinic). In many cases, ACSPs 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.
8.3.2 The ACSP
and Sole
Providers must:
8.3.2.1 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;
Note: The TOP
contractor shall ensure professional liability insurance is in accordance
with the TOP contract.
8.3.2.2 Submit to the contractor all
documents necessary to support an application for designation as
a TRICARE ACSP/Sole Provider.
8.3.2.3 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.
Note: The contractor shall submit
a list of non-compliant providers. The Government retains final decision
making for provider termination.
8.3.2.4 Employ directly, or
contract with, qualified authorized
ABA supervisors, assistant behavior analysts, and/or BTs, if applicable.
8.3.2.5 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.
8.3.2.6 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.
8.3.2.7 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.
8.3.2.8 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.
Contractor
termination of the Participation Agreement
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.
8.3.2.9 Familiarize themselves
, 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
are 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.
8.3.2.10 Attend a contractor-hosted “provider
education” training, no less than annually, beginning no later than January 1, 2022.
8.3.2.11 Comply with all applicable
requirements of the Government designated utilization and clinical
quality management organization.
8.4 Provider
Requirements
8.4.1 Authorized
ABA Supervisors (BCBA, BCBA-D, or Clinical Psychologist)
8.4.1.1 Have a master’s degree or above
in a qualifying field as defined by the state licensure/ certification
where defined or in the absence of
State
licensure/certification, a graduate degree from an accredited institution
(per TPM,
Chapter 11, Section 3.3) in behavior analysis,
psychology, special education, or a related field; and
8.4.1.2 Have a current:
8.4.1.2.1 Unrestricted State-issued
license or State certification 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 Analysts
8.4.2.1 Have a bachelor’s degree or above
in a qualifying field as defined by the State
licensure/ certification where defined or in the absence of State
licensure/certification, a degree in a field accepted by a certification
body approved by the Director, DHA; and
8.4.2.2 Have a current:
8.4.2.2.1 Unrestricted State
issued license or State certification
if they practice in a State that offers State
licensure or State certification; or
8.4.2.2.2 Certification from the BACB
or the Qualified Applied Behavior Analysis (QABA) certification
board.
Note: Should a State
licensure or State certification specify
criteria for an assistant behavior analyst that results in a previously
authorized TRICARE assistant behavior analyst not meeting the requirements
for State licensure or State
certification, that provider may be recognized by TRICARE as only
a BT without having to obtain the BT certification (if allowed by State
law) and shall be subject to all BT requirements once the State
licensure language becomes effective. A certification as an ABA provider
must be maintained.
8.4.2.3 Assistant behavior analysts
must receive supervision in compliance with their certification board.
Assistant behavior analysts must work under the supervision of an
authorized ABA supervisor who meets the requirements specified in
paragraph 8.4.1.
8.4.2.4 Assistant behavior analysts
who conduct supervision of BTs must be in compliance with their
certification board for supervisory activities.
8.4.3 BTs
8.4.3.1 All BTs must possess
either 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,
effective July 1, 2021.
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
TOP contractor
shall ensure ABA services provided overseas
follow
all the requirements in this manual.
8.5.1.1 The TOP contractor
shall not authorize the tiered model outside of the U.S. and U.S. territories.
8.5.1.2 The TOP contractor
shall ensure ABA providers follow
all requirements laid out in this manual.
8.5.1.3 The TOP contractor
shall ensure reimbursement for ABA services in U.S. territories
are paid in accordance with reimbursement rates (see
http://www.health.mil/rates).
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
TOP 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
TOP contractor
shall ensure the reimbursement of TOP claims for ABA services obtained
overseas
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
Policy
8.6.1 Referral
for ABA Services
A complete
referral
, including level of severity/support 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 a TRICARE authorized ASD diagnosing
provider, if the initial diagnosis was made greater than two years
prior to a referral for ABA services for new beneficiaries
entering the program on or after 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 Services
8.6.2.1 The contractor shall, upon receipt
of the completed referral for ABA services, issue an evaluation
authorization for an initial assessment and TP development.
Then
the authorized ABA supervisor
must complete 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 Authorizations
8.6.3.1 If ongoing services are clinically
indicated, prior to the expiration of each six-month treatment authorization
period, as early as 60 calendar days in advance and no later than
30 calendar days in advance, a re-authorization for ABA services
should be requested by the ABA provider for the next six months
from the contractor.
If the ABA provider
submit
s 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 Effective August
1, 2021, 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 receives.
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 to include
an updated DSM 5 checklist, 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. Subsequent
referrals may be accepted up to six months in advance.
8.6.4 Outcome
Measures
For 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
,
effective August 1, 2021. 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).
Effective
August 1, 2021, submission of all outcome measure
results must include the full publisher print report or hand-scored
protocol and summary score sheet(s)
that include T-scores.
Imbedding
T-scores within the treatment
plan or other clinical documents is insufficient to meet the submission
requirements.
8.6.4.1 PDDBI, Current Edition
8.6.4.1.1 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 must
match and 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
must
match and 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
must
match and 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, 2021
The Short
Form is required. The name of the respondent and relation to the
beneficiary
must match and 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, 2021
The Profile Form is required.
The name of the respondent and relation to the beneficiary
must
match and 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 all
outcome measures scores to treating providers of ACD
beneficiaries.
8.6.4.7 The contractor
shall ensure that all outcome measures are completed no greater
than 90 calendar days prior to each outcome measure’s current due
date.
8.6.5 Medical Team Conference
(MTC)8.6.5.1 MTCs 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
MTC 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 MTC; 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.
8.6.5.6 MTCs are not
required, but are available, to treatment teams for the purpose
of case collaboration. However, when an MTC is scheduled, an assigned
ASN must participate per paragraph 6.3.1.2.
8.7 ABA Service Documentation
All 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 Information
The beneficiary’s name, date
of birth, date the initial ABA assessment and initial ABA TP were completed,
the beneficiary’s DoD Benefit Number (DBN) or sponsor’s Social Security
Number (SSN), and the name of the referring provider;
8.7.1.2 Reason for Referral
The ABA TP and TP updates must
include the ASD diagnosing/referring provider’s ASD diagnosis, to include
symptom severity level/level of support required according to DSM-5
ASD criteria.
8.7.1.3 Background
Information
Background
and history to include, but is not limited to, information that
clearly reports the beneficiary’s condition, diagnoses, medical
co-morbidities (to include over-the-counter (OTC) medications),
family history, school enrollment status, number of hours enrolled
in school, the number of hours receiving other support services
such as OT, PT, and SLP, documentation of the age of the child and
year of the initial ASD diagnosis, and how long the beneficiary
has been receiving ABA services.
8.7.1.4 Summary of Assessment Activities
The TP must include objectively
measured behavioral excesses and deficits that impede the beneficiary’s
safe, healthy, and independent functioning in all domains applicable
(language, development, social communication, and clinical adaptive
behavior skills). This assessment may indicate a need for a behavior
intervention plan (
paragraph 11.6) for each 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 Goals
The ABA TP must clearly define
measurable targets in all relevant DSM-5 (or most current edition) symptom
domains, including parent/caregiver goals as identified in the initial
assessment, and objectives and goals individualized to the strengths,
needs, and preferences of the beneficiary and his/her family members.
The ABA TP goals must address core symptoms of ASD:
• Social Communication and Social
Interaction Behavior (to include restricted, repetitive, and/or stereotypical
patterns of behavior, interests, and/or activities);
• Restrictive/Repetitive/Stereotypical
Patterns of Behavior (i.e., stereotyped/ repetitive motor movements,
insistence on sameness, inflexible adherence to routines, highly
fixated interests, hyper/hypo-activity to sensory input).
8.7.1.5.1 Goals must be measurable, objective,
achievable, developmentally appropriate, and clinically significant.
8.7.1.5.2 Goals must be described as
follows:
• Objective, baseline and ongoing
measurement levels for each target behavior/symptom in terms of frequency,
intensity, and duration;
• A description of treatment
interventions and techniques specific to each of the targeted behaviors/symptoms;
• Identify the objective measures
of assessment for each goal specified; and
• Functional goals must be specific
to the 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 Recommendations
TP recommendations of units of
ABA services are based upon 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) 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).
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 Progress
ABA reassessments and TP updates
must document the evaluation of progress for each current behavior
target identified on the initial ABA TP and prior TP updates. Documentation
of the ABA reassessment and TP update must be completed every six
months and include all of the following but not limited to (the
contractor may request additional information based upon 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 upon 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 there
is a regression or if no progress has been made and
the provider must incorporate revisions to the individual TP to
address the lack of progress.
8.7.1.8 Signatures
The ABA TP and TP updates must
contain signatures by the authorized ABA supervisor, and the parent/caregiver
to ensure the parent/caregiver is fully cognizant of the care being
provided to their child.
8.7.1.9 The reassessments, to include
the completion of the PDDBI, and TP updates are required every six
months (one assessment for each authorization period). Reassessments
must be conducted, completed and submitted
no later than 30 calendar days prior to the end of the current authorization for
review for re-authorization. Any delay in submission of the ABA
reassessment and TP updates may delay the subsequent authorization
for ABA services.
8.7.2 Progress Note Documentation
In addition to TPM,
Chapter 1, Section 5.1, “Requirements for
Documentation of Treatment in Medical Records,” progress note documentation
must contain the following documentation elements for each CPT code
session:
8.7.2.1 Beneficiary’s full name (not
initials);
8.7.2.2 The date and time of session
to include start and end time;
8.7.2.3 Location of rendered services;
8.7.2.4 Length of session;
8.7.2.5 A legible name of the rendering
provider, to include provider type/level;
8.7.2.6 A signature of the rendering
provider with the date signed;
8.7.2.7 Name of authorized ABA supervisor;
8.7.2.8 Name of all session participants
(excluding other beneficiaries in CPT codes 97157 and 97158);
8.7.2.9 A notation of the patient’s
current clinical status evidenced by the patient’s signs and symptoms;
8.7.2.11 A statement summarizing the
techniques attempted during the session;
8.7.2.12 Narrative description of the
response to treatment, the outcome of the treatment, and the response
to significant others (group session notes must contain individualized
responses to treatment);
8.7.2.13 A narrative statement summarizing
the patient’s degree of progress towards the treatment goals;
8.7.2.14 Each section of the progress
note documentation must be individualized to the beneficiary and
each session, and
8.7.2.15 Effective January 1, 2019,
the final product for CPT code 97151 must be in the format of a TP.
However, all encounters using CPT code 97151 must document a 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
Planning
8.8.1 The following
discharge criteria are established to determine if/when ABA services
are no longer appropriate:
8.8.1.1 Loss of eligibility for TRICARE
benefits as defined in
32 CFR 199.3.
8.8.1.2 The authorized ABA supervisor,
the contractor, or the family has determined one or more of the
following:
• 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).
8.8.6 The contractor
shall ensure discharge summaries meet minimum requirements for compliance
with paragraph 8.8.
8.9 ABA Quality Monitoring and
Oversight
8.9.1 This demonstration
is subject to existing program requirements for quality monitoring
and oversight.
8.9.2 The contractor
shall conduct, on an annual basis, an audit, which
include
s 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 per supporting documentation for
claims payment.
8.9.7 Administrative Claims Review
8.9.7.1 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 Documentation
8.9.8.1 The contractor shall review ABA
session documentation
to ensure
the
notes include at a minimum, but
are not
limited to:
8.9.8.1.3 Sufficient documentation to
justify a medical record.
8.9.8.1.4 No billing for office supplies
to include therapeutic supplies.
8.9.8.1.5 No billing for ABA services
using aversive techniques to include restraints (even if billed using
a covered CPT code).
8.9.8.1.6 Group ABA services are not
billed as authorized one-on-one ABA services.
8.9.8.1.7 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.
8.9.8.1.8 Additional prohibited
activities. See exclusions (
paragraph 8.10)
.
8.9.8.2 The contractor
shall ensure clinical content reviews are completed
by licensed, BCBA, or like-peer 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 more than
12 months.
8.9.8.4 The contractor shall conduct
a probe audit sample (see
Chapter 13, Section 3)
on these identified providers to review medical record documentation
progress.
8.9.8.5 The contractor shall place any
ABA provider who has not improved after a minimum of six months,
but not more than 12 months of education
and monitoring on pre-payment review.
8.9.9 New
ACSP/Sole Provider Review
8.9.9.1 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)
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 Reviews
The contractor shall conduct
an annual audit of a statistically valid number of providers, to
include collecting proof of documentation (either through source
verification or actual document), to ensure ABA providers meet the
requirements set forth in
paragraphs 8.2 through
8.4.
8.10 Exclusions
The contractor shall not reimburse
for the following services when billed to TRICARE,
to include but not limited to:
8.10.1 BTs training.
8.10.2 ABA Services for any other
diagnoses other than ASD.
8.10.3 ABA services are not covered
for symptoms and 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).
8.10.4 Emails and
phone calls.
8.10.5 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 Report
writing outside of what is included in the assessment code (CPT
code 97151).
8.10.7 Office
supplies or therapeutic supplies (i.e., binders, building blocks,
stickers, crayons, etc.).
8.10.8 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 Asynchronous
telehealth services.
8.10.10 ABA
services involving any aversive techniques or restraints.
8.10.11 Services
outside of the physical space 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 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. The contractor shall ensure all educational/academic
and vocational goals are removed from
the TP prior to giving approval.
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
or preschool setting
must be specifically preauthorized in the TP for use in the school
or preschool 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.
Note: The daycare setting
is not considered an academic setting and therefore may be authorized per
clinical necessity as determined by the contractor.
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 School
tuition.
8.10.18 Autism schools.
These 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
) 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 Custodial,
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 Direct
and indirect supervision of BTs and assistant behavior analysts.
8.10.23 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 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 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 Two
ABA providers at the same time.
8.10.27 Interventions
considered psychotherapy to include but not limited to: Cognitive
Behavior Therapy, Acceptance and Commitment Therapy, Prolonged Exposure,
group psychotherapy, etc.
8.10.28 Non-ABA
services by ABA providers.
8.11 Reimbursement
8.11.1 Network and non-network provider
claims for ABS CPT codes must be submitted electronically.
8.11.2 The contractor shall pay all
claims by electronic funds transfer
, effective August
1, 2021.
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 8.2.1.1 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 upon license/certification
8.11.6 ABS
Approved CPT Codes
The 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
Assessment
8.11.6.2.1.1 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.
8.11.6.2.1.11 If the ABA provider
completes the outcome measures greater than 90 calendar days before
the outcome measure due date. No additional units will be authorized
to re-administer the measures.
8.11.6.2.2 CPT
Code 97153 - Adaptive Behavior Treatment by Protocol
8.11.6.2.2.1 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 Modification
8.11.6.2.3.1 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
may not be conducted via telehealth.
8.11.6.2.3.4 CPT code 97155 must be completed
at least one time per month by the authorized ABA supervisor
effective
August 1, 2021.
• The contractor shall complete
a post-claims payment review. If the
provider does not meet this requirement,
the contractor shall recoup a 10% penalty on all
ABA claims for that beneficiary for
the entire six-month authorization.
• For audit purposes,
the contractor shall ensure a minimum of four sessions of CPT code
97155 are completed within the six month authorization period.
• For authorizations
that are less than six months in duration, e.g., as a result of
a PCS transition, a minimum of 50% of the authorized months must
meet the requirement in paragraph 8.11.6.2.3.4.
Note: In the absence
of rendered direct treatment in a calendar month (CPT codes 97153,
97156, 97157, or 97158), CPT code 97155 is not required per paragraph 8.11.6.2.3.4 and no penalties will
be applied for that month. If the only CPT code rendered in a calendar
month is CPT code 97151, then paragraph 8.11.6.2.3.4 is not applicable.
8.11.6.2.3.5 The contractor shall not authorize this
code 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 Guidance
8.11.6.2.4.1 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 or guardian
must actively participate in the continuing care of the beneficiary.
Documentation of contraindication must be documented in the TP for
continued eligibility in 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 use 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 Effective August
1, 2021, 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 for CPT code
97156 or 97157 within the first 30 calendar days
of all 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 or 95 modifier
on 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 use the
ABA TP protocols. This code is to be used for identifying behavior
excesses and deficits, and teaching parent(s)/caregiver(s) to use treatment
protocols designed to reduce maladaptive behaviors 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 (or as delegated
to an assistant behavior analyst) to treat beneficiaries
in a group setting. The focus of the skills group are 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 upon 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 is expected that one to one services will 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 for MTC conducted 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 MTC with
patient by healthcare professional for a minimum of
30 minutes.
8.11.6.2.7.3 CPT code 99368 MTC without
patient by health care professional for a minimum
of 30 minutes.
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 telehealth 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 they
submit claims for this CPT code.
8.11.7 Reimbursement Rates for ABS
Services
8.11.7.1 Reimbursement of claims in accordance
with the guidance in
paragraph 8.11.6 is established
based
upon 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 The Government
will update ABA reimbursement rates
at
the same time as the annual CHAMPUS Maximum Allowable Charge (CMAC)
Update
. ABA reimbursement rates are 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 The contractor
shall authorize Behavior Identification Assessment for
only the authorized ABA supervisor. 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
(see reference at paragraph 8.11.7.2 for the location of reimbursement
rates).
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 The contractor
shall not reimburse concurrent billing for
all ACD Category I CPT codes except when the family and the beneficiary
are receiving separate services and the beneficiary is not present
in the family session. Documentation must indicate two separate
rendering providers and locations for the services.
8.11.7.3.9 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
Government will post reimbursement
for T1023
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
using 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 Section are
not allowed.
8.11.7.7 Policies in this section must
be adhered to or claims may be recouped.
8.11.8 Cost-Sharing
8.11.8.1 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
TRICARE 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. The contractor
shall follow normal TRICARE cost-share/copayment
rules for other (non-ABA) services rendered on the
same day as ABA services.
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, the
contractor shall apply only one copay.
8.11.8.4 For Other Health Insurance (OHI),
beneficiaries receiving ABA services must obtain
a referral and prior authorization.
8.11.8.5 The contractor
shall reimburse for only ABA services under OHI that
are covered in this manual
section.
9.0 ACD
REQUIREMENTS
9.1 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 Responsibilities
9.3.1 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 section and 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.
Note: The TOP contractor,
USFHP DPs, and TFL are excluded from paragraph 9.3.1.
9.3.2 For beneficiaries
without an ASN, the contractor shall,
forward
to the “gaining” contractor all ACD related documents within 10
calendar days of
notification that
a beneficiary is transferring to a location under the jurisdiction
of another contractor.
The gaining contractor shall
accept all verified ACD documents from the outgoing contractor during
the transfer process.Note: For beneficiaries
who are assigned an ASN, the contractor shall send any additional documents
received between the original notification date and the beginning
of the 30 calendar day overlapping period to the gaining contractor.
9.3.3 The contractor shall designate
an ACD complaint officer to receive and address beneficiary family
member/caregiver complaints. The contractor shall
provide contact information for the
ACD complaint officer 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), TRICARE
Basic
program 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 8.3.2.10 by retaining evidence of attendance/completion.
9.3.4.4 The contractor shall impose a
10% claims penalty for all ABA 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 ABA provider 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 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 deny services and recoup claims 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 Oversight
9.3.10.1 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 use 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 Effective May
1, 2021, the contractor shall ensure that all beneficiaries entering
the ACD align the Vineland and SRS to their respective one year
outcome measure cycle date.
9.3.10.3 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 effective
July 1, 2021. 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.
9.3.10.4 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.
9.3.10.5 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, or ABA services
for more than 180 calendar days, the timeline resets to collect
outcome measures.
9.3.10.6 The contractor shall accept
and report only complete and valid outcome measures.
9.3.10.7 The contractor shall accept
valid measures for baseline data with dates up to one year prior to
initiation of services.
9.3.10.8 The contractor shall terminate
ASN services and not issue a subsequent ABA treatment authorizations
for failure to complete any and all outcome measures.
9.3.10.9 The contractor shall transition
to the new edition within one year of its release, should the outcome
measure edition update.
9.3.11 Provider Networks
This 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 complete
the active provider placement process within 15 business
days.
9.3.11.6.2 The contractor shall have a process
that confirms the authorized
ABA supervisor or ACSP 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 is 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 are 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 Model
The TOP
and USFHP DPs contractors are exempt from
paragraphs 9.3.12 through
9.3.12.3.
9.3.12.1 The contractor shall develop
an ABA provider steerage model, to be implemented no later than
January 1, 2022, for
ABA providers (ACSP or authorized
ABA supervisor) that take
s into
account, at a minimum:
9.3.12.1.1 Compliance with access standards.
9.3.12.1.2 At
least one other determinant into their ABA provider steerage model.
9.3.12.1.2.1 The contractor
shall submit any additional determinants to
DHA for approval prior to implementation.
9.3.12.1.2.2 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 the
highest ranking providers when assigning patients.
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
meet all
TRICARE Encounter Data (TED) requirements outlined in the TRICARE
Systems Manual (TSM),
Chapter 2 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.
9.3.15.1 The contractor
shall ensure all ACD-specific customer service staff are knowledgeable
of the most up to date ACD policy and provide consistently accurate
information.
9.3.15.2 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 A
dministrative I
nstruction-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 DEFINITIONS
11.1 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)
Assessment
A developmentally
appropriate assessment and reassessment tool must be used for formulating
an individualized ABA TP and is conducted by an authorized ABA supervisor.
For TRICARE purposes, an ABA assessment shall include data obtained
from multiple methods to include direct observation, the measurement,
and recording of behavior. A functional assessment that may include
a functional behavior analysis may be required to address problematic
behaviors. Data gathered from a parent/caregiver interview and 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 Services
ABA methods designed to improve
the functioning of a specific ASD target deficit in a core area affected
by ASD such as social interaction, communication, or behavior. The
ABA provider delivers ABA services to the beneficiary through direct
administration of the ABA specialized interventions during one-on-one
in-person (i.e., face to face) interactions with the beneficiary.
ABA services may be comprehensive (addressing many treatment targets
in multiple domains) or focused (addressing a small number of treatment
targets, such as specific problem behaviors and/or adaptive behaviors).
11.4 ABA
Sole Provider Model
A service
delivery model that includes only the use of the authorized ABA
supervisor to implement a TP designed by the authorized ABA supervisor.
The ABA sole provider delivery model is authorized in the Continental
United States (CONUS), U.S. territories, and TOP.
11.5 ABA
Tiered Delivery Model
A service
delivery model that includes the use of supervised assistant behavior
analysts and/or BTs, in addition to the authorized ABA supervisor,
to implement a TP designed by the authorized ABA supervisor. Supervised
assistant behavior analysts may assist the authorized ABA supervisor
in clinical support to include the supervision of BTs and the provision
of parent(s)/caregiver(s) treatment guidance. Tiered delivery models
are only authorized in the CONUS and U.S territories.
11.6 ABA
TP
11.6.1 A written document outlining
the ABA service plan of care for the individual, including the expected
outcomes of ASD symptoms. For TRICARE purposes, the ABA TP shall
consist of an “initial ABA TP” based on the initial ABA assessment,
and the “ABA TP Update” that is the revised and updated ABA TP based
on periodic reassessments of beneficiary progress toward the objectives
and goals.
11.6.2 Components of the ABA TP include:
the identified behavior targets for improvement, the ABA specialized
interventions to achieve improvement, and the short-term and long-term
ABA TP objectives and goals that are defined below. The ABA TP shall
also include a discharge plan.
11.7 ABA TP Goals
These are the broad spectrum,
complex short-term and long-term desired outcomes of ABA services.
11.8 ABA TP Objectives
The short, simple, measurable
steps that must be accomplished in order to reach the short-term
and long-term goals of ABA services.
11.9 Assistant Behavior Analyst
The term “assistant behavior
analyst” refers to supervised Licensed Assistant Behavior Analyst
(LABA), Board Certified Assistant Behavior Analyst (BCaBA), and
Qualified Autism Service Practitioner (QASP).
11.10 Authorized ABA Supervisor
An authorized ABA supervisor,
whether or not currently supervising, is defined as a Licensed Behavior Analyst
(LBA), BCBA, BCBA-Doctorate (BCBA-D), or 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 Providers
11.13.1 ASD diagnosing and referring
providers include: TRICARE-authorized PCMs and specialized ASD diagnosing
providers. TRICARE authorized PCMs for the purposes of the diagnosis
and referral include: TRICARE authorized 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.
11.13.4 Co-signature
from an approved ASD diagnosing/referring provider is required when
a requirement is completed by non-approved ASD diagnosing/referring
providers as defined in paragraph 11.13.Note: Adult beneficiaries
participating in the ACD who age out of the diagnosing/referring provider
pediatric scope of practice may only be diagnosed/referred by a
clinical psychologist.
11.14 Behavior
Analysis
Behavior
analysis is the scientific study of the principals of learning and
behavior, specifically about how behavior affects, and is affected
by, past and current environmental events in conjunction with biological
variables. ABA is the application of those principles and research
findings to bring about meaningful changes in socially important
behaviors in everyday settings. ABA, by a licensed and/or certified
behavior analyst, focuses on treating behavior difficulties by changing
an individual’s environment (i.e., shaping behavior patterns through
reinforcement and consequences). ABA is delivered optimally when
family members/caregivers actively participate by consistently reinforcing the
ABA interventions in the home setting in accordance with the prescribed
TP developed by the behavior analyst.
11.15 Behavior Analyst Certification
Board (BACB)
The BACB
is a nonprofit 501(c)(3) corporation established to “protect consumers
of behavior analysis services worldwide by systematically establishing,
promoting, and disseminating professional standards.” The BACB certification
offers the BCBA for master’s level and above behavior analysts,
the BCaBA certification for bachelor’s level assistant behavior
analysts, and the RBT credential for BTs with a minimum of a high
school education.
11.16 Behavior Intervention Plan
Behavior Intervention Plans
must include an operational definition of the target behavior excesses
and deficits, prevention and intervention strategies, schedules
of reinforcement, and functional alternative responses. Behavior
Intervention Plans shall be submitted along with any TP identifying
a target behavior excess or deficit.
11.17 Behavior Technician (BT)
The term “behavior technician”
refers to high-school graduate level paraprofessionals who deliver
one-on-one ABA services to beneficiaries under the supervision of
the authorized ABA supervisor, and includes RBTs, ABATs, and BCATs.
11.18 Behavioral Intervention Certification
Council (BICC)
“The BICC
was established in 2013 to promote the highest standards of treatment
for individuals with ASD through the development, implementation,
coordination, and evaluation of all aspects of the certification
and certification renewal processes. BICC is an independent and
autonomous governing body for the BCAT certification program, a
certification for BTs.”
11.19 Clinical Necessity
Clinical necessity refers to
services that are clinically indicated and appropriate to address
a beneficiary’s diagnosed condition and not in excess of the beneficiary’s
needs. The services must be individualized, specific, and consistent
with the confirmed diagnosis of the beneficiary.
11.20 Comprehensive
Care Plan (CCP)
The CCP
refers to a plan that is developed and maintained by the ASN. The
CCP shall identify all care and services for the diagnosis of ASD,
as well as, transition timelines to include, but not limited, to Permanent
Change of Station (PCS) orders. The CCP will allow for a more consistent
and beneficiary-centric approach to care.
11.21 Family/Caregiver
11.21.1 Family/Caregiver follows the
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 Analysis
The process of identifying
the variables that reliably predict and maintain problem behaviors
that typically involve: identifying the problem behavior(s); developing
hypotheses about the antecedents and consequences likely to trigger
or support the problem behavior; and, performing an analysis of
the function of the behavior by testing the hypotheses.
11.23 Medical Team Conferences
Medical team conferences are
for the purpose of the treating providers to periodically meet to
discuss the beneficiary and the overall program and progress towards
goals. All CPT coding guidance and ACD requirements must be met
for reimbursement of this code.
11.24 Parent-Mediated Programs
Parent-mediated interventions
often focus on social reciprocity. In these programs, professionals
train parents one-on-one or in group formats in home or community
settings with methods that may include didactic instruction, discussion,
modeling, coaching, or performance feedback. Once trained, parents
implement all or part of the intervention(s) with their child.
11.25 Parenting
Stress Index, 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. For the purposes of the ACD, the intent
of this tool is to identify potential resources for the beneficiary
and family. 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 Board
QABA “is an organization established
in 2012 to meet para-professional credentialing needs identified by
behavior analysts, ABA providers, insurance providers, government
departments, and consumers of behavior analysis and behavior health
services.” QABA offers the QASP certification for bachelor’s level assistant
behavior analysts, and the ABAT certification for BTs with a minimum
of a high school education or equivalent.
11.28 Qualified Health Care Professional
(QHP)
A QHP
is an individual who is qualified by education, training, licensure/regulation
(when applicable) and facility privileging (when applicable) who
performs a professional service within his/her scope of practice
and independently reports that professional service.
11.29 Social
Responsiveness Scale, Second Edition (SRS-2) 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. For
the purposes of the ACD, the intent of this tool is to identify
potential resources for the beneficiary and family. The
SIPA is the upward age extension of the PSI-Third edition (PSI-3).
Applicable for ages 11-19 years, 11 months.
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.