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 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 each beneficiary participating in the ACD who serves as the primary
clinical advocate
for the beneficiary and family.
6.1.1 The contractor
shall provide the name and contact information of the assigned ASN
in writing to the family.
6.1.2 The ASN
shall 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
: take
the lead role and coordinate with other Case Management (CM) activities
when the beneficiary has a CM and an ASN.6.1.4.1 Take the lead
role and coordinate with other Case Management (CM) activities when
the beneficiary has a CM and an ASN.
6.1.4.2 Be assigned
and serve as the primary Point Of Contact (POC) for the beneficiary/family
even when the beneficiary is eligible for services from the TRICARE
Select Navigator.
6.1.4.3 Coordinate with
the TRICARE Select Navigator.
6.2 Comprehensive
Care Plan (CCP)
6.2.1 The ASN
shall conduct an initial care management assessment to develop a
written CCP (see
paragraph 11.20) in order to identify the
needs of the beneficiary and family.
6.2.1.1 The ASN shall incorporate in
the CCP the results of all respective outcome measures
(see paragraph 6.2).
6.2.1.2 The ASN shall 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.
6.2.3 The contractor shall, for CCPs
not completed within 90 calendar days as a result of family/beneficiary noncompliance,
suspend ASN and applicable ABA services
through the duration of the existing authorization or until the
CCP is complete whichever occurs first.
6.2.4 The ASN shall notify the medical
home, Primary Care Manager (PCM), or referring provider, and parent/caregivers when the
CCP is complete and established.
6.2.5 The ASN shall share the CCP and
CCP updates with the respective providers when complete.
6.2.6 The ASN shall update the CCP
at least every six months to include updated outcome
measures.
6.3 Outcome
Measures6.3.1 All
TRICARE eligible beneficiaries participating in the ACD must complete
respective outcome measures that are norm-referenced, valid, and
reliable evaluation tools.6.3.1.1 The ASN shall
ensure the following measures are completed and submitted at baseline
and by the respective repeated intervals:
|
Outcome Measure
(current edition)
|
Repeated Due Date
|
Applicable for ASN
Services
|
Applicable for ABA
Services
|
Completed by:
|
|
Note: See
definitions sections for descriptions of outcome measure.
|
|
Parenting Stress
Index (PSI)
|
Every Six Months
|
X
|
X
|
ASN
|
|
Stress Index for
Parents of Adolescents (SIPA)
|
Every Six Months
|
X
|
X
|
ASN
|
|
Vineland Adaptive
Behavior Scales (Vineland)
|
Annually
|
|
X
|
ASN
|
|
Social Responsiveness
Scale (SRS)
|
Annually
|
|
X
|
ASN
|
|
Pervasive Developmental
Disorder Behavior Inventory (PDDBI)
|
Every Six Months
|
|
X
|
Authorized ABA Supervisor
|
6.3.1.2 The non-clinical
support person may assist in the administration tasks of completing
this requirement.
6.3.1.3 The contractor
may use other sources for collection of these measures, such as
a provider (TRICARE-authorized or equivalent) submitting the measures
as part of their standard assessment process.
6.3.1.4 The ASN shall
accept and report only complete and valid outcome measures.
6.3.1.5 The contractor
shall accept valid outcome measures for baseline data with dates
up to one year prior to initiation of both ASN and ABA services.
6.3.2 The contractor
shall deny ASN services and authorization/reauthorization for ABA
services for failure to complete outcome measures at baseline and
repeated interval due dates for outcome measures.6.3.2.1 The ASN shall
identify any beneficiary, parent/caregiver, or authorized ABA supervisor
who is unable or unwilling to meet this requirement and assist the
family in resolving the lack of completion of outcome measures.
6.3.2.2 The ASN shall
document non-compliance in the beneficiary’s ASN record.
6.3.3 The outcome
measures timeline does not change when changing regions, provider,
or beneficiary category. If the beneficiary or family elects to
pause services from the ACD, ASN, and/or ABA services for more than 180
calendar days, the timeline resets to collect outcome measures.
6.3.4 The contractor
shall transition to the new edition within one year of its release,
should the outcome measure edition update.
6.3.5 The contractor
shall ensure all outcome measures scores are reported in the corresponding
DD Form 1423, Contract Data Requirements List (CDRL), located in
Section J of the applicable contract.
6.3 The ASN shall serve as a single
Point
of Contact (POC
), in coordination
with 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), MTF services, 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 MTC meetings and document in the contractor on-line system a summary
of the MTC calls. The ASN notes shall be available to the PCM, referring
provider, and the Government. Any provider may request an MTC, however,
the ASN, or outreach coordinator, shall coordinate the meeting.
6.3.2 Work with the family to coordinate
services, and treatments,
and hours as appropriate for
the family and beneficiary and document all types
of referred care in a 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 ABA referrals transfer
without requiring a new ASD diagnosing/referring provider appointment.
6.3.3.3 The incoming ASN shall work
with the family to ensure all ACD program requirements are met if
there is missing information in the case transfer.
6.3.3.4 The outgoing ASN shall forward
to the incoming ASN all ACD related documentation, including, but not
limited, to the CCP and outcomes measures
within 10 calendar days of 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.
6.3.3.5 The incoming ASN or
non-clinical outreach coordinator shall identify providers for care
and services for the diagnosis of ASD at the beneficiary’s 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 at
the new location as the contractors cannot guarantee provider availability
for extended periods of time.
6.3.3.6 The ASN shall coordinate with
the MTF or appointing center for appointments that are required within
the MTF.
6.4 The ASN or non-clinical outreach
coordinator shall identify and facilitate connections with local
level resources that may benefit TRICARE eligible beneficiaries
in the ACD to include, but not limited to, access to State Medicaid
services, community services, respite care, and support
groups, etc.
6.5 The ASN or non-clinical outreach
coordinator shall assist the family in accessing available respite
service options, as well as assist in identifying necessary documents
for the respective options. All beneficiaries may be eligible for
State, local level services, or both. ADFMs may also be eligible
for Uniformed Service/EFMP respite or TRICARE ECHO Respite services
(see TPM,
Chapter 9, Section 12.1).
6.6 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.
6.6.1 The ASN or non-clinical outreach
coordinator shall document that the family acknowledged receipt
of the materials.
6.6.2 The contractor shall make resources
available electronically on the contractor’s website and by mailing/emailing
if requested.
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) to beneficiaries
for whom they are rendering treatment services. The ASN role shall
be external to any agency rendering services to the beneficiary.
6.9 The contractor
shall analyze data on a monthly basis, through the referral, authorization,
claims process, and other data elements relevant to identifying
beneficiaries diagnosed with ASD to identify potentially eligible beneficiaries
with a diagnosis of ASD (DSM-5 F84.0) and offer ASN services to
these beneficiaries.
6.8 If a beneficiary or the family
declines the ASN for any reason (i.e., declines at outset, meets
ABA services goals, takes a break from services, etc.), they are
no longer eligible for the ACD.
6.8.1 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 pending all criteria
are met.
6.9 The contractor shall document
ASN notes in the contractor’s CM system visible to Government designated
authorities.
7.0 PARENTAL AND FAMILY SUPPORT
The contractor shall make information
and resources related to ASD publicly available on the contractor
website (see
paragraph 9.3.1). The ASN shall notify the
family about the website. The website includes at a minimum:
7.1 Information regarding support groups
and resources in the local area.
7.2 Information regarding support
groups and services on military installations when available.
Note: Support groups are a community
resource, not a TRICARE covered benefit.
7.3 A “New to the ACD information
toolkit” (approved by DHA prior to use) provides new beneficiaries
and their families with information about the ACD, including but
not limited to ECHO enrollment, description of all services available
to the beneficiary, the role of the ASN, and what to expect every
six months, one year, and two years if receiving services.
7.4 Information regarding mental
health services (i.e., individual, family, and group) and non-clinical
services (i.e., Military OneSource), in each local area (based on
the Prime Service Area (PSA)/market if located in a PSA/market)
that offer specialized services for family members of a beneficiary
with a diagnosis of ASD
(in accordance with paragraphs
6.4.1 and 6.5). Telehealth (TH) services may be leveraged
for accessing appropriate mental health services (see TPM,
Chapter 7, Section 22.1 regarding TH services).
7.5 Information regarding parent-mediated
programs (see
paragraph 11.24), rendered by TRICARE authorized
individual providers under the TRICARE Basic Program, where available.
The ASN shall identify these resources to each family
,
when requested by the family. Parent-mediated programs
shall be reimbursed based upon the TRICARE authorized individual
provider’s discipline for treatment (i.e., Licensed Clinical Social
Workers (LCSWs) and the provider shall use Current Procedural Terminology
(CPT) codes for individual/group/family psychotherapy sessions).
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 plans,
delivers, and/or supervises an ABA program. Both models are eligible
for authorization and the model recommended shall be 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. All TRICARE ABA providers authorized
under the ACD (master’s level and above, assistant, and BT level)
must:
8.2.1 Obtain
a National Provider Identifier (NPI) number (all claims must have
the rendering provider’s name and NPI for processing).
8.2.2 Complete the training for Basic
Life Support (BLS) or a Cardiopulmonary Resuscitation (CPR) equivalent certification,
as demonstrated by completion of a hybrid course comprised of a
web-based instruction component and live component to demonstrate
skills on a dummy. Any course that is done entirely in person is
also acceptable. This certification must be maintained and current.
8.2.3 The contractor shall obtain
respective documents from the authorized ABA supervisor:
8.2.3.1 A copy of a Criminal History
Review for all authorized ABA supervisors with whom the contractor enters
into a Participation Agreement. The Criminal History
Review for all authorized ABA Supervisors may search federal, state,
and county public records.
8.2.3.2 A copy of a Criminal History
Background Check (CHBC) of assistant behavior analysts and BTs.
8.2.3.3 The CHBC of assistant behavior
analysts and BTs shall include current Federal, State, and County Criminal
and Sex Offender reports for all locations the assistant behavior
analyst or BT has resided or worked during the previous 10 years;
and
8.2.4 Any provider
who is convicted for any felony of any kind, or a misdemeanor involving
crimes against a child or domestic violence is ineligible to become
a TRICARE authorized provider.
8.2.5 The contractor shall
issue a provider certification after completing its 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
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 (see paragraph
8.10.19 for additional details). The ACSP and Sole Providers
must:
8.3.1 Submit evidence
to the contractor that professional liability insurance in the amounts
of one million dollars per claim and three million dollars in aggregate,
is maintained in the ACSP’s/Sole Provider’s name, unless State requirements
specify greater amounts.
8.3.2 Submit
to the contractor all documents necessary to support an application
for designation as a TRICARE ACSP/Sole Provider.
8.3.3 Enter into a Participation
Agreement,
Addendum A, approved by the Director, DHA
or designee (i.e., the contractor).
All ACSPs/Sole
Provider practices must re-sign all of their participation agreements
within 120 calendar days of the implementation of this manual change.
8.3.4 Employ directly, or contract
with, qualified authorized ABA supervisors,
assistant behavior analysts, and/or BTs, if applicable.
8.3.5 Certify that all authorized
ABA supervisors, assistant behavior analysts, and BTs employed by
or contracted with the ACSP meet the education, training, experience,
competency, supervision, and ACD requirements specified in this
section.
8.3.6 Comply
with all applicable organizational and individual licensing or certification
requirements that are extant in the State, county, municipality,
or other political jurisdiction in which ABA services are provided
under the ACD.
8.3.7 Maintain
all applicable business licenses and employment or contractual documentation
in accordance with Federal, State, and local requirements and the
authorized ABA supervisor’s business policies regarding assistant
behavior analysts and BTs.
8.3.8 Report to
the contractor within 30 calendar days of notification of a State
sanction or BACB sanction issued to the BCBA or BCBA-Doctoral level
(BCBA-D) for violation of BACB Professional and Ethical Compliance
Code for Behavior Analysts (
http://www.bacb.com/ethics-code)
or notification of loss of BACB certification or State licensure.
Loss of State licensure or certification, or loss of BACB certification
shall result in termination of the Participation Agreement with
the authorized ABA supervisor with an effective date of such notification.
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.
8.3.9 Familiarize
themselves, and comply with program requirements as stated in
32
CFR 199.6 and
32 CFR 199.9.
This information is available on-line and is accessible to the public.
TRICARE Manuals and the Code of Federal Regulation (CFR) are found
on-line at
https://manuals.health.mil/.
All authorized ABA providers agree to abide by all rules and regulations
of the TRICARE Program, but additionally agree to bill for services
that are only deemed clinically necessary and appropriate.
8.3.10 Attend a contractor-hosted
“provider education” training, no less than annually. The provider education
training includes at a minimum: ACD requirements (to include ABA
provider requirements, correct billing practices/claims filing,
authorizations, exclusions, medical records documentation, provider
responsibilities, and program requirements), basic TRICARE rules,
and 32 CFR 199.
8.3.11 Comply with all applicable
requirements of the Government designated utilization and clinical
quality management organization.
8.4 Provider
Requirements
8.4.1 Authorized
ABA Supervisors (BCBA, BCBA-D, or Clinical Psychologist)
8.4.1.1 Have a master’s degree or above
in a qualifying field as defined by the State licensure/certification where
defined or in the absence of State licensure/certification, a graduate
degree from an accredited institution (per TPM,
Chapter 11, Section 3.3) in behavior analysis,
psychology, special education, or a related field; and
8.4.1.2 Have a current:
8.4.1.2.1 Unrestricted State-issued license
or State certification if practicing in a State that offers State licensure
or State certification in behavior analysis or psychology; or
8.4.1.2.2 Certification from the BACB
where such State-issued license or certification is not available.
8.4.2 Assistant Behavior Analysts
8.4.2.1 Have a bachelor’s degree or
above in a qualifying field as defined by the State licensure/certification where
defined or in the absence of State licensure/certification, a degree
in a field accepted by a certification body approved by the Director,
DHA; and
8.4.2.2 Have a current:
8.4.2.2.1 Unrestricted State issued license
or State certification if they practice in a State that offers State licensure
or State certification; or
8.4.2.2.2 Certification from the BACB
or the Qualified Applied Behavior Analysis (QABA) certification
board.
Note: Should a State licensure or State certification
specify criteria for an assistant behavior analyst that results in
a previously authorized TRICARE assistant behavior analyst not meeting
the requirements for State licensure or State certification, that
provider may be recognized by TRICARE as only a BT without having
to obtain the BT certification (if allowed by State law) and shall
be subject to all BT requirements once the State licensure language becomes
effective. A certification as an ABA provider must be maintained.
8.4.2.3 Assistant behavior analysts
must receive supervision in compliance with their certification
board. Assistant behavior analysts must work under the supervision
of an authorized ABA supervisor who meets the requirements specified
in
paragraph 8.4.1.
8.4.2.4 Assistant behavior analysts
who conduct supervision of BTs must be in compliance with their certification
board for supervisory activities.
8.4.3 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.
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.
The TOP contractor shall ensure ABA providers follow all requirements
laid out in this manual. The TOP shall ensure reimbursement for
ABA services in US territories are paid in accordance with reimbursement
rates (see
http://www.health.mil/rates).
The TOP contractor shall not authorize the tiered model outside
of the US and US territories.
8.5.2 The TOP
contractor shall verify compliance with all requirements outlined
in the ACD.
8.5.3 Where
there are no BCBAs or BCBA-Ds certified by the BACB within the TRICARE
specialty care access standards in the host nation, there is no
ABA benefit.
8.5.4 The 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.
8.5.5 The TOP contractor shall ensure
the reimbursement of TOP claims for ABA services obtained overseas are
based upon the lesser of billed charges, the negotiated reimbursement
rate, or the Government-directed reimbursement rate foreign fee
schedule. (See
Chapter 24, Section 9 and
the TRICARE Reimbursement Manual (TRM),
Chapter 1, Section 35 for additional guidance).
8.6 ABA
Policy
8.6.1 Referral for ABA Services
A complete referral, 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
shall not be accepted.
8.6.1.1 A referral must specify ABA
services are being requested.
8.6.1.2 For beneficiaries first diagnosed
with ASD at age eight years or older, and requesting ABA services,
a specialized ASD diagnosing provider evaluation, meeting all requirements
set forth in
paragraph 4.24.3,
is required as part of the referral for ABA services.
8.6.1.3 If the initial diagnosis of
ASD was made greater than two years prior to a referral for ABA
services, an updated evaluation, to include diagnostic criteria
and a validated assessment tool, by an ASD diagnosing provider is
required to determine the current level of supports needed.
8.6.1.4 The contractor shall use the
referral receipt date confirmed by the contractor’s system of the
verified referral as the start date of the two-year referral timeline.
8.6.2 Authorization for ABA Services
8.6.2.1 The contractor shall, upon receipt
of the completed referral for ABA services, issue an evaluation authorization
for an initial assessment and TP development. Then the authorized
ABA supervisor must complete and submit the initial documentation
(assessment and TP) including recommended Adaptive Behavior Services (ABS)
CPT codes and number of units to the contractor for review and subsequent
appropriate approval for a six month treatment and reassessment/TP
update authorization for active delivery of ABA services in accordance
with
Chapter 1, Section 3.
8.6.2.1.1 The contractor shall issue
the treatment authorization identifying approved units in accordance with
the guidance defined in
paragraph 8.11.6.
8.6.2.1.2 The contractor shall issue
an initial six-month treatment authorization only when all initial outcomes
measures are complete.
8.6.2.1.3 The contractor shall ensure
all ABA services are preauthorized.
8.6.2.2 The contractor shall:
8.6.2.2.1 Complete a clinical necessity
review on every TPs recommended goals, targets, progress, and hours (see
paragraph 8.7.1 for
TP requirements) prior to issuing any six month treatment authorization
for ABA services.
8.6.2.2.2 Authorize TPs containing clinically
necessary and appropriate services in accordance with the Section
(exclusions
as defined in paragraph 8.10 shall not be authorized).
8.6.2.2.3 Deny and return TPs
containing exclusions as defined in paragraph 8.10.
8.6.2.2.4 Work with the ABA provider
to revise the TP to address any findings requiring resolution prior
to authorization of that TP.
8.6.2.3 The contractor shall complete
100% clinical necessity reviews for ABA services for all compliant
TPs within five business days for authorization processing standards.
8.6.3 Subsequent Referrals and Authorizations
8.6.3.1 If ongoing services are clinically
indicated, prior to the expiration of each six-month treatment authorization
period, as early as 60 calendar days in advance and no later than
30 calendar days in advance, a re-authorization for ABA services
should be requested by the ABA provider for the next six months
from the contractor. If the ABA provider submits the reauthorization
request less than 30 calendar days in advance of the expiring authorization,
the ABA provider is at risk for non-reimbursable ABA services until
the new authorization is issued if the existing authorization expires
prior to the approval of the next authorization.
8.6.3.1.1 The contractor shall not back
date late submissions.
8.6.3.1.2 The request for re-authorization
must be supported by submission of the every six month ABA reassessment
and TP update that includes documentation of progress. Outcome measures
must be completed/submitted prior to issuing the next six-month
authorization.
8.6.3.1.3 The contractor shall complete
a clinical necessity review of the documentation submitted every
six months, including Pervasive Developmental 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 authorization 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 update
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 MeasuresFor all TRICARE eligible beneficiaries
receiving ABA services, all outcome measures must be completed and reported
using norm-referenced, valid, and reliable evaluation tools prior
to issuing the treatment authorization. For the purpose of the ACD,
all outcome measures completed by ABA providers are considered an
indirect service and are to be completed under CPT code 97151 (see
paragraph 8.11.6.2.1). Submission of all outcome measure results
must include the publisher print report (including cover page and
all data tables) or hand-scored summary score sheet(s) that include
T-scores. Embedding T-scores within the treatment plan or other
clinical documents is insufficient to meet the submission requirements.
8.6.4.1 PDDBI, Current EditionThis 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 preauthorization. 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.
8.6.4.2 Vineland Adaptive Behavior
Scales, Third Edition (Vineland-3) (or Current Edition)The Parent Form, the
Interview Form (if completed by a TRICARE-authorized provider),
or the Teacher 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 11.32.
8.6.4.3 Social Responsiveness
Scale, Second 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)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)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.
8.6.4.8 The contractor shall
ensure all T 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.
8.6.5 MTC
8.6.5.1 MTCs include face-to-face participation
(in-person or via a compliant TH platform) by a minimum of three
Qualified Health Care Professionals (QHPs) from different specialties
or disciplines (each of whom provides direct services to the beneficiary),
with or without the presence of the beneficiary/family member(s),
who convene to collaborate or discuss a specific beneficiary case.
The participants are actively involved in the development, revision,
coordination, and implementation of health care services clinically
necessary for the beneficiary. See
paragraph 8.11.6.1.7 for requirements
for using this CPT code. Though not required, family member/beneficiary participation
as appropriate is recommended.
8.6.5.2 The ASN shall participate in
these MTC discussions.
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 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, the ASN must participate per
paragraph 6.3.1.26.4.1.2.
8.7 ABA Service Documentation
All ABA documentation must
be completed by the authorized ABA provider according to the following:
8.7.1 ABA assessments
and TP documentation (completed by the authorized ABA supervisor)
must include:
8.7.1.1 Identifying Information: The
beneficiary’s name, date of birth, date the initial ABA assessment
and initial ABA TP were completed, the beneficiary’s DoD Benefit
Number (DBN) or sponsor’s Social Security Number (SSN), and the
name of the referring provider.
8.7.1.2 Reason for Referral: The ABA
TP and TP updates must include the ASD diagnosing/referring provider’s ASD
diagnosis, to include the level of support required according to
DSM-5 ASD criteria.
8.7.1.3 Background Information: Background
and history to include, but is not limited to, information that clearly
reports the beneficiary’s condition, diagnoses, medical co-morbidities
(to include over-the-counter (OTC) medications), family history,
school enrollment status, number of hours enrolled in school, the
number of hours receiving other support services such as OT, PT,
and SLP, documentation of the age of the child and year of the initial
ASD diagnosis, and how long the beneficiary has been receiving ABA
services.
8.7.1.4 Summary of Assessment Activities:
The TP must include objectively measured behavioral excesses and
deficits that impede the beneficiary’s safe, healthy, and independent
functioning in all domains applicable (language, development, social
communication, and clinical adaptive behavior skills). This assessment
may indicate a need for a behavior intervention plan (
paragraph 11.6)
for each targeted behavior excess and deficit. The TP shall include
the list of assessments administered. The initial ABA assessment
must include the PDDBI Parent Form Domain/Composite Score Summary
Table.
8.7.1.5 TP Goals: The ABA TP must clearly
define measurable targets in all relevant DSM-5 (or most current edition)
symptom domains, including parent/caregiver goals as identified
in the initial assessment, and objectives and goals individualized
to the strengths, needs, and preferences of the beneficiary and
his/her family members. The ABA TP goals must address core symptoms
of ASD:
• Social Communication and Social
Interaction Behavior (to include restricted, repetitive, and/or
stereotypical patterns of behavior, interests, and/or activities).
• Restrictive/Repetitive/Stereotypical
Patterns of Behavior (i.e., stereotyped/repetitive motor movements, insistence
on sameness, inflexible adherence to routines, highly fixated interests,
hyper/hypo-activity to sensory input).
8.7.1.5.1 Goals must be measurable, objective,
achievable, developmentally appropriate, and clinically significant.
8.7.1.5.2 Goals must be described as
follows:
• Objective, baseline, and ongoing
measurement levels for each target behavior/symptom in terms of
frequency, intensity, and duration;
• A description of treatment
interventions and techniques specific to each of the targeted behaviors/symptoms;
• Identify the objective measures
of assessment for each goal specified; and
• Functional goals must be specific
to the child, objectively measurable within a specified time frame,
attainable in relation to the child’s prognosis and developmental
status, relevant to child and family, and directly related to the
core symptoms of ASD as defined by the DSM.
8.7.1.5.3 The ASN shall ensure goals
typically treated by specialty providers are identified and addressed
in the CCP. When developing goals for children with suspected or
diagnosed co-morbid medical or behavioral health conditions, the
ABA supervisor must coordinate with the appropriate skilled and
licensed professionals in order to assess the most appropriate treatment
intervention. In order for the ABA provider to address co-morbid
condition targets, documentation on the TP must demonstrate coordination
with the appropriate medical specialty service, to include the name
of the consulting provider. For example:
8.7.1.5.3.1 A child with a co-morbid diagnosis
of a motor disorder who has TP goals addressing speech or motor
skill development would require coordination with SLP, OT, or PT
as appropriate.
8.7.1.5.3.2 A child with a co-morbid diagnosis
of anxiety disorder would require coordination with the appropriate
behavioral health provider.
8.7.1.5.3.3 A child with a feeding disorder
would require coordination with the appropriate medical provider to
include, but not limited to: physician, dietitian, OT, or SLP.
8.7.1.6 TP ABA Services Recommendations:
TP recommendation of units of ABA services are based 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 the 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 weekly hours, submitted as units, and measurable objectives and
goals for parent/caregiver treatment guidance on implementation
of selected treatment protocols with the beneficiary at home and
in other settings where applicable is required. Participation by
the parent(s)/caregiver(s) is required, and re-authorization for
ABA services is contingent upon their involvement. If parent(s)/caregiver(s) participation
is not possible, the TP must document the reasons for non-participation
(i.e., the parent/caregiver is deployed, is physically unable to
deliver the ABA services). All attempts to mitigate the lack of
involvement/participation must be documented by the ABA provider.
Implementation of the TP should begin with parent guidance sessions
(CPT code 97156 or 97157), especially if other ABA services are
delayed because the authorized ABA supervisor hiring a new BT for
the TP.
8.7.1.6.2 TP must identify recommended
units for each requested CPT code including the location of rendered
services.
8.7.1.6.3 Documentation of parent/caregiver
engagement and implementation of the ABA TP must be included as
a required TP goal that is reassessed every six months during the
ABA TP update. Reasons for lack of/inability for parental involvement
must be documented.
8.7.1.6.4 Recommendation for continued
ABA services (if continuation is indicated), to include a recommendation
for the number of weekly units of one-on-one ABA services, including
documentation of clinical necessity if additional units are required.
8.7.1.7 TP Progress: ABA reassessments
and TP updates must document the evaluation of progress for each current
behavior target identified on the initial ABA TP and prior TP updates.
Documentation of the ABA reassessment and TP update must be completed
every six months and include all of the following but not limited to
(the contractor may request additional information based 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
session note. This session note must include, but is not limited
to:
8.7.2.15.1 The date and time of session,
to include start and end time;
8.7.2.15.2 Length of assessment session;
8.7.2.15.3 A legible name of the rendering
provider, to include provider type/level;
8.7.2.15.4 A signature of the rendering
provider;
8.7.2.15.5 Content of the session to include
what activity, measures, observations were administered during the
assessment.
8.8 Discharge Planning
8.8.1 The following
discharge criteria are established to determine if/when ABA services
are no longer appropriate:
8.8.1.1 Loss of eligibility for TRICARE
benefits as defined in
32 CFR 199.3.
8.8.1.2 The authorized ABA supervisor,
the contractor, or the family has determined one or more of the following:
8.8.1.2.1 The patient has met ABA TP
goals and is no longer in need of ABA services.
8.8.1.2.2 The patient has made no measurable
progress toward meeting goals identified on the ABA TP after successive
progress review periods and repeated modifications to the TP.
8.8.1.2.3 ABA TP gains are not generalizable
or durable over time and do not transfer to the larger community
setting after successive progress review periods and repeated modifications
to the TP.
8.8.1.2.4 Recommended by the contractor
through the clinical necessity review process.
8.8.1.2.5 The patient can no longer participate
in ABA services (due to medical problems, family problems, or other
factors that prohibit participation).
8.8.1.3 Termination of services if
the diagnosing/referring provider or PCM either changes the diagnosis,
or does not believe continued ABA services are clinically necessary.
8.8.2 Termination of ABA services
under any circumstance must not occur abruptly by the authorized
ABA supervisor. All termination plans must be submitted at least
45 calendar days prior to the termination of services.
8.8.2.1 The contractor shall work with
the ABA provider to ensure a smooth transition when services are determined
to no longer be clinically necessary or otherwise need to be terminated
on short notice.
8.8.2.2 The contractor shall, should
ABA services be terminated abruptly by the authorized ABA supervisor, report
the authorized ABA supervisor to the appropriate credentialing/licensure
board.
8.8.3 The contractor
shall, if the clinical necessity review determines direct ABA services,
either one to one or group, are no longer clinically necessary,
use parent training services to fade an ABA service program for
one six-month authorization.
8.8.4 Discharge
planning must be documented in every initial TP, every updated TP,
and at termination of services.
8.8.5 A discharge summary is required
for all beneficiaries whose ABA services are terminated to include
the reason for termination. Discharge summary writing is not a reimbursable
service as this is an indirect activity (report/summary writing).
8.8.6 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 includes a minimum
of 30 records for each ASCP/Sole Provider group that include a combination
of administrative records (
paragraph 8.9.78.9.6)
and medical documentation (
paragraph 8.9.88.9.7)
reviews and one MTC session 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 administration 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 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 (PI) 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:
• Compliance with the requirements
set forth in
paragraph 8.7.2.
• Compliance with ABS approved
CPT codes per
paragraph 8.11.6.
• Sufficient documentation to
justify a medical record.
• No billing for office supplies
to include therapeutic supplies.
• No billing for ABA services
using aversive techniques to include restraints (even if billed
using a covered CPT code).
• Group ABA services are not
billed as authorized one-on-one ABA services.
• No billing for educational
or vocational ABA services, and other non-medical services such
as changing of diapers or billing for services while the beneficiary
is sleeping.
• 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 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 calendar 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 BT training.
8.10.2 ABA Services for any 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 Any administrative tasks (i.e.,
filing, telephone, appointment scheduling), or supplies or items
to include office supplies or therapeutic supplies (i.e., binders,
building blocks, stickers, crayons, etc.).
8.10.8 ABA services provided remotely
through Internet technology or through telemedicine/TH (except as allowed
under
paragraph 8.11.6.1.4.9).
8.10.9 Asynchronous TH 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 TH. Certain community settings
such as sporting events, camps, and other setting as determined
by the contractor are also excluded. Any location not listed must
be reviewed and approved by the contractor.
8.10.12 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 setting.
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 The contractor shall authorize
and reimburse only CPT code 97153 rendered by the authorized ABA supervisor
(not delegated to the assistant) in the school setting.
8.10.17 ABA services for a beneficiary
that are written in a beneficiary’s IEP and are required to be provided without
charge by the local public education facility in accordance with
the Individuals with Disabilities Act or other applicable laws and
regulations. In order for ABA services to be authorized within a
school setting, the parent/caregiver must voluntarily provide the
IEP (or equivalent for non-public school placement) in order for
the contractor to make an appropriate determination.
8.10.18 School tuition.
8.10.19 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.
8.10.20 Goals targeting a functional/activities
of daily living (ADLs) skills (see
32
CFR 199.2 definitions of ADLs) are excluded. However,
the principles of ABA (i.e., backward chaining, schedules of reinforcement)
may be targeted as a goal of parent/caregiver guidance to introduce
how the parent should teach ADLs outside of ABA services rendered
by an ABA provider.
8.10.21 Custodial, personal care, and/or child
care childcare.
8.10.22 Durable Equipment (DE) whose
safety and efficacy have not been established as described in
32
CFR 199.4.
8.10.23 Direct and indirect supervision
of BTs and assistant behavior analysts.
8.10.24 ABA evaluation or intervention
services provided by a clinic or agency owned by the child’s responsible adult
(e.g., biological, adoptive, or foster parents, guardians, court-appointed
managing conservators, other family members by birth or marriage).
8.10.25 ABA evaluation or intervention
services provided directly by the child’s responsible adult (e.g., biological,
adoptive, or foster parents, guardians, court-appointed managing
conservators, other family members by birth or marriage). Billing
for rendered ABA services to family members is considered a conflict
of interest and therefore may be subject to the Civil Money Penalties
Law (CMPL).
8.10.26 Concurrent billing is excluded
for all ABS Category I CPT codes except when the family and the beneficiary
are receiving separate services and the beneficiary is not present
in the family session.
8.10.27 Two ABA providers at the same
time under one CPT code.
8.10.28 Interventions considered psychotherapy
to include, but not limited to: Cognitive behavior therapy, Acceptance
and Commitment Therapy, Prolonged Exposure, group psychotherapy,
etc.
8.10.29 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.
8.11.3 The contractor shall reimburse
claims using the ABS CPT codes. These codes apply to the provision
of ABA services rendered by ACD approved providers in all authorized
settings (clinic, school, home, TH, or certain community setting).
8.11.4 The contractor shall ensure
paid claims identify the name of the rendering provider for each
ABA service delivered, to include the NPI of the rendering provider
per unique claim line (i.e., every session must be identified as
its own unique line on any claim submitted).
8.11.5 Application of Health Insurance
Portability and Accountability Act (HIPAA) taxonomy designation.
All claims for ABS CPT codes must include the HIPAA taxonomy designation
of each provider type. Each provider on a claim form must be identified
by the correct HIPAA taxonomy designation. The designations to be
used are only:
8.11.5.1 103K00000X Behavior Analyst
for master’s level and above;
8.11.5.2 106E00000X Assistant Behavior
Analyst;
8.11.5.3 106S00000X Behavior Technician;
or
8.11.5.4 Other appropriate HIPAA taxonomy
based upon license/certification.
8.11.6 ACD
Approved CPT Codes
The contractor
shall only authorize ABS codes for only ABA providers under the
demonstration authority using the Special Processing Code (SPC), AS.
8.11.6.1 Category I CPT Codes
Concurrent billing is excluded
for all ACD Category I CPT codes except when the family and the
beneficiary are receiving separate services and the beneficiary
is not present in the family session.
8.11.6.1.1 CPT Code 97151 - Behavior Identification
Assessment
8.11.6.1.1.1 The initial ABA assessment,
ABA TP development, and the ABA reassessments and TP updates, conducted
by the authorized ABA supervisor during a one-on-one encounter with
the beneficiary and parents/caregivers, must be coded using CPT
code 97151, “Behavior Identification Assessment.”
8.11.6.1.1.2 Elements of ABA assessment
include:
• One-on-one observation of the
beneficiary (must be completed in person, face-to-face).
• Obtaining a current and past
behavioral functioning history, to include functional behavior analysis
if appropriate.
• Reviewing previous assessments
and health records.
• Conducting interviews with
parents/caregivers to further identify and define deficient adaptive
behaviors.
• Administering assessment tools,
to include the administration of the PDDBI.
• Interpreting assessment results.
• Development of the TP, to include
design of instructions to the supervised assistant behavior analysts
and/or BTs (under the ACD).
• Discussing findings and recommendations
with parents/caregivers.
• Preparing the initial ABA assessment,
semi-annual ABA re-assessment (to include progress measurement reports),
initial ABA TP and semi-annual ABA TP updates.
8.11.6.1.1.3 This code is intended for reporting
initial assessments and reassessments by the authorized ABA supervisor
once every six months.
8.11.6.1.1.4 CPT code 97151 is a timed code
(per 15 minutes), meaning this code is reimbursed per authorized units
provided by an authorized ABA supervisor (or as delegated to an
assistant behavior analyst).
8.11.6.1.1.5 CPT code 97151 may not be conducted
via TH.
8.11.6.1.1.6 The contractor shall authorize
CPT code 97151 for up to 32 units (eight hours) for the initial request
of ABA services to complete an initial ABA assessment and TP development
(to include administration, scoring, and review of the PDDBI). CPT
code 97151 must be used within 14 calendar days of the first date
of service for CPT code 97151 and is a use or lose concept.
8.11.6.1.1.7 The contractor shall, after
the initial assessment, authorize CPT code 97151 for up to 24 units
(six hours) for reassessments and TP updates for every subsequent
authorization.
8.11.6.1.1.8 A second opinion authorization
(for 32 units of CPT code 97151) may be permitted to overlap with
another approved authorization. Two “ongoing” treatment authorizations
of direct services (CPT codes 97153, 97155, 97156, 97157, and 97158)
are not permitted.
8.11.6.1.1.9 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.
8.11.6.1.1.10 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 measure.
8.11.6.1.2 CPT
Code 97153 - Adaptive Behavior Treatment by Protocol
8.11.6.1.2.1 The code, CPT code 97153, must
be used for direct one-on-one ABA services delivered per ABA TP
protocol to the beneficiary. Direct one-on-one ABA services are
most often delivered by the supervised BT or assistant behavior
analyst under the tiered delivery model, but they can also be delivered
by the authorized ABA supervisor under the Sole Provider or tiered
delivery model.
8.11.6.1.2.2 CPT code 97153 is a timed,
15 minutes, increment code.
8.11.6.1.2.3 The contractor shall authorize
CPT code 97153 units in a six-month authorization and monitor to ensure
TP recommendations per week are maintained and not exceeded.
8.11.6.1.2.4 The contractor shall deny CPT
code 97153units greater than 32 units (eight hours) per day or 160 units
(40 hours) per week.
8.11.6.1.2.5 CPT code 97153 may not be conducted
via TH.
8.11.6.1.3 CPT
Code 97155 - Adaptive Behavior Treatment by Protocol Modification
8.11.6.1.3.1 The code, CPT code 97155, is
used by authorized ABA supervisors (or as delegated to an assistant behavior
analyst) for direct one-on-one time with one beneficiary to develop
a new or modified protocol. This code may also be used to demonstrate
a new or modified protocol to a BT with the beneficiary present.
The focus of this code is the addition or change to the protocol.
8.11.6.1.3.2 CPT code 97155 is a timed,
15-minute, increment code.
8.11.6.1.3.3 CPT code 97155 may not be conducted
via TH.
8.11.6.1.3.4 CPT code 97155 must be completed
at least one time per month by the authorized ABA supervisor.
8.11.6.1.3.4.1 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.
8.11.6.1.3.4.2 For audit purposes, the contractor
shall ensure a minimum of four sessions of CPT code 97155 are completed
within the six months authorization period.
8.11.6.1.3.4.3 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 8.11.6.1.3.4.
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 8.11.6.1.3.4 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 8.11.6.1.3.4 is not applicable.
8.11.6.1.3.5 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.
8.11.6.1.4 CPT Code 97156 - Family Adaptive
Behavior Treatment Guidance
8.11.6.1.4.1 It is important that family members
or caregivers learn to apply the same treatment protocols to reduce
maladaptive behaviors and reinforce appropriate behavior. It is
expected that as families become more capable of providing treatment
protocols or as beneficiary symptoms improve, the amount of one-on-one
ABA services provided by an ABA provider will decrease. Unless therapeutically
contraindicated, the family 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.
8.11.6.1.4.2 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 teaching to assistant
behavior analysts working under their supervision, but only the
authorized ABA supervisor may bill for this service using this code.
8.11.6.1.4.3 The beneficiary is not required
to be present for the parent/caregiver sessions; however, presence of
the beneficiary is encouraged.
8.11.6.1.4.4 CPT code 97156 is a timed,
15-minute, increment code.
8.11.6.1.4.5 The contractor shall deny CPT
code 97156 units greater than eight units (two hours) per day.
8.11.6.1.4.6 CPT code 97156 may be used
only in a home or clinic/office-based setting. School settings are prohibited.
8.11.6.1.4.7 A minimum of six parent/caregiver
sessions are required every six months. These six sessions may include
CPT codes 97156, 97157, or a combination of the two.
8.11.6.1.4.7.1 The contractor shall work with
the family and the provider to resolve barriers for parent/caregiver
sessions. The first session shall be for CPT code 97156 or 97157 within
the first 30 calendar days of all treatment authorization.
8.11.6.1.4.7.2 The contractor shall deny renewed
ABA services for a subsequent authorization period for that beneficiary
if this requirement is not met for two consecutive authorization
periods.
8.11.6.1.4.8 Parent/caregiver sessions for
CPT code 97156 may be conducted via TH only after the first six-month
authorization period per authorized provider. Additionally, all
services provided via TH must adhere to State laws governing TH
services.
8.11.6.1.4.9 Parent/caregiver sessions conducted
remotely must include the
GT or
95 modifier
on claims. Remote Family Adaptive Behavior sessions must be in compliance
with TPM,
Chapter 7, Section 22.1.
8.11.6.1.5 CPT
Code 97157 - Multiple-Family Group Adaptive Behavior Treatment Guidance
8.11.6.1.5.1 It is important that parents
or caregivers learn to apply the same treatment protocols to reduce maladaptive
behaviors and reinforce appropriate behavior. This code is used
by the authorized ABA supervisor (or as delegated to an assistant
behavior analyst) for guiding the parents/caregivers to 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.
8.11.6.1.5.2 Groups must not exceed eight
participants (i.e., each individual parent/caregiver or pair of parents/caregivers
counts as one participant and only one claim may be filed per beneficiary).
8.11.6.1.5.3 The contractor shall recoup
all claims for groups that exceed eight participants.
8.11.6.1.5.4 CPT code 97157 may only be
used in a clinic/office-based setting.
8.11.6.1.5.5 CPT code 97157 may not be conducted
via TH.
8.11.6.1.5.6 CPT code 97157 is a timed,
15-minute, increment code.
8.11.6.1.5.7 The contractor shall only authorize
CPT code 97157 units at a minimum of four, 15-minute units (one
hour) and shall not exceed six, 15-minute units (1.5 hours) per
day.
8.11.6.1.6 CPT
Code 97158 - Group Adaptive Behavior Treatment by Protocol Modification
8.11.6.1.6.1 The code, CPT code 97158, is
used by the authorized ABA supervisor (or as delegated to an assistant
behavior analyst) to treat beneficiaries in a group setting. The
focus of the skills group are is 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.
8.11.6.1.6.2 CPT code 97158 must only be used
when the beneficiary’s TP identifies goals targeted for generalization
of mastered skills. As beneficiaries demonstrate generalized skills,
it is expected that one to one services will decrease as group services
increase, then ABA services fade altogether.
8.11.6.1.6.3 Groups must not exceed eight
participants.
8.11.6.1.6.4 The contractor shall recoup
all claims for groups that exceed eight participants.
8.11.6.1.6.5 CPT code 97158 may not be conducted
via TH.
8.11.6.1.6.6 CPT code 97158 is a timed,
15-minute, increment code.
8.11.6.1.6.7 The contractor shall only authorize
CPT code 97158 units at a minimum of four, 15-minute units (one
hour) and shall not exceed six, 15-minutes units (1.5 hours) per
day.
8.11.6.1.7 CPT
Codes 99366 and 99368 MTC
8.11.6.1.7.1 CPT codes 99366 and 99368 are
permitted only for MTC conducted face-to-face interaction, either
in person or through the TH platform. Telephone-only is not permitted
for providers.
8.11.6.1.7.2 CPT code 99366 MTC with patient
by healthcare professional for a minimum for 30 minutes.
8.11.6.1.7.3 CPT code 99368 MTC without
patient by health care professional for a minimum for 30 minutes.
8.11.6.1.7.4 The following criteria must be
met to report and be reimbursed for the MTC codes:
• A minimum of three QHPs from
different specialties or disciplines who provide direct care to
the patient must participate in the reported team conference.
• No more than one individual
from the same specialty may report CPT codes 99366 or 99368 at the
same encounter.
• The
ASN must be present, via TH or telephone, for provider reimbursement
of the MTC.
• Reporting participants must be
present for the entire MTC.
• Reporting participants must have
performed face-to face evaluations or treatments of the patient, independent
of any MTC, within the previous 60 calendar days.
8.11.6.1.7.5 The ASN must be present,
via TH or telephone, for provider reimbursement of the MTC.
8.11.6.1.7.6 Reporting participants should
record and document their role in the conference, contributed information,
and subsequent treatment recommendations. The time for the MTC starts
at the beginning of the case review and ends at the conclusion of
the review. Record keeping or report generation time is not included.
8.11.6.1.7.7 All approved TPs will receive
a minimum of one unit of 99366 and one unit of 99368 on each six-month
treatment authorization for the ABA provider to participate in an
MTC.
8.11.6.1.7.8 ABA providers must use the ACD
SPC, 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 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
each May 1st. The rates will also be posted at
http://www.health.mil/rates.
8.11.7.3 The contractor shall update
their reimbursement systems, once posted on the website, to reflect
the annually updated rates in compliance with
Chapter 1, Section 4.
8.11.7.4 The contractor shall, for claims
submitted beginning January 1, 2019, reimburse ABA services under the
ACD in accordance with the reimbursement rates for the covered ACD
CPT codes (rates are also listed at
https://health.mil/Military-Health-Topics/Conditions-and-Treatments/Autism-Care-Demonstration):
• CPT code 97151. The contractor
shall authorize Behavior Identification Assessment for only the
authorized ABA supervisor (or as delegated to an assistant behavior
analyst). CPT code 97151 is authorized for up to 32 units (eight
hours) at $125/hour of services for the initial assessment only.
Subsequent authorization periods shall be authorized up to 24 units
(six hours) of services at $125/hour. CPT code 97151 shall be conducted
over no more than a 14 calendar-day period. The contractor
may authorize one additional unit of CPT code 97151 per outcome
measure for ABA providers that complete the Vineland, SRS, and PSI/SIPA,
when prior authorized.
• CPT code 97153. Adaptive Behavior
Treatment by Protocol. CPT code 97153 is a timed code reimbursed
no lower than $31.25 per 15-minute increments ($125.00/hour) for
authorized ABA supervisors, $18.75 per 15-minute increment ($75.00/hour)
for assistant behavior analysts, and $12.50 per 15-minute increment
($50.00/hour) for BTs.
• CPT code 97155. Adaptive Behavior
Treatment by Protocol Modification is rendered by an authorized
ABA supervisor for treatment protocol modification with the beneficiary
present. CPT code 97155 is reimbursed no lower than $31.25 per 15-minute
increment ($125.00/hour) for the authorized ABA supervisor and $18.75
per 15-minute increment ($75.00/hour) for the assistant behavior
analyst delegated this responsibility.
• CPT code 97156. Family Adaptive
Behavior Treatment Guidance. Authorized ABA supervisor (or as delegated
to an assistant behavior analyst) treatment guidance to the parents/caregivers
(with or without the beneficiary present) is reimbursed no lower
than $31.25 per 15-minute increment ($125.00/hour) for the authorized
ABA supervisor.
• CPT code 97157. Multiple-Family
Group Adaptive Behavior Treatment Guidance. Authorized ABA supervisor treatment
guidance in a group setting to the parents/caregivers (without the
beneficiary present) is reimbursed at the geographically adjusted
reimbursement methodology for CPT code 90853 (group psychotherapy)
for each participant.
• CPT code 97158. Group Adaptive
Behavior Treatment with Protocol Modification. Authorized ABA supervisor treatment
guidance in a group setting to the beneficiaries is reimbursed at
the geographically adjusted reimbursement methodology for CPT code
90853 (group psychotherapy) for each participant (see reference
at
paragraph 8.11.7.2 for the location of reimbursement
rates).
• For CPT codes 99366 and 99368,
see
https://health.mil.
Reimbursement rates can be found using the search word “CMAC”.
8.11.7.5 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.
8.11.7.6 The contractor shall pay the
higher rate and deny the other, if CPT codes 97153 and 97155 are
billed concurrently.
|
CPT Codes
|
97151
|
97153
|
97155
|
97156
|
97157
|
97158
|
|
97151
|
N/A
|
|
|
|
|
|
|
97153
|
Y
|
N/A
|
|
|
|
|
|
97155
|
N
|
N
|
N/A
|
|
|
|
|
97156
|
Y
|
Y
|
Y
|
N/A
|
|
|
|
97157
|
Y
|
Y
|
Y
|
N
|
N/A
|
|
|
97158
|
Y
|
N
|
N
|
Y
|
Y
|
N/A
|
8.11.7.7 Negotiated provider rates lower
than those directed in this Section are not allowed.
8.11.7.8 The balance billing provisions
for non-participating providers as outlined in the TRM,
Chapter 3, Section 1 do not apply. ABA providers
may not bill the beneficiary more than 100% of the rates posted
at
http://www.health.mil/rates.
8.11.7.9 Policies in this section must
be adhered to or claims may be recouped.
8.11.8 Cost-Sharing
8.11.8.1 There is no maximum Government
payment or annual cap specifically for ABA services. Established TRICARE
deductibles, enrollment fees, copayments, cost-shares, and the annual
catastrophic cap protections apply to beneficiaries participating
in the ACD.
8.11.8.2 All beneficiary cost-sharing,
deductibles, and enrollment fees will be those applicable to the
specific TRICARE plan and beneficiary category of the TRICARE eligible
beneficiary receiving services under this demonstration; e.g., TRICARE
Prime, TRICARE Select; and
TRICARE for Life (TFL
).
For information on fees for 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.
8.11.8.3 The contractor shall, for services
rendered on or after January 1, 2019, only apply one copay for all ABA
services rendered on the same day. The contractor shall follow normal
TRICARE cost-share/copayment rules for other (non-ABA) services
rendered on the same day as ABA services.
8.11.8.4 The contractor shall, for CPT
code 97151, apply one copayment for all assessment services rendered within
a 14-day calendar period using this CPT code. If CPT code 97151
is billed on the same day as other ABA service, the contract shall
apply only one copay.
8.11.8.5 For Other Health Insurance (OHI),
beneficiaries receiving ABA services must obtain a referral and
prior authorization.
8.11.8.6 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 to assist in guiding clinical decision making for all clinical necessity
reviews that shall occur when approving all TPs; i.e., for the initial
authorization and every six months thereafter.
9.1.2 The contractor’s UM tools shall
provide a set of evidence-based standards on TPs for beneficiaries diagnosed
with ASD. UM tools/criteria are used to guide reviewers to consider
the severity of behaviors in the context of patient-specific variables
that help place a patient in the most appropriate level of care.
Standardized decision paths provide UM reviewers with a common language
that enables consistent, objective decision-making. UM addresses
treatment needs of individuals diagnosed with ASD who frequently
receive treatments by providers from several different disciplines--such
as ABA services, PT, OT, and SLP--that target the same core symptoms
or functional deficits.
9.1.2.1 The basis of the UM tool shall
integrate the comprehensive picture of treatment and progress to evaluate
the extent to which skill domains are clinically necessary and appropriate.
9.1.2.2 The contractor shall select
a UM tool that includes at a minimum the criteria to evaluate:
• Level of clinical support/need;
• TP programming;
• Dose response (intensity, frequency,
duration);
• Progress towards improved symptom
presentation, to include baseline functioning and cumulative periodic assessments
(every six months) using, at a minimum, the identified outcome measures;
• Duration of services; and
• Other rendered/recommended
services.
9.1.2.3 The contractor shall use the
UM tool to determine clinical necessity determinations for all ABS
CPT codes.
9.1.3 The contractor
shall ensure that all clinical necessity reviews include an assessment
of progress towards treatment goals. The TP and corresponding outcome
measures must demonstrate progress towards symptom improvements.
9.1.4 The contractor shall, if no
progress is made in the previous six months, engage the ABA provider
to address the TP and goals prior to issuing another treatment authorization
or transition services to more appropriate treatment (see
paragraph 8.8 for
discharge planning).
9.1.5 In general,
ABA treatment hours should gradually decrease over time as beneficiaries
reach treatment goals and parents/caregivers gain skills and proficiency
effectively managing behaviors related to the diagnosis of ASD.
9.1.6 The contractor shall employ
a BCBA or a master’s/doctoral level professional in a like-specialty
to complete clinical necessity reviews.
9.1.7 This contractor’s UM person
shall be different from the ASN.
9.1.8 The contractor shall submit,
as part of the annual Medical Management plan, a comprehensive UM plan
that incorporates all services for the diagnosis of ASD to DHA.
For plan submission requirements, refer to DD Form 1423, CDRL, located
in Section J of the applicable contract.
9.2 Program Integrity (PI)
9.2.1 The contractor shall leverage
existing PI actions in accordance with
Chapter
13, unless otherwise noted in this section.
9.2.2 The contractor shall, in addition
to the requirement set forth in
Chapter 13, Section 1,
have an ACD PI subject matter expert knowledgeable about the ACD.
9.2.3 The contractor’s PI unit shall
take action in accordance with
Chapter
13, developing for potential patient harm, fraud, and
abuse issues.
9.3 Additional
Contractor Responsibilities
9.3.1 The contractor shall develop
an ACD-specific website within the existing TRICARE website requirement, that
provides ACD information and resources, designed for use by families,
beneficiaries (when appropriate), and providers to include, but
not limited to:
• Online directory of ACD providers,
including but not limited to ABA providers, parent-mediated programs,
ASD diagnosing providers, respite care, SLP, OT, PT, etc. (the on-line
ACD provider directory may be part of the contractor’s main on line
provider directory).
• ACD Education and Resources
link as identified in this policy 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, accessible to all TRICARE authorized providers and ACD
providers serving a beneficiary with a diagnosis of ASD, including
direct and private sector care that serves as a platform for providers
to communicate directly with the contractor for: secure messaging;
beneficiary referral and authorization timeline information; TP
submissions, privileging, certification, directory changes.
• Contact information or link
for submitting beneficiary or family member/caregiver complaints.
Note: The TOP contractor, USFHP DPs,
and TFL are excluded from
paragraph 9.3.1.
9.3.2 The contractor shall designate
an ACD complaint officer to receive and address beneficiary family member/caregiver
complaints. The contractor shall provider contact information for
the ACD complaint officer to all parents/caregivers of beneficiaries
receiving services under this demonstration on the contractor ACD
specific website.
9.3.3 The
contractor shall develop a provider education training 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 199.9.3.3.1 The TOP and USFHP contractors
may use other provider education strategies to achieve the requirement
set forth in paragraph 9.3.3.
9.3.3.2 The contractor shall submit
the ABA provider training curriculum for DHA review and approval
per CDRL requirements prior to executing the training.
9.3.3.3 The contractor shall ensure
compliance with
paragraph 8.3.9 by retaining evidence of attendance/completion.
9.3.3.4 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.
9.3.4 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.
9.3.5 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.
9.3.6 The contractor shall deny services
and recoup claims for session notes that describe the rendering
of non-ABA services.
9.3.7 The contractor
shall authorize all CPT code units (per week/month respectively;
see 8.11.6.2) based on the approved TP in the six-month authorization
and monitor the authorization to ensure paid claims do not exceed what
was authorized.
9.3.8 The contractor
shall deny claims containing units (hours) over the approved authorization
and the MUEs set for each CPT code.
9.3.9 The contractor shall report
allegations of abuse to authorities responsible for child protective
services, military and family advocacy programs, and to State and
national license or certification boards as appropriate, and to
the Director, DHA, or designee.
9.3.10
Outcome
Measures Oversight9.3.10.1 The contractor shall
ensure completion of the Vineland, the SRS, PDDBI, and 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 The contractor shall
ensure 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
use the date of receipt of the specific measure to determine the
next chronological interval (six months or one year) for outcome
measures due dates.
9.3.10.4 The outcome measures
timeline does not change when changing regions, provider, or beneficiary category.
If the beneficiary or family elects to pause services from the ACD
for more than 180 calendar days, the timeline to collect outcome
measures resets.
9.3.10.5 The contractor shall
accept and report only complete and valid outcome measures.
9.3.10.6 The contractor shall
accept valid measures for baseline data with dates up to one year
prior to initiation of services.
9.3.10.7 The contractor shall
terminate ASN services and not issue a subsequent ABA treatment
authorization for failure to complete any and all outcome measures.9.3.10.7.1 The contractor shall
identify any beneficiary, parent/caregiver, or authorized ABA supervisor
who is unable or unwilling to meet this requirement and assist the
family in resolving the lack of completion of outcome measures.
9.3.10.7.2 The contractor shall
document non-compliance in the beneficiary’s record.
9.3.10.8 The contractor shall
transition to the new outcome measure edition within one year of
its release, should the edition update.
9.3.10.9 The contractor shall
ensure all outcome measures scores are reported in the corresponding
DD Form 1423, CDRL, located in Section J of the applicable contract.
9.3.11 ABA Provider Networks
This paragraph applies only
to the 50 US, District of Columbia, and US territories. See
paragraph 8.5 for
TOP.
9.3.11.1 The contractor shall establish
network contracting targets sufficient to support the ACD program
in accordance with access standards and network expansion prescribed
in
Chapter 5, Section 1 and apply existing network
requirements and access standards to providers under the ACD program.
9.3.11.2 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 certified
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 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, TH capabilities, and settings
for ABA services (i.e., in-home, clinic-based, both) in their directory.
9.3.11.6 The contractor shall engage
in an active provider placement process 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, 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
9.3.12.1 The contractor shall develop
an ABA provider steerage model for ABA providers (ACSP or authorized ABA
supervisor) that takes 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. The contractor shall submit any
additional determinants to DHA for approval prior to implementation.
This additional determinant shall be an objective, verifiable measure
that has a direct impact on beneficiaries or their families.
9.3.12.2 The contractor shall assign
beneficiaries to ABA providers who rank highest in the steerage
model when possible consistent with access to care standards.
9.3.12.3 The contractor shall list ABA
providers who rank highest in the steerage model first in on line
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.
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 SPC,
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.
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.9.3.15.1 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
provider 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 Administrative Instruction
(AI)-102.
9.3.17 The contractor shall contact
DHA for clarification if the contractor identifies a gap in the
ACD policy, and shall not automatically default to normal TRICARE
policy.
11.0 DEFINITIONS
11.1 Adaptive Behavior Services
(ABS)
According
to the American Medical Association (AMA) CPT coding guidance, ABS
address deficient adaptive behaviors (e.g., instruction-following,
verbal and nonverbal communication, imitation, play and leisure,
social interactions, self-care, daily living, and personal safety
skills) or maladaptive behaviors (e.g., repetitive and stereotypic
behaviors, and behaviors that risk physical harm to the patient,
others, and/or property).
11.2 Applied
Behavior Analysis (ABA) Assessment
A developmentally appropriate
assessment and reassessment tool must be used for formulating an
individualized ABA TP and is conducted by an authorized ABA supervisor.
For TRICARE purposes, an ABA assessment shall include data obtained
from multiple methods to include direct observation, the measurement,
and recording of behavior. A functional assessment that may include
a functional behavior analysis may be required to address problematic behaviors.
Data gathered from a parent/caregiver interview and a parent report
rating scales are also required. The ABA assessment will also include
required standardized outcomes measures at appropriate intervals
as noted above.
11.3 Applied Behavior Analysis (ABA)
Services
ABA methods
designed to improve the functioning of a specific ASD target deficit
in a core area affected by ASD such as social interaction, communication,
or behavior. The ABA provider delivers ABA services to the beneficiary through
direct administration of the ABA specialized interventions during
one-on-one in-person (i.e., face to face) interactions with the
beneficiary. ABA services may be comprehensive (addressing many
treatment targets in multiple domains) or focused (addressing a
small number of treatment targets, such as specific problem behaviors and/or
adaptive behaviors).
11.4 Applied Behavior Analysis (ABA)
Sole Provider Model
A service
delivery model that includes only the use of the authorized ABA
supervisor to implement a TP designed by the authorized ABA supervisor.
The ABA sole provider delivery model is authorized in the Continental
United States (CONUS), US territories, and TOP.
11.5 Applied
Behavior Analysis (ABA) Tiered Delivery Model
A service delivery model that
includes the use of supervised assistant behavior analysts and/or
BTs, in addition to the authorized ABA supervisor, to implement
a TP designed by the authorized ABA supervisor. Supervised assistant behavior
analysts may assist the authorized ABA supervisor in clinical support
to include the supervision of BTs and the provision of parent(s)/caregiver(s)
treatment guidance. Tiered delivery models are only authorized in
the CONUS and US territories.
11.6 Applied Behavior Analysis (ABA)
Treatment Plan (TP)
11.6.1 A written document outlining
the ABA service plan of care for the individual, including the expected outcomes
of ASD symptoms. For TRICARE purposes, the ABA TP shall consist
of an “initial ABA TP” based on the initial ABA assessment, and
the “ABA TP Update” that is the revised and updated ABA TP based
on periodic reassessments of beneficiary progress toward the objectives
and goals.
11.6.2 Components of the ABA TP include:
the identified behavior targets for improvement, the ABA specialized
interventions to achieve improvement, and the short-term and long-term
ABA TP objectives and goals that are defined below. The ABA TP shall
also include a discharge plan.
11.7 Applied Behavior Analysis (ABA)
TP Goals
These
are the broad spectrum, complex short-term and long-term desired
outcomes of ABA services.
11.8 Applied
Behavior Analysis (ABA) TP Objectives
The short, simple, measurable
steps that must be accomplished in order to reach the short-term
and long-term goals of ABA services.
11.9 Assistant Behavior Analyst
The term “assistant behavior
analyst” refers to supervised Licensed Assistant Behavior Analyst
(LABA), BCaBA, and QASP.
11.10 Authorized
ABA Supervisor
An authorized
ABA supervisor, whether or not currently supervising, is defined
as a Licensed Behavior Analyst (LBA), BCBA, BCBA-Doctorate (BCBA-D),
or clinical psychologist TRICARE authorized ABA providers practicing within
the scope of their State licensure or State certification.
11.11 Autism
Services Navigator (ASN)
The ASN
collaborates and oversees the assessment, planning, facilitation,
care coordination, evaluation, and advocacy for options and services
to meet an individual’s comprehensive health needs through communication and
available resources to promote quality, cost-effective outcomes.
An ASN must hold a current, valid, unrestricted license which includes:
a Registered Nurse (RN) with CM experience, clinical psychologist,
or Licensed Clinical Social Worker or other licensed mental health
professionals who possess a certification in case management (CCM).
The ASN must have clinical experience in: pediatrics, behavioral
health, and/or ASD; a healthcare environment; and proven care management
experience. This definition specifically excludes both BCBAs and
assistant behavior analysts.
11.12 Autism Spectrum Disorder (ASD)
For ACD eligibility, the covered
diagnosis is ASD (F84.0) according to the DSM-5/Autistic Disorder
according to the International Classification of Diseases, Tenth
Revision, Clinical Modification (ICD-10-CM). The ASD diagnosis must specify
the level of support according to the DSM-5 criteria (Level 1 =
mild, Level 2 = moderate, or Level 3 = severe).
11.13 ASD
Diagnosing and Referring Providers
11.13.1 ASD diagnosing and referring
providers include: TRICARE-authorized PCMs and specialized ASD diagnosing
providers. TRICARE authorized PCMs for the purposes of the diagnosis
and referral include: TRICARE authorized pediatrician, family medicine
physicians, and pediatric or family Nurse Practitioners (NPs). Authorized specialty
ASD diagnosing providers include: TRICARE-authorized physicians
board-certified or board-eligible in developmental-behavioral pediatrics,
neurodevelopmental pediatrics, child neurology, child psychiatry;
doctoral-level licensed clinical psychologists, or board certified
Doctors Of Nursing Practice (DNP). For DNPs credentialed as developmental
pediatric providers, dual American Nurses Credentialing Center (ANCC)
board certifications are required as follows: 1) either a pediatric
NP or a family NP; and 2) either (Family, or Child/Adolescent) Psychiatric Mental
Health Nurse Practitioner (PMHNP) or a (Child/Adolescent) Psychiatric
and Mental Health Clinical Nurse Specialist (PMHCNS).
11.13.2 For DNPs credentialed as psychiatric
and mental health providers, single ANCC board certification is required
as follows: as either a (Family or Child/Adolescent) PMHNP or a
PMHCNS.
11.13.3 Diagnoses and referrals from
Physician Assistants (PAs) or other providers not having the above qualifications
shall not be accepted.
11.13.4 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 PCS
orders. The CCP will allow for a more consistent and beneficiary-centric
approach to care.
11.21 Family/Caregiver
11.21.1 Family/caregiver follows the
32 CFR 199.2(b) definition: [t]he spouse,
natural parent, child and sibling, adopted child and adoptive parent,
stepparent, stepchild, grandparent, grandchild, stepbrother and
stepsister, father-in-law, mother-in-law of the beneficiary, and
legal guardian as appropriate. A “nanny” may be considered an eligible
caregiver pending the following requirements are met:
• At least 18 years of age.
• Employed full-time by the family
or an agency on behalf of the family (but must work full-time with
the child).
• The nanny is documented in
the Service family care plan. Documentation must be submitted to
the contractor.
• Has medical Power of Attorney.
• The approved TP must identify
the level of the nanny’s participation to include specific goals.
• Caregiver (nanny) training
cannot exceed parent training (CPT codes 97156 and 97157).
11.21.2 No other individual is considered
“family” or “caregiver” under the ACD.
11.22 Functional Behavior Analysis
The process of identifying
the variables that reliably predict and maintain problem behaviors
that typically involve: identifying the problem behavior(s); developing
hypotheses about the antecedents and consequences likely to trigger
or support the problem behavior; and, performing an analysis of
the function of the behavior by testing the hypotheses.
11.23 MTCs
MTCs 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. 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 Disabilities Behavior Inventory (PDDBI) or current
edition (Cohen, I.L. and Sudhalter, V. 2005)
11.26.1 The PDDBI is an informant-based
rating scale that is designed to assist in the assessment (for problem behaviors,
social, language, and learning/memory skills) of children who have
been diagnosed with ASD. The PDDBI provides age-standardized scores
for parent and teacher ratings. Applicable for ages 2 through 18.5
years.
11.26.2 The standard or extended form
must be submitted by the authorized ABA supervisor. The name of
the respondent and relation to the beneficiary is required on all
forms. Only the Parent Form is required at baseline. The Parent
Form and the Teacher Form must be completed and submitted every
six-months thereafter to align with the TP submission and reauthorization.
The Teacher Form must be completed by only the BCBA/BCBA-D. Responsibility for
the completion of the Teacher Form by the BCBA/BCBA-D cannot be
delegated. The Domain/Composite Score Summary Table, including all
domain and composite scores, must be submitted to the contractor.
Note: Per guidance from the PDDBI
manual and the publisher, the teacher form may be completed by the authorized
ABA supervisor.
11.27 Qualified
Applied Behavior Analysis (QABA) Certification Board
QABA “is an organization established
in 2012 to meet para-professional credentialing needs identified
by behavior analysts, ABA providers, insurance providers, government
departments, and consumers of behavior analysis and behavior health
services.” QABA offers the QASP certification for bachelor’s level
assistant behavior analysts, and the ABAT certification for BTs
with a minimum of a high school education or equivalent.
11.28 Qualified Health Care Professional
(QHP)
A QHP
is an individual who is qualified by education, training, licensure/regulation
(when applicable) and facility privileging (when applicable) who
performs a professional service within his/her scope of practice
and independently reports that professional service.
11.29
Social
Responsiveness Scale, Second Edition (SRS-2
) or
current
edition Current Edition (Constantino)
11.29.1 The SRS-2 identifies social
impairment associated with ASD and quantifies its severity. Applicable
for ages 2-1/2 through 99 years.
11.29.2 The Parent Form is required.
The name of the respondent and relation to the beneficiary is required
on all forms.
11.30
Stress Index for
Parents of Adolescents (SIPA
) or
current
edition 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 third edition of the Parenting Stress Index (PSI-3). Applicable
for ages 11-19 years, 11 months.
11.32
Vineland
Adaptive Behavior Scale, Third Edition (Vineland-3
) or
current
edition Current Edition (Sparrow,
S.S. et
. al)
11.32.1 The Vineland-3 is a valid and
reliable measure of adaptive behavior for individuals diagnosed
with intellectual disabilities and developmental disabilities (to
include ASD). The Vineland-3 consists of an interview, a parental/caregiver,
and teacher rater forms. Applicable for ages birth to 90 years.
11.32.2 The Parent Form, the Interview
Form (if completed by a TRICARE-authorized provider or ASN), or
the Teacher Form are required. The name of the respondent and relation
to the beneficiary is required on all forms.