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TRICARE Operations Manual 6010.59-M, April 1, 2015
Demonstrations And Pilot Projects (Except Value-Based Initiatives)
Chapter 18
Section 4
Department Of Defense (DoD) Comprehensive Autism Care Demonstration
Copyright:   CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:   C-36, September 14, 2018
1.0   PURPOSE
The Comprehensive Autism Care Demonstration (“Autism Care Demonstration”) provides TRICARE reimbursement for Applied Behavior Analysis (ABA) services to TRICARE eligible beneficiaries diagnosed with Autism Spectrum Disorder (ASD). Beneficiary eligibility is outlined in paragraph 7.0 . The purpose of the Autism Care Demonstration (ACD) is to further analyze and evaluate the appropriateness of the ABA tiered-delivery model under TRICARE in light of current and anticipated certification board guidelines. Currently, there are no established uniform ABA coverage standards in the United States (U.S.). The ACD seeks to establish appropriate provider qualifications for the proper diagnosis of ASD and for the provision of ABA services, assess the feasibility and advisability of establishing a beneficiary cost-share for ABA services for ASD, and develop more efficient and appropriate means of increasing access and delivery of ABA services under TRICARE while creating a viable economic model and maintaining administrative simplicity. The overarching goal of this demonstration is to analyze, evaluate, and compare the quality, efficiency, convenience, and cost effectiveness of ABA services that do not constitute proven medical care provided under the medical benefit coverage requirements that govern the TRICARE Basic Program.
2.0   BACKGROUND
2.1   ASD affects essential human behaviors such as social interaction, the ability to communicate ideas and feelings, imagination, and the establishment of relationships with others. The TRICARE Basic Program offers a comprehensive health benefit providing a full array of medically necessary services to address the needs of all TRICARE beneficiaries with a diagnosis of ASD. The TRICARE Basic Program provides Occupational Therapy (OT) to promote the development of self-care skills; Physical Therapy (PT) to promote coordination/motor skills; Speech-Language Pathology (SLP) services to promote communication skills; child neurology and child psychiatry to address psychopharmacological needs; clinical psychology for psychotherapy; and psychological testing; and neurodevelopmental and developmental behavioral pediatrics for developmental assessments. The full range of medical specialties to address the additional medical conditions common to this population are covered.
2.2   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 Treatment Plan (TP) developed by the behavior analyst.
2.3   The Behavior Analyst Certification Board (BACB) has established national guidelines for behavior analysts and assistant behavior analysts. The 2014 BACB publication for credentialing of Registered Behavior Technicians (RBTs) established national competency standards and registration for the Behavior Technicians (BTs) (formerly ABA Tutors) who interact with ASD-diagnosed beneficiaries for multiple hours per day. The Qualified Applied Behavior Analysis (QABA) certification board also offers a certification for BTs, the Applied Behavior Analysis Technician (ABAT), as well as a certification for assistant behavior analysts, Qualified Autism Services Practitioner (QASP). The Behavioral Intervention Certification Council (BICC) certification for BTs (Board Certified Autism Technician, BCAT) is also acceptable. If a State requires licensure or certification, the ABA provider is required to possess that State licensure or certification to be a TRICARE authorized or network provider. National certification standards are evolving. The American Medical Association (AMA) implemented Category III Current Procedural Terminology (CPT) codes (defined as a temporary set of codes for emerging technologies, services, and procedures) for ABA services (effective July 1, 2014), for the purpose of allowing time for data collection to determine the case for widespread usage of the ABA CPT codes as established “medical” treatment.
3.0   Demonstration Goals
Demonstration goals include:
3.1   Analyzing and evaluating the appropriateness of the ACD under TRICARE in light of current and future 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 (see paragraph 9.0 ), 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 SLP services, OT, 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.
4.0   Definitions
4.1   Applied Behavior Analysis (ABA)
According to the BACB Guidelines for “Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers” (2014 or current edition), ABA is “a well-developed scientific discipline among the helping professions that focuses on the analysis, design, implementation, and evaluation of social and other environmental modifications to produce meaningful changes in human behavior. ABA includes the use of direct observation, measurement, and functional analysis of the relations between environment and behavior. ABA uses changes in environmental events, including antecedent stimuli and consequences, to produce practical and significant changes in behavior. These relevant environmental events are usually identified through a variety of specialized assessment methods. ABA is based on the fact that an individual’s behavior is determined by past and current environmental events in conjunction with organic variables such as their genetic endowment and physiological variables. Thus, when applied to ASD, ABA focuses on treating the problems of the disorder by altering the individual’s social and learning environments.”
4.2   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, as defined in paragraph 4.15 , may be required to address problematic behaviors. Data gathered from a parent/caregiver interview and a parent report rating scales are also required.
4.3   ABA Specialized Interventions
ABA methods designed to improve the functioning of a specific ASD target deficit in a core area affected by the 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).
4.4   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. The tiered delivery model is contrasted with the sole provider model which includes only the use of the authorized ABA supervisor. Supervised assistant behavior analysts may assist the authorized ABA supervisor in clinical support and case management duties to include the supervision of BTs and the provision of parent(s)/caregiver(s) treatment guidance.
4.5   ABA TP
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. 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.
4.5.1   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.
4.5.2   ABA TP Goals
These are the broad spectrum, complex short-term and long-term desired outcomes of ABA services.
4.6   Assistant Behavior Analyst
The term “assistant behavior analyst” refers to supervised Licensed Assistant Behavior Analyst (LABA), Board Certified Assistant Behavior Analyst (BCaBA), and QASP.
4.7   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 other master’s level or above TRICARE authorized ABA providers practicing within the scope of their state licensure or state certification.
4.8   Autism Spectrum Disorder (ASD)
For ACD eligibility, the covered ASD diagnosis is Autism Spectrum Disorder (F84.0) according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)/Autistic Disorder according to the International Classification of Diseases, Tenth Revision, Clinical Modification. According to DSM-5, Autistic Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS) were converted into the single diagnosis of ASD (F84.0). Beneficiaries diagnosed with one of the five ASD diagnoses under the DSM, Fourth Edition, Text Revision: Autistic Disorder, Rett’s Syndrome, Childhood Disintegrative Disorder (CDD), Asperger’s Disorder, and PDD-NOS may continue to be eligible for the ACD. However, previously diagnosed beneficiaries (those diagnosed prior to October 20, 2014) receiving ABA services for these disorders must have their diagnosis updated to conform to the DSM-5 criteria upon the next Periodic ABA Program Review per paragraph 8.4 . This update of the diagnosis does not necessarily require a new diagnostic evaluation. The beneficiary must possess the diagnosis of ASD (F84.0) to continue eligibility in the ACD. Rett’s Syndrome and CDD alone are no longer considered an ASD in the DSM-5 and therefore beneficiaries diagnosed with Rett's Syndrome or CDD after October 20, 2014 are not eligible for ABA unless a secondary diagnosis of ASD is also present. The ASD diagnosis must specify the symptom severity level according to the DSM-5 criteria (Level 1 = mild, Level 2 = moderate, or Level 3 = severe).
4.9   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.
4.10   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.
4.11   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 Registered Behavior Technician (RBT) credential for BTs with a minimum of a high school education.
4.12   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.
4.13   Direct Supervision of BTs
Authorized ABA supervisors must provide ongoing supervision to BTs for a minimum of 5% of the total hours spent providing one-on-one ABA services per a 30 consecutive day period per beneficiary. Supervision in excess of 20% of the ABA hours per a 30 consecutive day period under the tiered delivery model shall result in contractor consultation with the authorized ABA supervisor and a review by the MCSC’s Medical Director or designee to determine whether the individual beneficiary’s needs are of such high complexity that the sole provider model is indicated. Direct supervision of every BT must include at least two face-to-face, synchronous contacts per a 30 consecutive day period during which the supervisor observes the BT providing services. One of these contacts must be one-on-one direct supervision whereby the authorized ABA supervisor, or the assistant behavior analyst delegated to provide supervision to the BT, directly observes the BT providing the face-to-face, one-on-one ABA services to one beneficiary at a time. The other direct observation supervision may take place in a group format whereby the authorized ABA supervisor observes each member of one team delivering the ABA services one at a time, each taking turns. At least one of the supervision sessions within the 30 consecutive day period, per beneficiary, individual or group, must be conducted in person (not remotely). The contractor shall work with the authorized ABA supervisor to ensure that the 5% requirement is met, to include adjusting the percent requirement when in instances such as when the beneficiary is ill or absent or when the BT is ill or absent.
4.14   Family/Caregiver
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, legal guardian or provider as appropriate. No other individual is considered “family” or “caregiver” under the ACD.
4.15   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.
4.16   Pervasive Developmental Disabilities Behavior Inventory (PDDBI) (Cohen, I.L. and Sudhalter, V. 2005 or current edition)
The PDDBI is an informant-based rating scale that is designed to assist in the assessment (for problem behaviors, social, language, and learning/memory skills) of children who have been diagnosed with ASD. The PDDBI provides age-standardized scores for parent and teacher ratings. Applicable for ages 2-18.5 years.
Note:   Per guidance from the PDDBI manual and the publisher, the teacher form may be completed by the teacher or the authorized ABA supervisor.
4.17   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 a minimum of a high school education or equivalent.
4.18   Remote Supervision
For the purposes of the ACD, authorized remote supervision is defined as supervision through the use of real time (synchronous) methods. Real-time is defined as the simultaneous “live” audio and video interaction between the authorized ABA Supervisor, or assistant behavior analyst, and the BT, with the beneficiary present, by electronic means such that the occurrence is the same as if the individuals were in the physical presence of each other. Such is usually done by electronic transmission over the Internet through a secured Health Insurance Portability and Accountability Act (HIPAA) compliant program. See TRICARE Policy Manual (TPM), Chapter 7, Section 22.1 for appropriate HIPAA compliance criteria.
4.19   Social Responsiveness Scale, Second Edition (SRS-2) (Constantino, or current edition)
The SRS-2 identifies social impairment associated with ASD and quantifies its severity. Applicable for ages 2-1/2 to 99 years.
4.20   Vineland Adaptive Behavior Scale, 3rd Edition (Vineland-3) (Sparrow, S.S. et.al, or current edition)
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.
5.0   Provider Roles in The ACD
5.1   ASD Diagnosing And Referring Providers
5.1.1   ASD diagnosing and referring providers include: TRICARE-authorized Physician-Primary Care Manager (P-PCM) or by a specialized ASD diagnosing provider. TRICARE authorized P-PCMs for the purposes of the diagnosis and referral include: TRICARE authorized family practice, internal medicine, and pediatric physicians. Authorized specialty ASD diagnosing providers include: TRICARE-authorized physicians board-certified or board-eligible in developmental-behavioral pediatrics, neurodevelopmental pediatrics, child neurology, adult or 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 Nurse Practitioner or a Family Nurse Practitioner; 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). 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.
5.1.2   Diagnoses and referrals from Nurse Practitioners (NPs) and Physician Assistants (PAs) or other providers not having the above qualifications shall not be accepted.
5.2   Role Of A Second Authorized ABA Supervisor
5.2.1   Consultation
Only one authorized ABA supervisor is authorized to provide for ABA services for each beneficiary at a time. Families/caregivers may seek consultation from another authorized ABA supervisor where the treating authorized ABA supervisor lacks sub-specialty expertise to treat a specific target behavior that another authorized ABA supervisor is specifically trained and competent to address. When a primary authorized ABA supervisor seeks consultation from another authorized ABA supervisor, the primary authorized ABA supervisor will remain responsible for the TP and is the sole provider authorized to bill for ABA services.
5.2.2   Second Opinion
Families/caregivers may obtain a referral for a second opinion for ABA services from another authorized ABA supervisor once per authorization period. A referral for an evaluation only for a second opinion and a prior authorization is required. Families/caregivers may request to switch to another authorized ABA supervisor, as appropriate for ongoing treatment. Only the authorized ABA supervisor who is responsible for the ABA TP is authorized to bill for ABA services. The concept of one treating provider overseeing a specific type of treatment per episode of care with the option to seek a second opinion is consistent with TRICARE Reimbursement Manual (TRM), Chapter 1, Section 16 which specifies requirements for TRICARE second opinion coverage under the TRICARE Basic Program for surgical and non-surgical benefits.
5.3   ABA Delivered As A Team Approach
Autism Demonstration Corporate Services Providers (ACSPs) who administer ABA services using a team approach can involve multiple BCBAs, assistant behavior analysts, and BTs treating one beneficiary. One authorized ABA supervisor must be named as responsible for the overall treatment of each beneficiary on the ABA TP. The ACSP shall bill for services under the ACSP as an autism clinic.
6.0   ABA PROVIDER REQUIREMENTS
6.1   Authorized ABA supervisors (BCBA, BCBA-Ds, or other qualified TRICARE authorized independent providers) must meet all of the following requirements:
6.1.1   Have a master’s degree or above in a qualifying field as defined by the state licensure/certification where defined or certification requirements from the BACB; and
6.1.2   Have a current BCBA certification; and
6.1.3   Have a current, unrestricted state issued license or state certification if practicing in a state that offers state licensure or state certification.
6.1.4   Enter into a Participation Agreement, Addendum A , approved by the Director, Defense Health Agency (DHA) or designee.
6.1.5   If applicable, employ directly or contract with assistant behavior analysts and/or BTs.
6.1.6   Report to the contractor within 30 calendar days of notification of a state sanction or BACB sanction issued to the BCBA or BCBA-D for violation of BACB Professional and Ethical Compliance Code for Behavior Analysts ( https://www.bacb.com ) or notification of loss of BACB certification. Loss of state licensure or certification, or loss of BACB certification shall result in termination of the Participation Agreement with the authorized ABA supervisor with an effective date of such notification. Termination of the Participation Agreement by the contractor may be appealed to DHA in accordance with the requirements of Chapter 13 .
6.1.7   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.
6.1.8   Meet all applicable requirements of the states in which they provide ABA services, including those states in which they provide remote supervision of assistant behavior analysts and BTs and oversee ABA services provided where the beneficiary is receiving services.
6.1.9   Cooperate fully with a designated utilization and clinical quality management organization which has a contract with the DoD for the geographic area in which the provider does business.
6.1.10   Authorized ABA supervisors under the Autism Care Demonstration: Serve as direct supervisors of the assistant behavior analysts and BTs and ensures that the quality of the ABA services provided by assistant behavior analysts and BTs meets the minimum standards promulgated by the applicable certifying body recommendations, rules, and regulations.
6.1.11   Supervision must be provided in accordance with the state licensure and certification requirements in the state in which ABA services are practiced where such state-issued license or certification is available.
6.1.12   The following training is required:
•   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.
•   For BCBAs and BCBA-Ds who supervise assistant behavior analysts and/or BTs, an eight-hour, competency-based training covering the BACB’s Supervising Training Curriculum Outline and three hours of continuing education related to supervision during each BACB certification cycle.
6.2   Assistant behavior analysts must meet all of the following requirements:
6.2.1   Have a bachelor’s degree or above in a qualifying field as defined by the state licensure/certification where defined or certification requirements from a certification body approved by the Director, DHA; and
6.2.2   Have a current certification from a certification body approved by the Director, DHA; and
6.2.3   Have a current, unrestricted state issued license or state certification in a state that offers state licensure or state certification.
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 (supervision, reimbursement, and may no longer complete the functions of an assistant behavior analyst) once the state licensure language becomes effective. A credential as an ABA provider must be maintained.
6.2.4   Assistant behavior analysts must receive supervision in compliance with the BACB or QABA (or those of another certification body approved by the Director, DHA) rules and regulations. Only direct supervision, where the authorized ABA supervisor directly observes the assistant behavior analyst providing services with the beneficiary or the beneficiary’s parents/caregivers, will be reimbursed. Indirect supervision, to include but not limited to, a review and discussion of case load, data collection procedures, and professional development, is not reimbursable under TRICARE.
6.2.5   A supervised assistant behavior analyst working within the scope of their training, practice, and competence may assist the authorized ABA supervisor in various roles and responsibilities as determined appropriate by the authorized ABA supervisor and delegated to the assistant behavior analyst, consistent with the most current BACB Guidelines for “Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers” (2014 or current edition) and current BACB and/or QABA certification requirements (or requirements of another certification body that is approved by Director, DHA, for TRICARE purposes). Assistant behavior analysts must work under the supervision of an authorized ABA supervisor who meets the requirements specified in paragraph 6.1 .
6.2.6   The assistant behavior analysts have the requisite bachelor’s degrees to qualify for the BCaBA certification exam administered by the BACB or the QASP certification exam administered by QABA (or exam of another certification body that is approved by Director, DHA, for TRICARE purposes). The authorized ABA supervisors are ultimately responsible for the delivery of care including the TP, and the contractor shall deny claims for unsupervised services of an assistant behavior analysts.
Note:   The following documents will be maintained in the authorized ABA supervisor and each assistant behavior analyst’s file: the BACB BCaBA Annual Supervision Verification Form or the QABA Fieldwork Verification Form.
6.2.7   The following training is required:
•   BLS or a CPR equivalent certification, as demonstrated by completion of a hybrid course comprised of a web-based instruction component and a live component to demonstrate skills on a dummy.
•   Eligibility requirement to conduct supervision:
•   For BCaBAs who supervise BTs, an eight-hour, competency-based training covering the BACB’s Supervising Training Curriculum Outline and three hours of continuing education related to supervision during each BACB certification cycle.
•   QABA certified QASPs must have completed the supervisory training, and possess the supervisory designation, S , in order to supervise any BT.
6.3   Behavior Technicians (BTs)
A BT may not conduct the ABA assessment, or establish a child’s ABA TP. Claims for BTs who are not properly supervised in accordance with ACD requirements will be denied. BTs must meet the following requirements:
6.3.1   All BTs must possess a current RBT, ABAT, or BCAT certification, or state certification, or certification from a body approved by the Director, DHA, before applying for TRICARE-authorized provider status.
Note:   Should a state licensure or certification specify criteria for an assistant behavior analyst that results in a previously authorized TRICARE ABA provider not meeting the requirements for licensure/certification, that provider may be recognized as only a BT without having to obtain the BT certification (if allowed by state law) and shall be subject to all BT requirements (supervision, reimbursement, and may no longer complete the functions of an assistant behavior analyst) once the state licensure language becomes effective. Additionally, should a state licensure or state certification specify a BT certification type, that state designation must be followed.
6.3.2   BLS or CPR equivalent certification (see paragraphs 6.1.12 and 6.2.7 ).
6.3.3   Once a BT has completed BACB, QABA, or BICC certification requirements, or state certification, has passed the BT examination, completed BLS or CPR equivalent certification, and a completed BT approval application has been submitted to the contractor, the contractor may place the BT in a provisional status, not to exceed 90 days, to allow for rendering of billable services pending final application approval. ABA supervisors are encouraged to contact the regional contractor to verify the date provisional status begins for each BT. If the BT is not approved for TRICARE certification for any reason within 90 days, then recoupment of claims paid by the contractor shall occur.
6.3.4   BTs must obtain ongoing supervision for a minimum of 5% of the hours spent providing one-on-one ABA services per a 30 consecutive day period per beneficiary. See paragraph 4.13 for the definition of direct supervision. Remote supervision is approved (see paragraph 4.18 ).
6.4   Autism Care Demonstration-Corporate Services Providers (ACSPs)
ACSPs include autism centers, autism clinics and individual authorized ABA supervisors with contractual agreements with individual assistant behavior analysts and BTs under their supervision.
6.4.1   The ACSP shall:
6.4.1.1   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 name, unless state requirements specify greater amounts;
6.4.1.2   Submit to the contractor all documents necessary to support an application for designation as a TRICARE ACSP;
6.4.1.3   Enter into a Participation Agreement, Addendum A , approved by the Director, DHA or designee (i.e., the contractor);
6.4.1.4   Employ directly or contract with qualified authorized ABA supervisors, assistant behavior analysts, and/or BTs;
6.4.1.5   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 herein;
6.4.1.6   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;
6.4.1.7   Maintain employment or contractual documentation in accordance with applicable Federal, State, and local requirements, and corporate policies regarding authorized ABA supervisors, assistant behavior analysts, and BTs;
6.4.1.8   Comply with all applicable requirements of the Government designated utilization and clinical quality management organization for the geographic area in which the ACSP provides ABA services; and
6.4.1.9   Comply with all other requirements applicable to TRICARE-authorized providers.
6.5   Provider Background Review
6.5.1   The contractor shall obtain a Criminal History Review, as specified in Chapter 4, Section 1, paragraph 8.0 , for ACSPs who are individual providers with whom the contractor enters into a Participation Agreement.
6.5.2   ACSPs, other than those specified in paragraph 6.5.1 , shall:
6.5.2.1   Obtain a Criminal History Review of authorized ABA supervisors directly employed by or contracted with the ACSP.
6.5.2.2   Obtain a Criminal History Background Check (CHBC) of assistant behavior analysts and BTs who are directly employed by or contracted with the ACSP.
6.5.3   The authorized ABA supervisor shall obtain a CHBC of assistant behavior analysts and BTs directly employed by or contracted with the authorized ABA supervisor.
6.5.4   The CHBC of assistant behavior analysts and BTs shall:
6.5.4.1   Include current Federal, State, and County Criminal and Sex Offender reports for all locations the assistant behavior analyst or Behavior Technician has resided or worked during the previous 10 years; and
6.5.4.2   Be completed prior to the assistant behavior analyst or BT providing ABA services to TRICARE beneficiaries.
7.0   BENEFICIARY ELIGIBILITY
7.1   The contractor shall cover ABA services under this demonstration for dependents of active duty, retirees, and TRICARE eligible Reserve Components, participants in member plus family coverage under TRICARE Reserve Select (TRS) and TRICARE Retired Reserve (TRR), individuals covered under the Transitional Assistance Management Program (TAMP) or TRICARE for Life (TFL), participants in TRICARE Young Adult (TYA), North Atlantic Treaty Organization (NATO) or Partnership for Peace (PfP) dependent beneficiaries, and those individuals no longer TRICARE eligible who are participating in the Continued Health Care Benefits Program (CHCBP).
7.2   Eligible beneficiaries for this demonstration must:
7.2.1   Have been diagnosed with ASD specified in paragraph 4.8 by a TRICARE-authorized ASD diagnosing provider specified in paragraph 5.0 .
7.2.2   Dependents of Service members must be registered in Extended Care Health Option (ECHO) per paragraph 10.0 as a requirement of the ACD and will continue to receive the other supplemental services offered under ECHO such as respite care, Durable Equipment (DE), and additional OT, PT, and SLP services beyond those offered under the Basic Program.
7.3   Eligibility for benefits under the ACD ceases as of 12:01 a.m. of the day after the end of the ACD, or when the beneficiary is no longer eligible for TRICARE benefits.
7.4   Ineligibility for the ACD does not preclude eligible beneficiaries from receiving otherwise allowable services under TRICARE.
7.5   For those beneficiaries whose diagnostic testing or specialized ASD diagnosing provider evaluation does not confirm the diagnosis of ASD, the current authorization will continue until expiration. ABA services will not be reauthorized. The contractor will work with the family to transition the beneficiary out of the ACD and identify other treatments appropriate for this beneficiary (see paragraph 4.8 ).
8.0   policy
8.1   Referral and Authorization
8.1.1   Referral
8.1.1.1   A referral for ABA services under the ACD is required. A P-PCM or specialized ASD diagnosing provider may submit the referral for ABA services. The beneficiary must be diagnosed with ASD using DSM-5 criteria in accordance with paragraph 5.1.1 . The referral for ABA services must contain documentation of the age of the child and year of the initial ASD diagnosis, documentation of any co-morbid psychiatric and medical disorders, and level of symptom severity (level of support required per DSM-5 criteria under ASD). Level of symptom severity shall be submitted by the specialized ASD diagnosing provider. The diagnosing/referring provider shall provide a copy of the referral for ABA services to the beneficiary’s parent(s)/caregiver(s). If the initial diagnosis is made by a P-PCM, the P-PCM must submit a referral for a specialized ASD diagnosing provider who must confirm the diagnosis of ASD within one year.
8.1.1.2   The specialized ASD diagnosing provider shall complete the outcome measures as described in paragraph 8.2.2.2 and 8.2.2.3 . If the specialized ASD diagnosing provider cannot complete the outcome measures requirement within one year of the initial diagnosis, then the specialized ASD diagnosing provider shall submit a referral to the managed care support or TOP contractor for outcome measures to be completed by another TRICARE authorized provider in accordance with paragraphs 8.2.2 and 8.2.3 .
8.1.2   Authorization
8.1.2.1   Upon receipt of the referral for ABA services, the contractor shall issue an authorization for six months of ABA services based on the referral request. To the extent practicable, each contractor authorization shall identify a specific TRICARE authorized ABA supervisor with an opening to accept the TRICARE beneficiary. This individualized approach is designed to provide families with timely access to ABA services. However, beneficiary families are free to choose any TRICARE authorized ABA network provider once the authorization is received or, with the managed care support or TOP contractor’s assistance, select a non-network provider if a network provider is no available.
8.1.2.2   The provision of ABA services under the ACD shall include:
8.1.2.2.1   The initial ABA assessment by the authorized ABA supervisor to include functional behavior analysis and behavior intervention plan (if needed), initial TP development, direct one-on-one ABA services as specified in the approved TP, reassessment to evaluate progress, TP updates and parent(s)/caregiver(s) treatment guidance. The initial ABA assessment and treatment plan must be completed and submitted to the contractor prior to the commencement of billable one-on-one ABA services (0364T/0365T) by any other provider type.
8.1.2.2.2   Beneficiaries will receive ABA services provided solely by master’s level or above authorized ABA supervisor and/or under the tiered delivery model, where an authorized ABA supervisor will plan, deliver, and/or supervise an ABA program. Both models are authorized and the model selected shall be based on the needs of the beneficiary as well as provider availability. The authorized ABA supervisor is supported by supervised assistant behavior analysts and/or paraprofessional certified BTs who work one-on-one with the beneficiary with ASD in the home and in the community to implement the ABA intervention protocol designed, monitored, and supervised by the authorized ABA supervisor.
8.1.2.3   Prior to the expiration of each six month authorization period, as early as 60 days in advance, the authorized ABA supervisor or ACSP shall request re-authorization of ABA services for the next six months from the contractor as supported by submission of the every six month ABA reassessment and TP Update that include documentation of progress using the PDDBI.
8.1.3   Subsequent Referrals And Authorizations
Every two years from the initial authorization (i.e., after the beneficiary has received ABA services for two consecutive years or four six-month authorization periods), a new referral for ABA services and a new referral for outcome measures from the P-PCM or specialized ASD diagnosing provider is required. The contractor shall conduct the periodic ABA services program review for clinical necessity prior to authorization of another six months of ABA in accordance with paragraph 8.4 . Clinical necessity refers to services that a licensed or otherwise authorized TRICARE provider of ABA services for the diagnosis of ASD determines are clinically indicated and appropriate to address a beneficiary’s diagnosed condition, beyond what is determined as medically necessary under TRICARE regulations. This review should take into account current status, progress toward meeting ABA TP objectives and goals, and referring provider and parental input. The TRICARE Regional Contractors’ Medical Director or designee reviews and approves authorizations for clinically necessary care.
8.2   Outcome Evaluations
8.2.1   The Senate Armed Services Committee directed the Secretary of Defense to provide quarterly reports on the effectiveness of care among military dependents participating in the program. The Secretary will report, at a minimum, the health-related outcomes for beneficiaries under the program.
8.2.2   Outcome Measures
For all beneficiaries participating in the ACD, outcome evaluations must be completed and reported, using norm-referenced, valid, and reliable evaluation tool (see DD form 1423). Outcome measures may be completed via telehealth (see the TPM, Chapter 7, Section 22.1 for requirements).
8.2.2.1   PDDBI
This outcome measure must be completed at baseline and every six months. Only the Parent form is required at baseline. The Parent form and the Teacher form must be submitted every six months thereafter to align with the treatment plan submission and reauthorization. The teacher form may be completed by the teacher or the BCBA/BCBA-D. Responsibility for the completion of the Teacher form by the BCBA/BCBA-D cannot be delegated except to a teacher who meets the requirements specified in the PDDBI Manual. Domain/Composite Score Summary Table must be submitted to the regional contractor. Only authorized ABA supervisors are eligible to submit the PDDBI to the managed care support or TOP contractor. For reimbursement of the PDDBI submitted by the BCBA, see paragraphs 12.6 and 13.6 .
8.2.2.2   Vineland-3
This outcome measure must be completed at baseline (within one year of the initial diagnosis) and every two years thereafter to align with the Periodic ABA Program Review. The Parent form, the Interview form, or the Teacher form will be accepted. The Score Summary Profile, to include the Maladaptive Behavior Results Submission, must be submitted to the regional contractor. The Vineland shall be completed and submitted by the specialized ASD diagnosing provider. If the specialized ASD diagnosing provider cannot complete the requirement per paragraph 8.1.1.2 , the following providers may be authorized by the managed care or TOP contractor:
•   A TRICARE authorized independent provider (TRICARE authorized independent providers must use the assessment code for their discipline for reimbursement); or
•   A BCBA/BCBA-D (for reimbursement of the Vineland-3 submitted by the BCBA/BCBA-D, see paragraphs 12.6 and 13.6 ); or
•   Parents/caregivers may provide the TRICARE authorized independent provider or the authorized ABA supervisor a school-completed Interview or Teacher form for submission to the regional contractor to meet this requirement. (The school is not eligible for reimbursement as these individuals are not TRICARE authorized independent providers.)
8.2.2.3   SRS-2
This outcome measure must be completed at baseline (within one year of the initial diagnosis) and every two years thereafter to align with the Periodic ABA Program Review. The Parent form is required. The Total Score Results and Treatment Subscale Results must be submitted to the regional contractor. The SRS-2 shall be completed and submitted by the specialized ASD diagnosing provider. If the specialized ASD diagnosing provider cannot complete the requirement per paragraph 8.1.1.2 , the following providers may be authorized by the managed care or TOP contractor:
•   A TRICARE authorized independent provider (TRICARE authorized independent providers must use the assessment code for their discipline for reimbursement); or
•   A BCBA/BCBA-D (for reimbursement of the SRS-2 submitted by the BCBA/BCBA-D, see paragraphs 12.6 and 13.6 ).
8.2.3   All outcome measures shall be completed and submitted by their respective deadlines. Beneficiaries who are unable or unwilling to meet this requirement shall be identified by the managed care support or TOP contractors, and the case managers shall assist in either resolving the lack of testing or termination from the ACD and all ABA services. The contractors shall document non-compliance in the beneficiary’s record.
8.2.4   To support efficiency of provider time, we encourage each contractor to implement tools which would allow the network providers to electronically submit results of these outcome measures to the contractor through a secure, HIPAA-compliant, web-based application.
8.2.5   As required in paragraph 8.1.1.2 , the outcome measures shall be completed/submitted by the specialized ASD diagnosing provider. If the specialized ASD diagnosing provider is not able to complete the outcome measures requirements within one year of the initial diagnosis, then the specialized ASD diagnosing provider shall submit a referral for authorization to the managed care support or TOP contractor who will identify another TRICARE authorized provider, to include an eligible BCBA, who is eligible to complete the measures. Claims for a Vineland-3 and/or SRS-2 submitted by a BCBA without prior authorization will be denied. No authorizations will be issued for outcome measures completed by a BCBA prior to January 1, 2018.
8.3   ABA Assessments and TPs completed by the authorized ABA supervisor shall include:
8.3.1   The beneficiary’s name, date of birth, date the initial ABA assessment and initial ABA TP was completed, the beneficiary’s DoD Benefit Number (DBN) or other patient identifiers, name of the referring provider, background and history (to include the number of hours enrolled in school, the number of hours receiving other support services such as OT, PT, and SLP, and how long the child has been receiving ABA services), objectives and goals, and ABA service recommendations. The ABA assessment shall include results of the assessments conducted to identify specific treatment targets and the ABA service procedures to address each target.
8.3.2   Background and history shall include information that clearly reports the beneficiary’s condition, diagnoses, medical co-morbidities (to include prescribed medications), family history, and how long the beneficiary has been receiving ABA services.
8.3.3   The initial ABA assessment must identify 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 adaptive behavior skills). This assessment may require a behavior intervention plan for each target behavior excess and deficit (see paragraph 4.9 ). The initial ABA assessment will include the PDDBI parent form Domain/Composite Score Summary Table.
8.3.4   The initial ABA assessment must state that the beneficiary is able to actively participate in ABA services as observed by the authorized ABA supervisor or ACSP during the ABA assessment.
8.3.5   The initial ABA TP shall include clearly defined, measurable targets in all relevant DSM-5 symptom domains 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.
8.3.6   The initial ABA TP and all TP updates shall also include all measurable objectives and goals for parent/caregiver treatment guidance on implementation of selected treatment protocols with the beneficiary at home and in multiple other settings. The protocols shall be selected jointly by the authorized ABA supervisor and the parent(s)/caregiver(s). Participation by the parent(s)/caregiver(s) is expected, and continued authorization for ABA services is contingent upon their involvement. If parent(s)/caregiver(s) participation is not possible, the TP shall document why not (i.e., the parent/caregiver is deployed, is physically unable to deliver the ABA services, etc.).
8.3.7   Documentation on the initial ABA TP shall also include the authorized ABA supervisor’s recommendation for the number of weekly hours of ABA services under the ACD to include the recommended number of weekly hours for ABA services provided by BTs. TPs are individualized and treatment goals and hours of ABA services are determined by the DSM-5 symptom domains and severity levels (levels of supports required per DSM-5 ASD criteria), and capability of the beneficiary to participate actively and productively in ABA services. Recommendations for hours shall reflect the clinical needs of each beneficiary. However, recommended ABA services shall take into account whether the child is attending school, the time available in the beneficiary’s schedule for ABA services, and individual beneficiary needs.
8.3.8   ABA reassessments and TP updates shall document the evaluation of progress for each behavior target identified on the initial ABA TP and prior TP updates. Documentation of the ABA reassessment and TP update shall be completed every six months and include all of the following but not limited to (the contractor may request additional information based on best practices):
•   Date and time the reassessment and TP update was completed.
•   ABA provider conducting the reassessment and TP update.
•   Evaluation of progress on each treatment target (i.e., Met, Not Met, Discontinued).
•   Revisions to the ABA TP must include identification of new behavior targets, objectives, and goals, to include TP modifications based on the six month assessment of the PDDBI and other outcomes measures evaluation. Note: If no progress has been made, the managed care support or TOP contractor shall engage the authorized ABA supervisor who will incorporate revisions to the individual treatment plan to address the lack of progress.
•   Recommendation for continued ABA services to include a recommendation for the number of weekly hours of one-on-one ABA services, including documentation of clinical necessity of additional hours required, under the ACD.
•   The reassessments and TP updates are required to be conducted every six months and must be dated as being conducted during that time frame. The reassessments and TP updates, to include the PDDBI, may be submitted once every six month reassessment period. Reassessments must be completed and submitted by the sixth month for review for continued reauthorization. Any delay in submission of the ABA reassessment and TP updates may delay or terminate continued authorization for ABA services.
•   The TP and TP updates shall 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.
8.4   Periodic ABA Program Review
The following criteria are established to determine if/when ABA services are no longer appropriate:
8.4.1   Loss of eligibility for TRICARE benefits as defined in 32 CFR 199.3 .
8.4.2   The authorized ABA supervisor has determined one or more of the following:
•   The patient has met ABA TP goals and is no longer in need of ABA services.
•   The patient has made no measurable progress toward meeting goals identified on the ABA TP after successive progress review periods and repeated modifications to the TP.
•   ABA TP gains are not generalizable or durable over time and do not transfer to the larger community setting after successive progress review periods and repeated modifications to the TP.
•   The patient can no longer participate in ABA services (due to medical problems, family problems, or other factors that prohibit participation).
8.5   ABA Benefits
The following ABA services are authorized under the ACD to TRICARE eligible beneficiaries diagnosed with ASD by an appropriate provider.
8.5.1   An initial beneficiary ABA assessment performed one-on-one by an authorized ABA supervisor to include administration of appropriate assessment tools, and a functional behavior assessment and analysis when appropriate.
8.5.2   Development of the initial ABA TP with objectives and goals.
8.5.3   Provision of one-on-one ABA services delivered directly by the authorized ABA supervisor or delivered by the supervised assistant behavior analyst and/or BT.
8.5.4   Monitoring of the beneficiary’s progress toward ABA TP objectives and goals specified in the initial ABA assessment and TP through the ABA reassessment and TP updates by the authorized ABA supervisor.
8.5.5   Providing treatment guidance to family member(s)/caregiver(s) by the authorized ABA supervisor or delegated to the supervised assistant behavior analyst to provide ABA services in accordance with the ABA TP.
8.5.6   Supervision of the delivery of BT one-on-one ABA services to the beneficiary by the authorized ABA supervisor, in accordance with these policies.
9.0   ABA Provided Under The TRICARE Overseas Program (TOP)
9.1   ABA services shall only be authorized to be provided by either a BCBA or a BCBA-D in countries that have BCBA and BCBA-Ds certified by the BACB. Tiered delivery model ABA services (assistant behavior analyst and BT services) are not authorized in the TOP. All providers overseas shall meet the requirements outlined in this Chapter.
9.2   The TOP contractor shall verify compliance with all requirements outlined in the ACD.
9.3   International providers certified by the BACB as a BCBA or BCBA-D are eligible to become TRICARE authorized providers of ABA services for the TOP.
9.4   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 under the ACD.
9.5   The contractor shall work with the TOP Office to identify the most appropriate claim form to use depending on the host nation country and the overseas provider’s willingness to use the Centers for Medicare and Medicaid Services (CMS) 1500 Claim Form.
9.6   The contractor shall report allegations of abuse to the host nation authorities responsible for child protective services and to the BACB in accordance with applicable law (including Status of Forces Agreements), and to state license or certification boards as appropriate.
9.7   Reimbursement of TOP claims for ABA services obtained overseas shall be 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 TRM, Chapter 1, Section 35 for additional guidance).
10.0   ECHO Program
The ECHO program as currently outlined in 32 CFR 199.5 remains unaffected, except all ABA services will be provided under the ACD. Participation in the Autism Care Demonstration by ADFMs requires enrollment in Exceptional Family Member Program (EFMP) and registration in ECHO and shall constitute participation in ECHO for purposes of ECHO registered beneficiary eligibility for other ECHO services. This will allow ADFMs to continue to receive the other supplemental services offered under ECHO such as respite care, DE, and additional OT, PT, and SLP services beyond those offered under the TRICARE Basic Program without unnecessary delays. In addition, ADFMs registered in ECHO shall be assigned an ECHO case manager and shall receive care coordination as they move from duty station to duty station from both the contractor and ECHO case management. The allowed costs of these supplemental ECHO services, except ECHO Home Health Care (EHHC), accrue to the Government’s maximum fiscal year cost-share of $36,000. ADFMs are to follow the ECHO registration procedures outlined in TPM, Chapter 9, Section 3.1 . That section outlines ECHO registration requirements to include provisional status and, in certain circumstances, waiver of the EFMP requirement. To meet the ECHO registration requirement of the ACD only, the DHA Clinical Operations Division Chief or their designee may approve an additional 90 day provisional status (up to 180 days total) in exceptional circumstances on a case-by-case basis. The provisional status will terminate upon completion of the registration process or at the end of the 90 or 180 day period, whichever occurs first. The authorization and Government liability for ACD benefits will terminate at the end of the provisional 90 or 180 day period. The Government will not recoup claims paid for ACD benefits provided during the provisional period.
11.0   Reimbursement
11.1   TRICARE will reimburse ACSPs, BCBAs, BCBA-Ds or authorized ABA supervisors for ABA services planned by these TRICARE authorized providers, and delivered by supervised assistant behavior analysts and/or paraprofessional BTs, or delivered by the authorized ABA supervisor themselves. Only ACSPs or authorized ABA supervisors may receive TRICARE reimbursement for ABA services. This is in accordance with the CPT guidance effective July 1, 2014, for the ABA Category III CPT codes which states: “While the adaptive behavior assessment and treatment codes may be used by any physician and/or qualified health care professional (licensed and/or credentialed), the majority of these services will be delivered by a behavior analyst (advanced degree professionals) or licensed clinical psychologist (who is authorized to practice ABA within the scope of their license) who designs and directs treatment protocols delivered by assistant behavior analysts or (behavior) technicians.” (CPT Assistant, June 2014/Volume 24 Issue 2). Assistant behavior analysts and/or BTs receive compensation from their authorized ABA supervisor. Authorized ABA supervisors who are employed directly or contracted with a TRICARE authorized ACSP receive compensation from the ACSP. ABA services must meet the minimum standards established by the current BACB Task List, the BACB Professional Disciplinary Standards, the BACB Guidelines for Responsible Conduct for Behavior Analysts, and current BACB and/or QABA rules and regulations (or those of another certification body that is approved by Director, DHA, for TRICARE purposes) when rendered by supervised assistant behavior analysts or BTs who meet all applicable ACD requirements and the minimum standards required under state regulation in the geographic location where the ABA services are delivered.
11.2   Network and non-network provider claims, under the ACD shall be submitted electronically using the Category III CPT codes defined in paragraph 12.0 .
11.3   The Category III CPT codes are a set of temporary codes that allow data collection for emerging technology, services, and procedures. These codes are intended for data collection to substantiate widespread usage or to provide documentation for the Food and Drug Administration (FDA) approval process. The ABA Category III CPT codes do not conform to the requirements of Category I CPT codes that are used for established medical care (AMA Category III CPT Codes, July 1, 2014).
11.4   Claims shall be reimbursed using the ABA Category III CPT codes. These codes apply to the provision of ABA services in all authorized settings (office, home, or community setting).
11.5   Application of HIPAA taxonomy designation. All claims for ABA CPT codes shall include the HIPAA taxonomy designation of each provider type. Each provider on a claim form must be identified by the correct HIPAA taxonomy designation. The designations to be used are:
•   103K00000X Behavior Analyst for master’s level and above;
•   106E00000X Assistant Behavior Analyst;
•   106S00000X Behavior Technician.
12.0   Category III And Other CPT Codes
12.1   CPT 0359T - ABA Assessment and ABA TP
12.1.1   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, shall be coded using CPT 0359T, “Behavior Identification Assessment.”
12.1.2   Elements of ABA assessment include:
•   One-on-one observation of the beneficiary.
•   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.
•   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.
12.1.3   CPT 0359T is an untimed code, meaning this code is reimbursed as a single unit of service procedure provided by an authorized ABA supervisor (or as delegated to an assistant behavior analyst), rather than for timed increments related to how long it takes to complete the assessment and ABA TP (CPT Assistant, June 2014). CPT 0359T may be reported twice during the first six month period (initial and re-authorization) and then once every six months for the ABA reassessment, progress measurement report, and TP update.
12.2   CPT 0360T and 0361T - Observational Behavioral Follow-Up Assessment - Supervised Fieldwork
Supervision of BTs by authorized ABA supervisors shall be in accordance with paragraph 4.13 . Each TRICARE beneficiary under the ACD must receive a minimum of one direct supervision contact per a 30 consecutive day period per BT.
12.2.1   Direct supervision (i.e., supervised fieldwork), is conducted to ensure the quality of BT services delivered during one-on-one ABA services with the beneficiary. Supervised fieldwork also provides an opportunity for the authorized ABA supervisor (or as delegated to an assistant behavior analyst) and the BT to use direct observation to identify and evaluate factors that may impede expression of the beneficiary’s adaptive behavior. Beneficiary areas assessed during CPT 0360T and 0361T include cooperation, motivation, visual understanding, receptive and expressive language, imitation, requests, labeling, play, leisure, and social interactions (CPT Assistant, June 2014). TRICARE modified CPT 0360T and 0361T to cover supervised fieldwork. Individual and group supervision are authorized (see paragraph 4.13 ). Indirect supervision, whereby the authorized ABA supervisor or the supervised assistant behavior analyst meets with a BT without the beneficiary present to review the treatment plan on one or more beneficiaries, is excluded from coverage under Category III CPT codes 0360T/0361T under TRICARE.
12.2.2   Authorized ABA supervisors and assistant behavior analysts, who complete the BACB eight-hour supervisory training course and competency, shall use CPT 0360T for the first 30 minutes and 0361T for each additional 30-minute increment of supervised field work of assistant behavior analysts and BTs. Authorized ABA supervisors are the only providers that shall bill and receive reimbursement for supervised field work. Supervision may be delegated to the assistant behavior analyst who is then the rendering provider. Billing for the rendering provider must still be completed by the authorized ABA supervisor. If the rendering provider is an assistant behavior analyst, reimbursement shall be at the assistant behavior analyst rate per paragraph 13.1 . Indirect supervision shall not be reimbursed.
12.2.3   The MCSC shall issue at least two units of 0360T to each beneficiary per BT to ensure that the two supervision sessions requirement is met.
12.2.4   All remote supervision shall include the GT modifier when submitting claims for remote supervision.
12.3   CPT 0364T and 0365T - Adaptive Behavior Treatment by Protocol
These codes are intended to code for the 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. CPT 0364T is coded for the initial 30 minutes of ABA protocol services provided during one-on-one with the beneficiary, and CPT 0365T shall be coded for each additional 30 minutes.
Note:   Authorized ABA supervisors direct the overall treatment by designing the overall sequence of stimulus and response fading procedures, analyzing the BT recorded progress data, and judging whether adequate progress is being made.
12.4   CPT 0368T and 0369T - Adaptive Behavior Treatment by Protocol Modification
These are codes 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. These codes may also be used to demonstrate a new or modified protocol to a BT and/or parents/caregivers. CPT 0368T and 0369T are timed 30-minute increment codes. These codes are also used for “treatment team meetings” where the authorized ABA supervisor, the parents/caregivers, the assistant behavior analysts, and/or BTs meet as a team to discuss the treatment modifications. “Treatment team meetings” will be authorized for protocol modification. These codes (CPT 0368T and 0369T) can also be used for transition/discharge reassessments and TP updates when circumstances require transition/discharge from ABA services.
Note:   An example of when transition/discharge reassessments may be required could be when a military family moves. The authorized ABA supervisor would modify the previous ABA TP protocol to incorporate changes in context and the environment. The modified protocol would then be provided to the BT and parents/caregivers to facilitate the desired behavioral target (such as reducing tantrums).
12.5   CPT 0370T - Family Adaptive Behavior Treatment Guidance
This code is used by the authorized ABA supervisor (or as delegated to an assistant behavior analyst) for guiding the parents/caregivers to utilize the ABA TP protocols to reinforce adaptive behaviors without the beneficiary present during a one-on-one encounter. 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.
12.6   Healthcare Common Procedure Coding System (HCPCS) T1023 - OUTCOME MEASURES SUBMITTED BY BCBA/BCBA-D
This code is used by only the BCBA/BCBA-D for the purpose of reimbursement for submission of required data for the ACD outcomes measures (Vineland-3, SRS-2, and PDDBI). See paragraph 8.2.2 for submission requirements and required data elements. For outcomes measures administered via telehealth, claims must include the modifier GT .
13.0   Reimbursement Rates
13.1   Reimbursement of claims in accordance with paragraphs 12.1 through 12.6 will be established based on independent analyses of commercial and CMS ABA reimbursement rates. The national rates for ABA services will then be adjusted by geographic locality using the Medicare Geographic Practice Cost Indices (GPCIs).
13.2   ABA reimbursement rates will be updated at the same time as the Annual CHAMPUS Maximum Allowable Charge (CMAC) Update, which normally occurs in March or April. The rates will also be posted at http://www.health.mil/rates . These updates shall be implemented and comply with Chapter 1, Section 4, paragraph 2.4 .
13.3   For claims with a date of service prior to the implementation of the April 1, 2016 ABA Reimbursement Rates, reimbursement of claims will be:
•   The negotiated rate; or
•   The reimbursement rates for the covered ABA CPT codes:
•   CPT 0359T. The Initial ABA assessment and ABA TP and every six month ABA reassessment and TP update by the authorized ABA supervisor (or as delegated to an assistant behavior analyst). CPT 0359T is a single unit of service code reimbursed at $500.00.
•   CPT 0364T and 0365T. Adaptive Behavior Treatment by Protocol. These codes are generally used by the BT for one-on-one ABA services with the beneficiary. Authorized ABA supervisors and assistant behavior analysts can also deliver this service. CPT 0364T and 0365T are timed codes reimbursed at $62.50 per in 30-minute increments ($125.00/hour) for authorized ABA supervisors, $37.50 per 30 minutes ($75.00/hour) per assistant behavior analysts, and $25.00 per 30 minutes ($50.00/hour) for BTs.
•   CPT 0360T and 0361T. Observational Behavioral Follow-Up Assessment for Supervised Field Work of assistant behavior analysts and BTs by the authorized ABA supervisor. These are timed codes reimbursed at $62.50 for each per 30 minutes ($125.00/hour) for authorized ABA supervisors and $37.50 per 30 minutes ($75.00/hour) for assistant behavior analysts delegated supervision responsibility.
•   CPT 0368T and 0369T. Adaptive Behavior Treatment by Protocol Modification for team meetings by the authorized ABA supervisor reimbursed at $62.50 per 30 minutes ($125.00/hour) and $37.50 per 30 minutes ($75.00/hour) for the assistant behavior analyst delegated this responsibility.
•   CPT 0370T. Family Adaptive Behavior Treatment Guidance. Authorized ABA supervisor (or as delegated to an assistant behavior analyst) treatment guidance to the parents/caregivers is a single unit of service CPT code reimbursed at $125.00.
13.4   For claims with a date of service between April 1, 2016 and December 22, 2016, the GPCI–adjusted reimbursement rates, with the no greater than 15% reduction cap, apply.
13.5   NDAA FY 2017, Section 716, signed December 23, 2016, directed that “in furnishing applied behavior analysis under the TRICARE program to individuals during the period beginning on December 23, 2016 and ending on December 31, 2018, the reimbursement rates for providers of applied behavior analysis will not be less than the rates that were in effect on March 31, 2016.” To comply, claims for ABA services with a date of service on or after December 23, 2016 through December 31, 2018, will be reimbursed the greater of:
•   The reimbursement rates for the covered ABA CPT codes:
•   CPT 0359T. The Initial ABA assessment and ABA TP and every six month ABA reassessment and TP update by the authorized ABA supervisor (or as delegated to an assistant behavior analyst). CPT 0359T is a single unit of service code reimbursed at $500.00.
•   CPT 0360T and 0361T. Observational Behavioral Follow-Up Assessment for Supervised Field Work of assistant behavior analysts and BTs by the authorized ABA supervisor. These are timed codes reimbursed at $62.50 per 30 minutes ($125.00/ hour) for authorized ABA supervisors and $37.50 per 30 minutes ($75.00/hour) for assistant behavior analysts delegated supervision responsibility.
•   CPT 0364T and 0365T. Adaptive Behavior Treatment by Protocol. These codes are generally used by the BT for one-on-one ABA services with the beneficiary. Authorized ABA supervisors and assistant behavior analysts can also deliver this service. CPT 0364T and 0365T are timed codes reimbursed at $62.50 per 30-minute increments ($125.00/hour) for authorized ABA supervisors, $37.50 per 30 minutes ($75.00/hour) per assistant behavior analysts, and $25.00 per 30 minutes ($50.00/ hour) for BTs.
•   CPT 0368T and 0369T. Adaptive Behavior Treatment by Protocol Modification for team meetings by the authorized ABA supervisor or for the authorized ABA supervisor treatment protocol modification, with or without the BT or parent/caregiver present, is reimbursed at $62.50 per 30 minutes ($125.00/hour) and $37.50 per 30 minutes ($75.00/hour) for the assistant behavior analyst delegated this responsibility.
•   CPT 0370T. Family Adaptive Behavior Treatment Guidance. Authorized ABA supervisor (or as delegated to an assistant behavior analyst) treatment guidance to the parents/caregivers is a single unit of service CPT code reimbursed at $125.00.
Note:   Negotiated provider rates lower than those directed in this paragraph are not allowed.
•   The provisions of paragraph 13.2 apply for annual GPCI rate adjustments.
13.6   For BCBAs submitting claims for T1023, reimbursement shall be the geographically adjusted reimbursement methodology for CPT code 96102. Reimbursement is limited to one unit per measure (PDDBI: [Parent and Teacher form]: one unit every six months or Vineland-3/SRS-2: one unit each per two year period).
14.0   Cost-Sharing
14.1   Effective October 1, 2015, all beneficiary cost-sharing and deductibles and enrollment fees will be the same as the TRICARE Basic Program: TRICARE Standard, as defined in 32 CFR 199.4 (through December 31, 2017), TRICARE Extra Program as defined in 32 CFR 199.17 (through December 31, 2017), TRICARE Select as defined in 32 CFR 199.17 (starting January 1, 2018), and TRICARE Prime Program enrollment fees and copayments as defined under the Uniform Health Maintenance Organization (HMO) Benefit Schedule of Charges in 32 CFR 199.18 . For information on fees for Prime enrollees choosing to receive care under the Point of Service (POS) option, refer to 32 CFR 199.17 . Also, refer to TRM, Chapter 2, Section 1 . These cost-sharing provisions are not retroactive. 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 in the ACD.
14.2   Effective January 1, 2018, all beneficiary cost-sharing and deductibles and enrollment fees will be those applicable to the specific category of the eligible beneficiary receiving services under this demonstration; e.g., TRICARE Prime, TRICARE Select; and TRICARE for Life (TFL). For information on fees for Prime enrollees choosing to receive care under the Point of Service (POS) option, refer to 32 CFR 199.17 . Also, refer to TRM, Chapter 2, Section 1 . There is no maximum Government payment or annual cap specifically for ABA services; TRICARE deductibles, enrollment fees, copayments, cost-shares, and the annual catastrophic cap protections implemented pursuant to 32 CFR 199 apply to beneficiaries.
15.0   Additional Contractor Responsibilities
The contractor shall:
15.1   Ensure all requirements outlined in this section are met when authorizing ABA services under the ACD.
15.2   Maintain all documents related to the ACD in accordance with Chapter 9 .
15.3   Forward to the “gaining” contractor all ACD related documents within 10 calendar days of being notified that a beneficiary is transferring to a location under the jurisdiction of another contractor.
15.4   Conduct annual audits on at least 20% of each authorized ABA supervisor’s assistant behavior analysts and BTs for compliance with the requirements governing ABA providers as specified in paragraph 6.0 . Auditors shall include assessment of compliance with the requirement for BT supervision for a minimum of 5% and a maximum or 20% of the hours spent providing one-on-one ABA services per 30 consecutive day period per beneficiary as per paragraph 4.13 . Upon determining non-compliance with one or more assistant behavior analyst or BT qualification requirements, the contractor shall immediately initiate a compliance audit of all assistant behavior analysts and BTs employed by or contracted with that authorized ABA supervisor.
15.5   Conduct semi-annual audits on 20% of beneficiaries receiving ABA services for compliance with paragraphs 8.1 through 8.4 . Audits shall include evaluation of the six month progress measurement using the same tool throughout the episode of care and shall include a breakdown of measures used. The annual audit cycle shall also include compliance with the requirement to complete the outcome evaluations (see paragraph 8.2 ) and shall include analysis of number of hours of supervision expressed as a percentage per month.
15.6   Complete and timely submit the monthly, quarterly, and semi-annual reports. Details for reporting are identified by DD Forms 1423, Contract Data Requirements Lists (CDRLs), located in Section J of the applicable contract.
15.7   Ensure all TRICARE Encounter Data (TED) requirements outlined in the TRICARE Systems Manual (TSM), Chapter 2 are met including appropriate use of Special Processing Code “ AS Comprehensive Autism Care Demonstration”.
15.8   The contractor shall ensure timely processing of referrals and authorization of ABA services. Case management services shall be offered to those NADFMs (retirees and other eligible beneficiaries of Reserve and National Guard sponsors) who meet contractor criteria for case management. ADFMs registered in ECHO are assigned a contractor ECHO case manager and shall receive care coordination from that contractor ECHO case manager. Additional case management services may be provided by the contractor, if needed.
15.9   After December 31, 2016, the contractor shall deny claims for all BTs who do not meet certification requirements of paragraph 6.3.1 .
15.10   After December 31, 2016, the contractor shall deny claims for all ABA providers that do not have BLS/CPR certification per paragraphs 6.1.12 , 6.2.7 , and 6.3.2 .
15.11   After December 31, 2016, the contractor shall deny supervision claims for all providers who have not completed the BACB eight-hour, competency-based training for Supervising Training Curriculum Outline and three hours of continuing education related to supervision during each BACB certification cycle or possession of the QASP Supervisor (QASP-S) designation for QABA providers per paragraphs 6.1.12 and 6.2.7 .
16.0   Quality Assurance
16.1   ABA services involves the provision of care to a vulnerable patient population. The contractor shall have a process in place for evaluating and resolving family member/caregiver concerns regarding ABA services provided by the authorized ABA supervisor, and the assistant behavior analysts, and/or BTs they supervise.
16.2   The contractor shall designate an ACD complaint officer to receive and address beneficiary family member/caregiver complaints. Contact information shall be provided to all family members/caregivers of beneficiaries receiving ABA services under this demonstration.
16.3   Allegations of risk to patient safety shall be immediately reported to the contractor’s Program Integrity (PI) unit and DHA PI Division. The contractor’s PI unit shall take action in accordance with Chapter 13 , developing for potential patient harm, fraud, and abuse issues.
16.4   Potential complaints shall be ranked by severity categories. Allegations involving risk to patient safety shall be considered the most severe, shall be addressed immediately, and shall be reported to other agencies in accordance with applicable law. For example, allegations of physical, psychological, or sexual abuse require immediate reporting to state Child Protective Services, or appropriate officials, to the BACB, BICC, and/or QABA, and to state license or certification boards as indicated in accordance with applicable laws, regulations, and policies concerning mandated reporting requirements.
16.5   Claims shall be denied for services of an authorized ABA supervisor who has any restriction on their certification imposed by the BACB, BICC, or QABA, or any restriction on their state license or certification for those having a state license or certification.
16.6   Risk Management policies and processes shall be established by the contractor for the authorized ABA supervisor.
17.0   Quality Monitoring And Oversight
17.1   Potential categories requiring quality monitoring and oversight by the contractor include, but are not limited to:
•   Fraudulent billing practices (to include concurrent billing, i.e., billing for two services at the same time).
•   Lack of ASD diagnosis from a provider qualified to provide such per paragraph 5.0 .
•   Lack of an ABA referral from a TRICARE authorized ASD referring provider as per paragraph 5.0 .
•   Lack of maintenance of the required medical record documentation.
•   Billing for office supplies to include therapeutic supplies.
•   Billing for ABA services using aversive techniques.
•   Group ABA services that are billed as authorized one-on-one ABA services.
•   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.
17.2   Documentation requirements shall address the requirements for session progress notes and the ABA TP (to include the initial ABA TP and ABA TP updates) that identify the specific ABA services used for each behavior target. Progress notes shall contain the following documentation elements in accordance with TPM, Chapter 1, Section 5.1 , “Requirements for Documentation of Treatment in Medical Records”:
•   The date and time of session;
•   Length of therapy session;
•   A legible name of the rendering provider, to include provider type/level;
•   A signature of the rendering provider;
•   A notation of the patient’s current clinical status evidenced by the patient’s signs and symptoms;
•   Content of the session;
•   A statement summarizing the techniques attempted during the session;
•   Description of the response to treatment, the outcome of the treatment, and the response to significant others;
•   A statement summarizing the patient’s degree of progress towards the treatment goals; and
•   Progress notes should intermittently (at least monthly) include reference to progress regarding the periodic ABA program review established early on in the patient’s treatment.
17.3   ABA Initial TP and TP updates:
•   Initial ABA TP documentation identifies short-term objectives, and short and long-term treatment goals to include specified treatment interventions for each identified target in each domain.
•   ABA TP update assessment notes address 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 note interventions that were ineffective and required modification of the TP. TP updates shall document TP modifications that were the result of the outcome evaluations.
•   The ABA TP and TP updates must include the ASD diagnosing and referring provider’s ASD diagnosis, to include symptom severity level/level of support required according to DSM-5 ASD criteria. Documentation on the initial ABA TP and the ABA TP updates shall reflect the authorized ABA supervisor’s determination of the level of support required for the beneficiary to demonstrate progress toward short and long-term goals (Note: The level of support required to demonstrate progress is important because it is directly associated with severity of the diagnosis of ASD and is an important factor in determining the number of hours of ABA services per week to authorize).
•   Documentation of family member/caregiver engagement and implementation of the ABA TP at home shall 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.
17.4   To conduct proper oversight for the potential of improper payments, and to verify that ABA services are appropriately performed as reflected on submitted claims, the following monitoring activities will be accomplished:
17.4.1   Conduct comprehensive medical reviews on a statistically valid number of applied behavior analysis providers’ claims (for CPT codes listed in paragraphs 12.1 through 12.6 ) to ensure an adequate number of claims are reviewed.
17.4.2   Reviews shall compare the beneficiaries’ session notes to the provider’s claims to determine whether all required documentation exists and is adequate to support the charges.
17.4.3   The contractor shall take corrective action on claims which indicate improper payments, including, but not limited to, payment recoupment. Contractors shall refer cases to DHA PI, as appropriate.
18.0   Applicability
The ACD is limited to TRICARE beneficiaries who meet the requirements specified in paragraph 7.0 . The ACD applies to the managed care support contractors, the TOP contractor, and the Uniformed Services Family Health Plan (USFHP) designated providers.
19.0   Exclusions
•   Training of BTs.
•   ABA services for all other diagnoses that are not ASD.
•   Billing for e-mails and phone calls.
•   Billing for driving to and from ABA services appointments.
•   Billing for report writing outside of what is included in the assessment code (CPT 0359T).
•   Billing for office supplies or therapeutic supplies (i.e., binders, building blocks, stickers, crayons, etc.).
•   Billing for ABA services provided remotely through Internet technology or through telemedicine/telehealth (except as allowed under paragraph 4.18 , Remote Supervision, and outcome measures as allowed under paragraph 8.2.2 ).
•   Billing for ABA services involving aversive techniques or rewards that can be construed as abuse.
•   Billing for multiple ABA providers time during one ABA session with a child when more than one ABA provider is present.
•   Educational/academic and vocational rehabilitation.
•   Educational ABA services.
•   ABA services for a beneficiary that are written in a beneficiary’s Individualized Education Program (IEP) and that are required to be provided without charge by the local public education facility in accordance with the Individuals with Disabilities Act. 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.
•   Billing the ACD for school tuition that includes educational ABA services and non-ABA services.
•   Use and billing of restraints.
•   Respite care (except as authorized under ECHO).
•   Custodian, personal care, and/or child care.
•   Group ABA services (defined as multiple beneficiaries with fewer providers, i.e., three plus children and one to two providers).
•   Indirect supervision.
20.0   Effective Date And Duration
Requirements for coverage under the ACD are effective as of July 25, 2014. The ACD will terminate December 31, 2023.
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