Overview
A Health Net Federal Services, LLC (HNFS) approval is required for applied behavior analysis (ABA) services for all beneficiaries, including those with other health insurance. HNFS will make specific coverage determinations for ABA services, to include locations, provider types, units, etc., during the treatment plan clinical necessity review process. ABA providers should familiarize themselves with TRICARE requirements for the various settings.
Settings
Home
Definition: Beneficiary's residence
Eligible provider types: All ABA provider types (if authorized and as specified in the approved treatment plan)
Place of service code: 12
Details: Refer to the home-schooling information in the "School Settings" section below.
Clinics/Centers
Definition: Outpatient clinic or center where beneficiaries receive ABA services
Eligible provider types: All ABA provider types (if authorized and as specified in the approved treatment plan)
Place of service code: 11
Details: Travel to and from a clinic/center is not reimbursable.
Daycare (non-preschool)
Definition: Daycare centers, child development centers, after-school programs, adult care settings
Eligible provider types: All ABA provider types (if authorized and as specified in the approved treatment plan)
Place of service code: 99
Details: A non-preschool daycare setting may be considered an eligible location if active delivery of ABA services that target the core symptoms of autism spectrum disorder (ASD) occurs, and the ABA provider does not function as a support aide or observer during care routines or activities (such as, lunch, group activities, arts and crafts, etc.). The use of these settings must clearly be outlined in the treatment plan including why a home or center location cannot be utilized and how caregivers are incorporated.
School Settings
Definition: Preschool, public school, or private school, or home-school
Eligible provider types:
- ABA supervisors providing active delivery of ABA services (if authorized and as specified in the approved treatment plan).
- New authorizations for any service performed by behavior technicians (BT) or assistant behavior analysts under Current Procedural Terminology (CPT®) code 97153 in the school setting will not be approved.
Details: HNFS may authorize ABA supervisors to provide active delivery of ABA services targeting core ASD symptoms in the school setting under CPT code 97153. These approved ABA services are focused, time-limited, and in accordance with the requirements of the Autism Care Demonstration (ACD). All exclusions as identified in the ACD under TRICARE Operations Manual, Section 18, Chapter 4 apply.
- A current Individualized Education Program (IEP) is required for beneficiaries if treatment requests include a request for direct ABA services within a public or private school setting by the ABA supervisor under CPT code 97153.
- ABA providers are not permitted to render duplicate services to those documented in the IEP.
In the recommendation section of the treatment plan, ABA providers must distinguish between the units rendered in the school setting by the ABA supervisor and the units rendered by the BT or assistant behavior analysts in other locations (home, center/clinic). ABA supervisors also must designate which specific treatment goals will be targeted in the school setting, the anticipated duration, as well as any planned gradual reduction for this treatment location. ABA services approved in the school setting should be for a limited duration.
For a beneficiary who is enrolled in home-schooling, authorized ABA services must be rendered outside of home-schooling hours. Home-schooling hours cannot overlap ABA services.
Academic/educational goals are excluded in all settings, including the school setting. ABA supervisors who have been authorized by HNFS to render ABA services in the school setting are still excluded from targeting educational, academic, and/or vocational areas. ABA is not a replacement for academic needs and/or related areas, including acting as support staff.
Community Settings
Definition: Any location not part of a home, outpatient ABA center or clinic, or school setting. Community settings include grocery stores, parks, restaurants, and events such as youth sports or local community activities. Certain community settings are specifically excluded, including medical offices (such as, doctor visits, physical therapy, etc.), participating in sports, or camps.
Eligible provider types: All ABA provider types (if authorized and as specified in the approved treatment plan)
Place of service code: 99
Details: Specific exclusions apply to sporting events, camps and medical appointments for the beneficiary or other family members. As well, some community locations and activities do not allow for frequent and repeated presentation of treatment opportunities and often target areas not specific to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition's (DSM-5) ASD diagnostic criteria. For example, community settings that address daily living and vocational skills will be excluded from treatment requests. Travel in a vehicle is also an excluded activity for ABA treatment and billing. These portions of any approved community location must not be included in the rendered time of the appointment.
Possible situations in which use of a particular community setting may be approved include:
- When a beneficiary presents with substantial levels of impairment in core ASD symptoms and/or severe behavior excesses that have the potential to cause harm to self or others and requires treatment to be able to access community locations.
- For social and communication generalization opportunities that would not be possible in the home or center/clinic setting.
When requesting approval for treatment in a community setting, the setting must directly coincide with treatment related to the DSM-5 (or current version) descriptions of ASD. For example, if a parent/caregiver reports significant behavior excess that prevents a beneficiary from engaging in a community setting, the provider may request to use that community setting for behavior intervention and parent/caregiver training specific to these needs.
Community location exclusions and pre-authorization requirements apply to all ABA provider types. HNFS will make specific coverage determinations on provider types during the clinical necessity review process. When pre-authorized, any ABA provider type may offer ABA services in a community setting under CPT code 97153. When the ABA supervisor or assistant behavior analyst is conducting program modification in the community setting, they will use CPT code 97155.
Family/caregiver support is critical for beneficiaries generalizing mastered skills into community settings. Family members who are targeting new skills in the community setting should refer to parent/caregiver training and parent/caregiver training goals for guidance, as well as feedback and direction from the ABA supervisor or assistant behavior analyst.
Academic/educational goals are excluded in all settings, including the community setting. ABA supervisors and assistant behavior analysts, when pre-authorized to render ABA services in the community setting, are still excluded from targeting educational/academic/vocational area.
TRICARE excludes ABA services rendered during other medical appointments (for example, doctor visits, physical therapy, etc.), to include another family member's appointment.
Indirect
Definition: Email, U.S. postal mail (for example, report writing, review records)
Eligible provider types: TRICARE-authorized ASD-diagnosing providers or, when authorized by HNFS, ABA supervisors
Place of service code: 99
Details: Applies to rendering of outcome measures.
Telemedicine
Definition: The use of secure video conferencing to provide medically and psychologically necessary services to beneficiaries at home. Specific technical requirements, outlined in TRICARE Policy Manual, Chapter 7, Section 22.1, must be met. Telehealth services may be synchronous (two-way audio and video, such as real-time video) or asynchronous (one direction at a time, such as submitting medical history from one party to another). Audio-only services are not allowed under the ACD.
Eligible provider types: ABA supervisors and assistant behavior analysts, based on CPT code 97156 (if authorized and as specified in the approved treatment plan)
Place of service code: Place of service 02 or the most appropriate place of service code that allows for accurate billing, with GT or 95 modifier.
The modifier, required for synchronous telehealth, allows the distant site provider to certify the beneficiary or parent was present at an eligible originating site when the telemedicine service was rendered.
Details:
Services billed under CPT codes 99366 and 99368 may be rendered via telehealth when authorized and performed by ABA supervisors.
Services billed under CPT code 97156 may be rendered via telehealth when authorized and performed by ABA supervisors or assistant behavior analysts. BTs cannot render CPT code 97156 services.
TRICARE will only reimburse for CPT code 97156 services rendered via telemedicine if authorized.
- CPT code 97156 services may not exceed eight units per day or the maximum units/month authorized.
- TRICARE will allow for the same-day rendering of CPT code 97156 via telemedicine and direct services.
- The first CPT code 97156 session must take place within the first 30 calendar days of the treatment authorization.
- Telehealth for CPT code 97156 will only be authorized after the initial six-month authorized treatment period has completed.
Services billed under CPT codes 97151, 97153, 97155, 97157, and 97158 are prohibited for delivery via telehealth.
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