Autism Care Demonstration Authorizations: Initial Assessment and First Treatment

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.

Authorization requests must be submitted electronically and will be processed within two to five business days once all required documentation has been received.
Submitting a request to HNFS is not a confirmation of authorization.
ABA providers can check the status of an authorization or download a copy of the approval letter by using our Check Authorization Status tool.

Not sure what HNFS' authorization status codes mean? Reference this printable Autism Care Demonstration (ACD) Authorization Codes & Determination Reasons guide to better understand request statuses and potential action required.

Tip: View/download our process flow that walks you through the ACD nomination to first treatment authorization.

(Full text of process flow)

Step 1 - Initial Assessment

After HNFS has verified a referral for ABA services, we may pend the request for initial provider placement (“Pended – Initial Provider Placement”) for up to 15 business days.

Once the referral for ABA services has been authorized for the initial assessment, ABA providers can start the initial assessment.

Access-to-Care Standards

Initial Assessment:

After receiving an approved authorization to start the initial assessment, ABA providers must provide the first date of service of the assessment (Current Procedural Terminology [CPT^®] code 97151) within 28 calendar days from the date HNFS verified the referral for the assessment.
As HNFS has up to 15 business days to complete active provider placement, the ABA provider needs to ensure the first date of service of CPT code 97151 is completed within 28 days of the “service from date” on the initial assessment authorization.
HNFS confirms the access-to-care standard was met for the initial assessment or obtains rationale if the access-to-care standard was not met. ABA providers are expected to respond to requests for information regarding the confirmation of meeting the access-to-care standards.

First Treatment:

ABA providers must conduct CPT code 97153, 97155 or 97156 services within 28 calendar days of the last date of initial assessment in the 14-day window that is allowed for CPT code 97151 after an authorization to start treatment has been approved.
- CPT codes 97157 and 97158 also are included in the requirement above.
- ABA providers must render the first session of parent/caregiver training (CPT codes 97156 or 97157) within 30 calendar days of each treatment authorization.
- HNFS confirms access-to-care standards were met for treatment or obtains rationale if not met. ABA providers are expected to respond to requests for information regarding the confirmation of meeting the access-to-care standards.
HNFS will not backdate authorizations and pre-authorization is required.

We encourage ABA providers to submit requests for treatment promptly following the last day of the assessment to help reduce the length of time between the end of the assessment period and the approval to initiate treatment.

Assessment approval letters

Providers and beneficiaries can view a copy of the determination letter online (log in to access your Secure Inbox and/or our Check Authorization Status tool).

The letter contains contact information for the beneficiary and ABA provider. HNFS encourages beneficiaries to contact the ABA provider listed on the approval to set up the initial appointment if the ABA provider has not contacted the beneficiary within three business days.

Beneficiaries who want to see a different provider from the provider listed on the authorization can contact our ACD customer service line for assistance with requesting a change to the approved authorization.
If the ABA provider and/or beneficiary are unable to connect with each other within one week, the ABA provider should contact our ACD customer service line for assistance.

Initial Assessment Requirements

An authorized ABA supervisor (or as delegated, an assistant behavior analyst) must conduct the initial assessment used to develop the treatment plan. This assessment must begin once the authorization has been approved within the 28-day TRICARE access-to-care standard and be completed within the 14-calendar day allowance from the first date of service. Initial assessment authorizations are approved for 45 days to facilitate meeting access-to-care standards and the 14-calendar day window.

All units billed for the assessment must be within the 14-day window. Please refer to our Billing page for more information on CPT code 97151 requirements.

Initial assessments must include direct service with the beneficiary and can include additional indirect methods to complete the treatment plan and recommendations.

This assessment must have the following:

Direct observation, measurement and recording of behavior;
Background information that clearly demonstrates the beneficiary's condition, diagnoses, family history, and how long the beneficiary has been receiving ABA services;
Functional assessment;
Data from parent/caregiver interview and parent report rating scales;
Treatment plan that meets all TRICARE Operations Manual (TOM), Chapter 18, Section 4 requirements; and
Results of the Pervasive Developmental Disorder Behavior Inventory (PDDBI) Parent Form.

Recommended Units and Request for Treatment Authorization

Recommended units align with best practices and refer to the amount of eligible CPT code units necessary to achieve desired treatment outcomes based on clinical necessity. Requests for authorization should reflect the number of units recommended for the treatment of a particular beneficiary and their family.

Requests for authorized units must be based on a combination of the symptom domains and levels of support required per Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria, outcome measure results (for treatment plan updates) and the capability of the beneficiary to actively participate in ABA services.
Recommendations and requests for treatment authorization must be submitted as units and will not be accepted in other formats (for example, hours) for each relevant TRICARE-approved adaptive behavior services (ABS) CPT code.
Treatment plans must include recommendations for monthly parent/caregiver training hours, submitted as units.
- If parent/caregiver participation is not possible, the treatment plan must reflect the reason and detail mitigation efforts undertaken by the provider to resolve.
- A minimum of six parent/caregiver training sessions must be conducted over the six-month authorized treatment period.
The treatment plan must identify the location of service for each requested CPT code (for example, home, clinic/center, school, community location type [parks, grocery store, etc.], or daycare).
The treatment plan must indicate sole or tiered delivery model.

Service Locations

Please review definitions/guidelines for home, clinics/centers, daycares, school settings, and community settings on our ABA Service Locations page.

Discharge plan

The process of establishing a discharge plan should occur during the initial assessment.

A discharge plan should be developed between the ABA provider and the beneficiary with short- and long-term plans to:

Generalize mastered skills.
Teach new skills in the natural environment.
Incorporate steps to transition care to the family when ABA services are no longer clinically necessary.

Step 2 – Request for Treatment Authorization

Once the initial assessment process has been completed, ABA providers must submit the first treatment authorization request. ABA providers must submit a complete packet meeting all requirements prior to HNFS conducting a clinical necessity review. HNFS will verify the following requirements have been met before starting the clinical necessity review process:

TRICARE eligibility
ACD eligibility
Treatment plan with all required elements, including parent/caregiver goals and engagement
PDDBI Parent Form scores
Individualized Education Program (IEP), when applicable
All outcome measures received

TRICARE and Autism Care Demonstration eligibility

Please refer to our ACD Eligibility page for details.

Treatment plans

Treatment plans should be organized into the following main categories:

Identifying Information
Reason for Referral
Background Information
Summary of Assessment Activities (when applicable)
Goals
Summary and Explanation of Progress
Recommendations & Units
Discharge Planning and Criteria
Signatures

Treatment plans must include all data points and areas outlined in the TOM.

View our Treatment Plan Requirements guide to ensure the necessary requirements have been met.

PDDBI scores

Providers are required to submit the full publisher print report or clearly and legibly written hand-scored protocol and summary score sheet(s), as well as label the PDDBI to distinguish between the Parent and Teacher Forms. HNFS will not accept PDDBI scores embedded as a table within the treatment plan.

If completing the PDDBI scoring manually, submit all documents related to scoring.
Invalid or incomplete scoring will not be accepted.
The PDDBI must include the name of the respondent and relationship to the beneficiary.

Visit our Outcome Measures page to learn more.

Individualized Education Program

For CPT code 97153, only regional contractors can authorize ABA supervisors to provide autism spectrum disorder (ASD) core symptom-specific ABA services in a school setting short term or for a limited duration of time.

If applicable, an IEP must be submitted with the treatment plan. ABA supervisors cannot render duplicate services to those documented in the IEP.

Outcome Measures

All beneficiaries must have complete, valid outcome measure scores for HNFS to process treatment authorization requests. Refer to our Outcome Measures page for complete details.

TRICARE requires ACD participants to complete and submit scores for the following outcome measures:

PDDBI (Parent/Teacher Forms, when applicable)
Vineland Adaptive Behavior Scales, Third Edition (Vineland-3)
Social Responsiveness Scale, Second Edition (SRS-2)
Parenting Stress Index, Fourth Edition Short Form (PSI-4-SF) (0 years–12 years and 11 months) or the Stress Index for Parents of Adolescents (SIPA) (11 years–19 years and 11 months). Similar to other outcome measures, providers submit only the PSI-4-SF or SIPA scores (not the questions or calculations) to HNFS.

If the ABA provider has submitted the request for treatment, the treatment plan, the PDDBI Parent Form (and Teacher Form if applicable), and the IEP (when applicable) but the outcome measures remain outstanding, HNFS will contact the beneficiary to facilitate their completion by the approved provider. To meet access-to-care standards, we may authorize beneficiaries to an ABA provider who has the ability to complete all additional ABA outcome measures (Vineland‐3, SRS‐2, PSI‐4-SF/SIPA) instead of the beneficiary's treating provider.

CLINICAL NECESSITY REVIEWS

HNFS is required to perform clinical necessity reviews and provider engagement, if needed, on all compliant treatment authorization requests prior to issuing coverage determinations. Please visit our Clinical Necessity Reviews page for complete details.

Providers must have an approved treatment authorization (with an authorization number) prior to rendering reimbursable ABA services.

Submitting a request to HNFS is not a confirmation of authorization.
Do not provide reimbursable ABA services without an approved authorization. HNFS will deny reimbursement for services performed outside the dates approved on the authorization.
HNFS does not issue backdated authorizations. If an authorization is pended or canceled due to missing supporting documentation or an incomplete clinical necessity review (to include the consultation with the ABA supervisor or an update to a treatment plan), the authorization will be re-issued from the date HNFS receives all required information.

Parent/Caregiver Engagement and Training

An important component of a strong, clinical ABA program integrates parents/caregivers by training them on ABA principles to work effectively with the beneficiary to achieve goals, target skills tailored to the improvement of the beneficiary, and to ensure generalization of skills.

The inclusion of parent/caregiver training and goals in the treatment plan is an opportunity for the ABA provider to support parents/caregivers with implementing ABA goals outside of program hours.

HNFS strongly encourages implementing parent/caregiver training immediately once the treatment authorization is approved. ABA providers must render the first session of parent/caregiver training (CPT codes 97156 or 97157) within 30 calendar days of each treatment authorization.
The initiation of parent/caregiver training, the implementation of ABA principles around Behavior Intervention Plans, and the progession of parent/caregiver goals can be done independently of the direct ABA service hours once the ongoing authorization has been approved.
As the direct ABA service hours are scheduled and initiated, parent/caregiver engagement and implementation can supplement the beneficiary’s hours to ensure ABA principles are integrated throughout their day.
Treatment plans must document the number of parent/caregiver training sessions over each authorization period or explain roadblocks and troubleshooting efforts made to meet the minimum requirement of six parent/caregiver training sessions.

For information on subsequent authorizations, visit our Subsequent Authorizations and Continuing Treatment page.

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