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Autism Care Demonstration: Timeline of Program Updates

The following has been updated per the requirements outlined in TRICARE’s revised Autism Care Demonstration (ACD). 

Timeline

(Not all-inclusive; please refer to TRICARE Operations Manual, Chapter 18, Section 4 for complete policy details.)

To access a print-friendly version, please click here.

April/May 2021
Requirement Summary Date
Referral Cycle Realignment Health Net Federal Services, LLC (HNFS) to realign existing ACD participants to a new two-year referral cycle timeline based on the date HNFS received the current two-year referral. April 1, 2021–May 1, 2021
Outcome Measures Cycle
(existing beneficiaries) 		 HNFS to realign existing ACD participants to a one-year cycle for the Vineland Adaptive Behavior Scales, Third Edition (Vineland-3) and Social Responsiveness Scale, Second Edition (SRS-2). April 1, 2021–May 1, 2021
Outcome Measures Cycle
(new beneficiaries)		 New beneficiaries start on a one-year cycle for Vineland-3 and SRS-2. May 1, 2021
Outcome Measure Referral HNFS can authorize directly to preferred outcome measure applied behavior analysis (ABA) provider groups (no primary care manager (PCM)/ABA provider referral required). May 1, 2021
Behavior Technicians/Assistant Behavior Analysts Not Authorized to Render ABA in School Setting  HNFS to no longer authorize behavior technicians and assistant behavior analysts for Current Procedural Terminology (CPT®) code 97153 services performed in a preschool or school setting (public or private). Current authorizations with approved school services may continue until expiration. May 1, 2021
Annual Rate Update Annual rate update for current ABA codes.  May 1, 2021
Confirming Diagnosis PCMs no longer required to refer to specialized autism spectrum disorder (ASD)-diagnosing provider to confirm diagnosis. May 1, 2021

 

 

July/August 2021
Requirement  Summary Date
Notification of New Referral and Outcome Measure Cycles HNFS to notify affected beneficiaries of new referral and outcome measure cycles. By July 1, 2021
National Provider Identifier 

National Provider Identifier (NPI) required on ABA provider claim submissions.

(Note: While this is a new requirement for the ACD, HNFS already requires an NPI for reimbursement. The NPI on the claim determines where we will send payment.)

July 1, 2021: new ABA providers

 

Aug. 1, 2021: existing ABA providers
Vineland-3 and SRS-2 Additional Requirements Name of the person completing the forms and their relationship to the beneficiary required on all submissions; ABA providers must submit full publishers report or manual scoring (imbedded tables within treatment plans will not be accepted). Aug. 1 2021
New Outcome Measures Age-based Parent Stress Index, Fourth Edition Short Form (PSI-4-SF) or Stress Index for Parents of Adolescents (SIPA) required prior to HNFS authorizing first treatment (after initial assessment) and for all reauthorizations for existing beneficiaries at the next reauthorization period after Aug.1 2021. Aug. 1, 2021
Outcome Measures for Authorization Valid outcome measures must be completed prior to HNFS authorizing first treatment (after initial assessment) and for all reauthorizations.  Aug. 1, 2021
Active Provider Placement HNFS to expand active provider placement for all referrals submitted and confirm availability of ABA providers within access to care standards prior to authorization. (Referrals from military facilities that name specific providers will be reviewed, but placement will be based on access to care standards.)  Aug. 1, 2021
Access to Care HNFS to complete confirmation with ABA providers that 28-day access to care standard was met for initial assessments and treatment authorizations. Aug. 1, 2021
Electronic Funds Transfer  HNFS will pay all claims billed by ABA sole providers and Autism Corporate Services Providers (ACSPs) by electronic funds transfer (EFT).
 Aug. 1, 2021
New CPT Codes Accepted TRICARE ACD to accept new (97157, 97158, 99366, 99368) CPT codes. Beneficiaries are not eligible for new codes until the next authorization period and requests submitted prior will be cancelled. Rates available on health.mil. Aug. 1, 2021
CPT Code Requirements Modified New MUE limits for existing and new CPT codes. Modifications to telehealth and minimum requirements for program modification and parent training effective for authorizations issued after Aug. 1. Aug. 1, 2021
Parent Training Providers required to initiate parent training (97156, 97157) within 30 days of the treatment authorization being issued.  Aug. 1, 2021
Parent Training Providers required to conduct a minimum of six parent training sessions per authorization period. (97157, 97158) Aug. 1, 2021
Program Modification ABA supervisors are required to render a minimum of one direct visit per month for 97155 or a 10% penalty to all claims will be applied for the authorization period.  Aug. 1, 2021
Treatment Plan Review HNFS to review 100% of treatment plans for clinical necessity prior to authorization; initiation of clinical necessity consultations with the ABA supervisor when needed prior to authorization.  Aug. 1, 2021
Treatment Plan Documentation New requirements for treatment plan documentation.  Aug. 1, 2021
Discharge Reports ABA providers required to submit discharge reports when care has been ended (not a billable service).  Aug. 1, 2021
Participation Agreements ACSPs/sole ABA providers must re-sign participation agreements. (HNFS to begin contacting providers in May.) Aug. 1, 2021
Family Definition Modification to the definition of a family member and/or caregiver.  Aug. 1, 2021

 

 

 

October 2021
Requirement Summary Date
Eligibility Requirements – Validated Assessment Tool The validated assessment tool is due for referrals that expire on or after Oct. 1 for new beneficiaries prior to enrollment and existing beneficiaries at the two-year referral cycle. Beneficiaries whose referral expires prior to Oct. 1 wait until their next two-year referral cycle to meet this requirement.  Oct. 1, 2021
Eligibility Requirements – DSM-5 Criteria Checklist HNFS to collect completed Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Criteria Checklist from the referring provider for new beneficiaries prior to enrollment and existing beneficiaries at their two-year referral cycle. Oct. 1, 2021
Evaluation for Beneficiaries Age 8 Years or Older A specialized ASD-diagnosing provider diagnostic evaluation (not a PCM) required for new beneficiaries first diagnosed with ASD at age eight years or older prior to authorization of ABA services. Oct. 1, 2021
Evaluation for Beneficiaries with Referral Over Two Years from Diagnosis  A specialized ASD-diagnosing provider diagnostic evaluation (not a PCM) required for new beneficiaries whose first referral for ABA is greater than two years from the initial date of diagnosis.  Oct. 1, 2021
Referring and Diagnosing Provider New definitions of a referring and diagnosing providers. Referrals must come from newly defined provider types for all new beneficiaries prior to authorization of ABA and existing beneficiaries at their two year referral cycle. Oct. 1, 2021
Autism Services Navigator New beneficiaries will be assigned an Autism Services Navigator (ASN) after enrollment.  Oct. 1, 2021
Comprehensive Care Plan A comprehensive care plan for beneficiaries with an ASN must be completed by the ASN within the first 90 days and prior to each reauthorization.  Oct. 1, 2021
Parent Toolkit HNFS to provide an ACD Parent Toolkit containing information about the ACD program on our website. Oct. 1, 2021
Online Resource Library Online beneficiary resource to include topics on treatments and services, parental education, military and civilian resources, family resources, etc. to be added to www.tricare-west.com. Oct. 1, 2021
Provider Audits HNFS to conduct annual provider audits, to include administrative records, medical documentation reviews and medical team conference progress note reviews. Oct. 1, 2021

 

 

 

January 2022
Requirement Summary  Date 
Annual Provider Training  Providers will be required to participate in an annual provider training. Jan. 1 2022: Training module available
Steerage Model HNFS to implement a steerage model and rank ABA providers according to access to care standards and other measures with positive impact to the beneficiary. Jan. 1, 2022
Directory Changes ABA providers who rank highest in the steerage model will be given priority placement in HNFS' Network Provider Directory. Jan. 1, 2022

 

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