Autism Care Demonstration: Authorization Changes

Applied behavior analysis (ABA) providers and beneficiaries can request certain changes to current (valid) authorizations. Health Net Federal Services, LLC (HNFS) cannot make changes to expired authorizations.

Unit Modifications

To request a change to the number of units authorized by HNFS, providers must submit a new request for ongoing services. If approved, HNFS will update the existing authorization.

This new request must:

Include an updated treatment plan that clearly identifies it as a unit modification request and documents the reason for the change and any applicable modifications to the beneficiary's goals. Note: This requires updated summaries of progress or updates on already approved goals.
Specify the requested units for all Current Procedural Terminology (CPT^®) codes.
Match what is documented in the treatment plan.

Unit modifications may be approved when there is a significant change in the clinical status of the beneficiary resulting in a modification to the treatment plan and recommended units. These may include but are not limited to:

The number of hours the beneficiary is available to receive when receiving less than maximum and clinically necessary recommended amounts.
The number of behavior excesses requiring management of the behavior intervention plan.
The acquisition rate of the beneficiary.
Frequency and rate of modifications to maintain progress.
The frequency needed to demonstrate modifications to the behavior technician or parent/caregiver.
The complexity of the programs requiring modifications.
The level of generalization of mastered skills.
The engagement and availability of the family.

Second Opinion

Beneficiaries or their families may request a second initial assessment from a different ABA provider to obtain another clinical recommendation or plan of care.
Second opinion assessments follow the same referral, access-to-care standard, treatment plan, outcome measure, and process requirements as an initial assessment. A new referral is not required for second opinions if within the two-year time frame.
The second opinion assessment can be completed by a different ABA provider, but only one ABA provider may be authorized to provide treatment at a time.
When an ABA supervisor seeks consultation from another authorized ABA supervisor, the primary ABA supervisor will remain responsible for the treatment plan and is the sole provider authorized to bill for ABA services.
Families are responsible for informing the first provider about this change and should proactively communicate when they will no longer need their services. If parents/caregivers move ahead with treatment recommendations from the second provider, the first provider's authorization will stop on the date before the beginning of the second provider’s approved treatment authorization. Providers who performed services but stopped as part of this change are responsible for submitting a discharge report.

Provider Changes

If a beneficiary would like to change ABA providers, he or she should contact our Autism Care Demonstration (ACD) customer service line and request a change of ABA providers.

HNFS will gather additional information and assist the beneficiary in facilitating the change based on the reasons and availability of other ABA providers.
If the beneficiary has an active referral within the current two-year period, a new referral is not required for provider changes.
Ongoing care from two ABA providers at the same time is not permitted.

Moving

Regional contractors can help beneficiaries transfer ABA services when moving within their current TRICARE region or to a different TRICARE region (East, West or overseas).

Important: Beneficiaries should update their address in the Defense Enrollment Eligibility Reporting System (DEERS), confirm their eligibility in the new region, and contact the new region when completed.

Moving from the TRICARE West Region (HNFS) to the TRICARE East Region (Humana Military):

TRICARE West Region beneficiaries can contact HNFS’ ACD customer service line to let HNFS know the date of an upcoming move and request that their West Region ABA-related documents be transferred to Humana Military in the TRICARE East Region. HNFS will transfer the documents, including a copy of the ABA therapy referral, the treatment plan and related assessments within 10 calendar days of the request.
Beneficiaries assigned an Autism Services Navigator (ASN) will remain eligible for an ASN if the beneficiaries continue to meet ACD eligibility requirements. ASNs will assist with care coordination during the transition.
Beneficiaries who have not been assigned an ASN may be eligible for case management services to assist with the process. Case management nominations can be made online or via the ACD customer service line.
Contact Humana Military for more information about receiving ABA services in the East Region.

Moving from the East Region (Humana Military) to the West Region (HNFS):

East Region beneficiaries can contact Humana Military to let Humana Military know the date of their upcoming move and request that their East Region ABA-related documents be transferred to HNFS in the West Region. Humana Military will transfer the documents, including a copy of the ABA therapy referral, the treatment plan and related assessments within 10 calendar days of the request.
Beneficiaries assigned an ASN will remain eligible for an ASN if the beneficiaries continue to meet ACD eligibility requirements. ASNs will assist with care coordination during the transition.
After a beneficiary’s enrollment has been transferred to the West Region, the parent/caregiver can call HNFS to request an initial ABA assessment for the beneficiariy. Authorization will depend on the beneficiary's West Region eligibility in DEERS and whether the beneficiary has met all ACD program requirements. Parents/caregivers should let HNFS know whether they have already requested the ABA document transfer from Humana Military.
HNFS will honor valid Humana Military referrals to authorize initial assessments while ABA services are being established with West Region providers. All beneficiaries who transfer from the East Region must receive a new initial assessment and meet all ACD requirements prior to approval of ongoing care. (Beneficiaries must show as eligible in the West Region before HNFS can authorize services.)

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