Overview
Applied behavior analysis (ABA) providers always must comply with medical documentation and billing requirements listed in the TRICARE Operations Manual (TOM), Chapter 18, Section 4; state and federal regulations; and provider participation agreements, policies and guidelines.
Health Net Federal Services, LLC (HNFS) reviews provider billing practices and supporting medical documentation to verify services ABA providers bill TRICARE for are:
- TRICARE-approved services under the Autism Care Demonstration (ACD).
- Supported by clear and complete progress notes (medical documentation).
The following information details review types and respective guidelines.
Audit Frequency
Autism Corporate Services Provider (ACSP) groups and sole ABA providers are subject to a minimum of 30 record reviews annually. These include administrative and medical documentation reviews and a review of one medical team conference progress note (if available).
In a separate review process, HNFS also looks at Current Procedural Terminology (CPT®) code billing practices of TRICARE West Region (West Region) ABA providers to ensure compliance with TOM requirements.
Reviews for New Providers
- HNFS monitors all new network and non-network ACSPs/sole ABA providers during their initial 180 days of participation in the West Region.
- New providers are not required to have the 30 record reviews that established ABA providers must have.
- Following the initial 180 days, we will review a minimum of 10 records. These will include administrative and medical documentation reviews to audit for consistency with program requirements.
- If the audit finds inconsistencies with meeting program requirements, we will share results with the provider, give them written education, and, if necessary, arrange a videoconference with the provider.
Administrative Reviews
HNFS monitors ABA claims data to identify and prevent potentially fraudulent billing practices. Anti-fraud software is used to review claims data and detect potential issues that may include:
- High-dollar, erratic or inconsistent billing and coding patterns.
- Changes in billing frequency.
- Concurrent billing (that is, billing for two services at the same time).
- Misrepresentation of the provider (that is, filing a claim for a non-rendering provider or non-authorized provider).
- Claims patterns of “impossible days” (provider’s total claims exceed 12 hours per any given calendar day).
- Patterns of high rates of claim errors.
If suspect billing patterns are identified, HNFS engages providers to address the findings and provides education on TRICARE requirements to mitigate ongoing issues. HNFS will conduct a post-payment review within 180 calendar days to verify that any suspect billing patterns have been resolved.
Providers with ongoing suspect billing patterns will be referred to HNFS' Program Integrity Department.
Medical Documentation Reviews
HNFS conducts medical documentation reviews to ensure compliance with the requirements listed in TOM, Chapter 18, Section 4. These reviews evaluate the following:
- Claims are supported by corresponding progress notes.
- Progress notes contain all required documentation elements.
- Services documented in progress notes comply with adaptive behavior services (ABS)-specific TRICARE-approved CPT codes.
- Exclusions were not rendered during the session.
Please visit our Progress Notes, Billing and Exclusions pages for additional details.
Medical Documentation Review Process
ACSPs/sole ABA providers must submit medical documentation in response to HNFS' review requests. Please ensure you respond to review requests on or before the due date specified on the review request.
Review steps
- HNFS contacts the ACSP/sole ABA provider to establish initial contact and verify contact information for the audit.
- HNFS sends a written medical documentation request to the ACSP/sole ABA provider. HNFS also may contact the ACSP/sole ABA provider regarding the written request.
- ACSP/sole ABA providers must promptly respond to HNFS' written requests.
- HNFS conducts a review to ensure medical documentation/records comply with ACD requirements.
- If the audit results in no findings, HNFS does not send correspondence to the ACSP/sole ABA provider.
- If the audit results in findings, HNFS sends the ACSP/sole ABA provider a written summary detailing education requirements or findings resulting in recoupment.
Audit Outcomes
Audit findings indicating failure to demonstrate compliance may result in any (or all) of the following:
- Outreach and education
- Payment recoupment
- Referral to HNFS Program Integrity Department
- Probe audit
- Placement into prepayment review
CPT Code Reviews
Separate from the medical documentation reviews detailed in the previous sections, HNFS also reviews West Region providers’ billing practices to ensure compliance with ACD and TRICARE-approved ABS CPT code requirements. This includes verifying ABA supervisors render a minimum of one direct visit (cannot be delegated to an assistant behavior analyst) per month for CPT code 97155.*
- Claims billed that do not meet ACD requirements are subject to denial or recoupment.
- Please visit our Billing page for more information on CPT code requirements.
*IMPORTANT: A 10% penalty will be applied to all ABA claims in an authorized treatment period if the CPT code 97155 requirement has not been met by the authorized ABA supervisor. Exception: The 10% penalty may be waived if no CPT code 97153 services were rendered in a calendar month.
