Beneficiary Program Nomination to First Treatment Authorization Process Full Text

1. Beneficiary nominated to ACD.
   
   
2. Sources
   
   
   • Referral from provider
     
     
   • Receipt of clinical documents
     
     
   • Beneficiary phone request
     
     
   • CareAffiliate nomination
     
     
   • Medical Management
     
     
   • Dashboard nomination
     
     
   • Program nomination via fax
     
     
   • Transfer from other TRICARE region
      
3. ACD program eligibility*
   
   
   • Referral or diagnostic evaluation
     
     
   • DSM-5 Diagnostic Checklist
     
     
   • Date of initial diagnosis
     
     
   • Validated assessment tool
     
     
   • Valid referring/diagnosing provider
      
4. ASD definitive diagnosis eligibility requirements met
   
   
   • Non-ADFM
     
     
     • Enrolled in ACD
        
       • Identified as a new beneficiary per criteria (Beneficiary provided up to 180 days of support from the Autism Services Coordinator to meet eligibility requirements) (concurrent with ABA referral received step)
         
         
         • Assigned ASN
           
           
         • Complete initial CCP within 90 days**
            
       • ABA referral received*** (concurrent with Identified as new beneficiary per criteria step)
         
         
         • Referral meets criteria*
           
           
           • ASD diagnosis
             
             
           • Severity of symptoms
             
             
           • Comorbid diagnosis
             
             
           • States referral for ABA
             
             
           • ASD referring/diagnosing provider
              
         • Request diagnostic evaluation if:*
           
           
           • Beneficiary was/is over age 8 at initial diagnosis or
             
             
           • It has been over 2 years since beneficiary’s initial diagnosis
              
   • ADFM
     
     
     • ECHO registration (400 code) OR provisionally registered for 90 days**
       
       
     • Enrolled in ACD
        
       • Identified as a new beneficiary per criteria (Beneficiary provided up to 180 days of support from the Autism Services Coordinator to meet eligibility requirements) (concurrent with ABA referral received step)
         
         
         • Assigned ASN
           
           
         • Complete initial CCP within 90 days**
            
       • ABA referral received*** (concurrent with Identified as a new beneficiary per criteria step)
         
         
         • Referral meets criteria*
           
           
           • ASD diagnosis
             
             
           • Severity of symptoms
             
             
           • Comorbid diagnosis
             
             
           • States referral for ABA
             
             
           • ASD referring/diagnosing provider
              
         • Request diagnostic evaluation if:*
           
           
           • Beneficiary was/is over age 8 at initial diagnosis or
             
             
           • It has been over 2 years since beneficiary’s initial diagnosis
              
5. If assigned an ASN, ASN role and responsibility screening
   
   
6. ABA referral verified
   
   
7. Active provider placement (15 business days)
   
   
   • Parent does not waive access-to-care standards
     
     
     • Obtain access-to-care standards availability from ABA providers
       
       
       • Provider available within access-to-care standards
         
         
         • Apply steerage scores
            
       • Provider not available within access-to-care standards
         
         
         • Cancel referral for provider recruitment
           
           
         • ACD waitlist tracking
           
           
         • Provider available within access-to-care standards
            
   • Parent waives access-to-care standards due to preferences
      
8. ABA initial assessment approved
   
   
9. Confirm assessment occurred within access-to-care standards
   
   
10. ABA provider submits request for treatment*
    
    
11. Outcome measures received*
    
    
12. Clinical necessity review
    
    
13. ABA treatment is either:
    
    
    • Certified in total (approved)
      
      
    • Modified
      
      
    • Denied
      
      
    • Canceled
       
14. Confirmation treatment started within access-to-care standards
     

*Incomplete submissions of requirements may result in requests for additional information and/or clinical consultations.

**Failure to complete within 90 days will result in termination of eligibility and authorization.

***If submitted during pre-enrollment process, HNFS will initiate review for minimum requirements and request additional information as needed. HNFS is unable to complete verification of the referral until after enrollment is complete.