Autism Care Demonstration Nomination to First Treatment

Friday, March 31, 2023

TRICARE-eligible beneficiaries can be nominated to the Autism Care Demonstration (ACD) for applied behavior analysis (ABA) services. To nominate to the ACD, the beneficiary or family can call Health Net Federal Services, LLC (HNFS) at 1-844-866-9378 and select option 5 for dedicated ACD support, or a referral can be provided to HNFS by a TRICARE-authorized autism spectrum disorder (ASD)-referring or diagnosing provider.

To help you with this process, HNFS offers a new visual aid detailing the steps from nomination to first treatment on our Eligibility and Diagnostic Criteria page. We encourage you to familiarize yourself with these steps and share the downloadable process flow with your staff. We also offer the following overview as a reminder.

Step 1: Enrollment Requirements

Nomination

Upon nomination, beneficiaries receive 180 days of enrollment support from HNFS. Our team of dedicated Autism Services Coordinators will reach out by phone and through written correspondence to provide information on the ACD, including program requirements and the process for accessing ABA services.

Review of Eligibility

HNFS will request the following documentation from the beneficiary and referring TRICARE-authorized ASD-diagnosing provider:

Referral or diagnostic evaluation for ACD enrollment by a TRICARE-authorized ASD-diagnosing provider or a TRICARE-authorized ASD-diagnosing provider supporting an ASD diagnosis.
Confirmation of ASD diagnosis, to include the date of diagnosis. HNFS requires, at a minimum, the year of diagnosis but will request “month/day/year” from the referring provider if not included in other submitted documentation.
A Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Diagnostic Checklist completed by a TRICARE-authorized ASD-diagnosing provider.
A validated assessment tool (VAT) completed by a TRICARE-authorized ASD-diagnosing provider. (Refer to the “Definitive Diagnosis Requirements” section of our Eligibility and Diagnostic Criteria page.)

Outcome Measures

To reduce potential gaps in care, HNFS will issue an authorization for a beneficiary to complete required outcome measures with an ABA provider who has agreed to accept TRICARE beneficiaries and is qualified to complete the measures within their scope of practice. Complete and valid outcome measures (Vineland Adaptive Behavior Scales, Third Edition [Vineland-3] and Social Responsiveness Scale, Second Edition [SRS-2], as well as the Parenting Stress Index, Fourth Edition Short Form [PSI-4-SF] or Stress Index for Parents of Adolescents [SIPA]) must be submitted to the ACD before we can start the initial treatment review process.

Active Duty Family Members

Beneficiaries with active duty sponsors must register in the Extended Care Health Option (ECHO) within 90 days of being enrolled into the ACD. HNFS will proactively process a provisional ECHO registration for up to 90 days. If the beneficiary does not complete ECHO registration within the 90-day time frame, they will no longer be eligible for ABA services until registration is complete. ECHO benefits accessed during the provisional period will also no longer be available.

Enrollment Criteria Met/Autism Services Navigators

Once the beneficiary has met enrollment criteria and is eligible, HNFS will assign an Autism Services Navigator (ASN) to provide support to the beneficiary. ASNs and families must work together to complete a comprehensive care plan (CCP) within 90 days. If HNFS does not receive the completed CCP within this 90-day time frame, the beneficiary will not be eligible for ABA services under the ACD until the CCP is complete.

Step 2: Initiating ABA Services

Documentation

HNFS requires the following documentation for a beneficiary to begin receiving ABA services under the ACD:

ABA referral that states both the diagnosis of ASD and severity, and includes a statement referring the beneficiary for ABA services by a TRICARE-authorized ASD-referring or diagnosing provider.
If the beneficiary’s initial ASD diagnosis occurred after age eight, or if it has been two years or longer since the original diagnosis and this is the first referral for ABA services under TRICARE, we need a copy of the TRICARE-authorized ASD-diagnosing provider’s diagnostic evaluation with a definitive ASD diagnosis (if not already on file).

Step 3: Initial Assessment

Once the beneficiary has met all ACD enrollment criteria and we have received the required documentation, we will reach out to the family to discuss ACD provider placement, which starts with us searching for a provider who has an available appointment within 28 days and is within 60 miles of the beneficiary’s residence (per access-to-care standards). HNFS has 15 business days to conduct this search. Note: Families can request placement with a specific provider, but by doing so they waive access-to-care standards and HNFS’ provider placement process. HNFS will authorize the initial assessment and Pervasive Developmental Disorder Behavior Inventory (PDDBI) to an ABA provider.

Step 4: Initial Treatment

Once the initial assessment has been completed, the authorized ABA provider must submit the treatment plan and the completed parent PDDBI. Refer to our Treatment Plan Requirements guide for details. HNFS reviews all initial treatment requests to ensure ACD enrollment, ABA program requirements and outcome measure requirements have been met. We may need to request additional information from the ABA provider if the treatment request is insufficient. Next, HNFS reviewers will begin the clinical necessity review.

Clinical Necessity Review

HNFS must perform clinical necessity reviews, and clinical consultations when necessary, on all treatment authorization requests prior to issuing coverage determinations and authorizing services. Providers must have an approved treatment authorization (with an authorization number) prior to rendering reimbursable ABA services.

Visit our ACD page for complete details on TRICARE’s ACD and to review related news articles and access printable resources.