Tips for Submitting Autism Care Demonstration Treatment Plans

Tuesday, July 23, 2024

Treatment plans are an essential part of treatment authorization requests for applied behavior analysis (ABA) services under TRICARE’s Autism Care Demonstration (ACD). Health Net Federal Services, LLC’s (HNFS) autism clinical care analysts carefully review treatment plans to make sure they meet all TRICARE ACD requirements. Please review the following tips to help you submit complete and compliant treatment plans on first submission. You play an important role in helping expedite the review process and getting your ACD-enrolled patients timely access to care. 

Treatment plan submission tips:

1. Address all requirements detailed in the TRICARE Operations Manual (TOM), Chapter 18, Section 4. To help, we offer our Treatment Plan Requirements Guide. 
   
   
2. Structure treatment plans clearly to address and meet all TOM requirements. 
   
   
3. Include relevant information from parents/caregivers, such as ABA treatment history; diagnosis referrals; school schedules; and, if applicable, Individualized Education Programs.
   
   
4. Include individualized discharge criteria and planning and detail adjustments when necessary.
   
   
5. Specify baseline and mastery criteria details in goals to help our reviewers clearly understand the core autism spectrum disorder symptoms being targeted. Be sure to maintain these criteria in updated plans.
   
   
6. Create recommendations using a combination of symptom domains and level of support required, outcome measure scores, beneficiary availability, and history of response to treatment to demonstrate clinical necessity.
   
   
7. Address and explain lack of progress or discrepancies in outcome measures and adjust related discharge criteria and treatment planning (for updated/modified treatment plans). 
   
   
8. Organize the content and use plain language. Is the treatment plan easy to read? Is the content organized in a logical manner? Are requirements easily identified? The treatment plan should be understood by all readers, including family members. Parent/caregiver signatures also must be included.
   
   
9. Check for missing or unclear requirements and ensure thorough detailing and explanations, when needed to substantiate clinical necessity. This includes making sure treatments listed aren’t excluded by TRICARE (for example, adaptive daily living skills, educational goals). 
   
   
10. Verify the accuracy of all content and review the treatment plan before submission, as the treatment plan is part of the beneficiary’s medical record. 

For more information, refer to our Treatment Plan Requirements Guide and visit our Clinical Necessity Reviews page.