Autism Care Demonstration: Clinical Necessity Reviews

Friday, December 10, 2021

Under TRICARE’s Autism Care Demonstration (ACD), regional contractors must perform clinical necessity reviews on all initial and subsequent treatment authorization requests before making coverage determinations. The clinical necessity review begins once an initial administrative review confirms all contract requirements are in place. Your understanding of the clinical necessity review process can help avoid treatment delays.

Step 1: Administrative review to verify requirements – within five business days. Upon receipt of a treatment authorization request, Health Net Federal Services, LLC (HNFS) must verify the following: the patient’s TRICARE eligibility; the patient’s ACD eligibility; receipt of a valid two-year referral for applied behavior analysis (ABA) services; receipt of a complete treatment plan that meets all TRICARE requirements (including all required sections and location of services); outcome measure scores (PDDBI, Vineland-3, SRS-2, and PSI-4 Short Form or SIPA), and an individual education program (IEP) (when treatment is recommended in the school setting) before we can start the clinical necessity review process.

If we need to request missing information, the request will be pended for up to 10 days. Note that we cancel requests that are missing ACD program eligibility (definitive diagnosis) or outcome measures but resume processing once ACD eligibility is met. Once the required information is received, we repeat the administrative review.

Step 2: Clinical necessity review – within five business days. Once all requirements have been verified in step 1, we begin the clinical necessity review. HNFS’ Autism Clinical Care Analysts (i.e., BCBAs, BCBA-Ds) follow a standardized approach when reviewing treatment plans, to include evaluating initial baseline data, recommended goals, parent training goals, outcome measure scores/changes to the scores over time, discharge plans, and CPT® code recommendations. Reviewers also look for any exclusions or missing required elements.

Collectively and when all requirements are in place, HNFS completes Step 1 and Step 2 reviews and issues a coverage determination within five business days. However, the timeline restarts each time we need to request additional information.

Step 3 (if needed): Updated treatment plan and/or clinical consultation – varies. If we require modifications to the treatment plan and/or a meeting with the ABA provider before making a coverage determination, we will contact the ABA provider.

For resubmissions of treatment plans only: ABA providers will have 10 business days to submit an updated treatment plan. Once received, we conduct a second clinical necessity review and, as long as the request is now compliant, we will make a coverage determination within five business days.
For clinical consultations in addition to an updated treatment plan: We will pend the request for up to 10 days to allow time for the meeting to be scheduled and conducted. After the clinical consultation, the ABA provider has up to 10 business days to submit an updated treatment plan. Once received, we conduct a second clinical necessity review and, as long as the request is now compliant, we will make a coverage determination within five business days. If we are unable to connect with the ABA provider to schedule the consultation and/or do not get the treatment plan in a timely manner, we will cancel the request and resume processing once these actions occur.

Review the following Frequently Asked Questions and explore our ACD web page featuring clinical necessity reviews for complete details.

Frequently Asked Questions

Q: Why is a clinical necessity review required?

A: Clinical necessity reviews allow HNFS to verify treatment plans are clinically appropriate and meet TRICARE’s ACD program requirements. This is a required step prior to completing a coverage determination of applied behavior analysis as outlined by the TRICARE Operations Manual.

Q: I thought HNFS processed authorization requests within 2-5 business days. Why is it so much longer for ACD authorizations?

A: Effective Aug. 1, 2021, the requirements for processing authorization requests changed. Under the ACD, HNFS must ensure each authorization request meets the updated requirements outlined in the TRICARE Operation Manual, Chapter 18, Section 4. HNFS’ ability to streamline the authorization process directly coincides with the receipt of compliant and complete treatment authorization requests. Timely responses to HNFS’ requests for clinical consultation, treatment plan modifications and/or additional documentation also help streamline the process.

Q: What are some common reasons HNFS might ask for a clinical consultation or an updated treatment plan?

A: Common reasons include: exclusionary goals in the treatment plan; regression in outcome measure scores and/or goal status without sufficient explanation; greater than 10% discrepancy between parent and teacher PDDBI scores; the presence of significant policy violations (i.e., restraints as part of treatment recommendations); low parent participation without explanation; a long history of ABA treatment with little or no discharge planning, and areas that need to be addressed regarding clinical necessity.

Q: I completed a clinical consultation and submitted the documentation requested. I’m now being asked to complete these steps again. Why?

A: If the resubmitted treatment plan fails to address all changes and/or demonstrate clinical necessity, an additional consultation may be required between the ABA supervisor and HNFS. The ABA provider must address all areas in the request for additional information. Refusal may result in a partial or complete denial of the treatment plan.

Q: What can I do to streamline the clinical necessity review process?

A: ABA providers can minimize requests for clinical consultation and/or additional documentation by adhering to treatment plan requirements; developing goals and recommendations that align with ACD requirements, providing clear narratives and rationale when applicable (e.g., community locations, school locations, lack of parent participation, etc.) and addressing areas of concern clearly (e.g., outcome measure regression, goals progress, etc.) with full explanations and treatment alterations. ABA providers asked to participate in a clinical consultation, submit treatment plan modifications or submit additional documentation should respond in a timely manner to help expedite HNFS’ clinical necessity review process.