Autism Care Demonstration: Preparing for Oct. 1 Diagnosis & Eligibility Criteria Updates

Thursday, August 5, 2021

Beginning Oct. 1, the following are required to document a definitive diagnosis of autism spectrum disorder (ASD) before we can enroll a beneficiary to the Autism Care Demonstration (ACD). There are also changes for who can diagnosis ASD and submit applied behavior analysis (ABA) referrals. Visit our ACD Eligibility page for complete details. (Note: For beneficiaries enrolled to the ACD prior to Oct. 1, these requirements do not apply until the next two-year referral cycle that occurs on or after Oct. 1; however, we offer an attestation option that can be done now to proactively prevent gaps in care.) 

1. DSM-5 Diagnostic Checklist (NEW): Primary care managers (PCMs) and specialists approved to diagnose and refer beneficiaries must attach this form to ABA referrals. An updated checklist will be required for each subsequent two-year referral period. ABA providers cannot complete the form.

2. Results from current versions of one of the following assessment tools (NEW) (also submitted with the ABA referral):

• Screening Tool for Autism in Toddlers and Young Children (STAT)
• Autism Diagnostic Observation Schedule-Second Edition (ADOS-2)
• Autism Diagnostic Interview-Revised (ADI-R)
• Childhood Autism Rating Scale-Second Edition (CARS-2)
• Gilliam Autism Rating Scale, Third Edition (GARS-3) (also requires submission of diagnostic evaluation with documentation of diagnosing methods used to supplement the GARS-3 parent questionnaire)

The following provider types can diagnose ASD and submit ABA referrals:

TRICARE-authorized primary care managers (PCM) 

TRICARE-authorized specialized ASD-diagnosing and referring providers:

How to submit the DSM-5 Diagnostic Checklist and assessment tool results:

• Beneficiaries new to the ACD as of Oct. 1: The DSM-5 Diagnostic Checklist and assessment tool results will be submitted with the initial ABA referral by one of the provider types listed on p. 1 as part of the ACD enrollment process. Only the DSM-5 Diagnostic Checklist will be required at each two-year referral cycle. 
  
  
• Beneficiaries enrolled to the ACD prior to Oct. 1: Definitive diagnosis eligibility will be updated at the next two-year referral cycle that starts on or after Oct. 1. However, if you are the referring provider, you can help prevent gaps in care by submitting documentation to HNFS before the referral renewal. 
  • Submit a Definitive Diagnosis Referring Provider Attestation. ASD-diagnosing and referring providers can submit a Definitive Diagnosis Referring Provider Attestation, which fulfills both the DSM-5 Diagnostic Checklist and assessment tool requirements. Find the form under Authorizations > Letters of Attestation. 
    OR
  • Submit the DSM-5 Diagnostic Checklist and assessment tool results. ASD-diagnosing and referring providers can submit the checklist. HNFS can accept any version of a validated assessment tool for beneficiaries enrolled prior to Oct. 1.

Key points:

• ABA providers may not complete or submit the DSM-5 Checklist or Definitive Diagnosis Referring Provider Attestation. 
• For beneficiaries enrolled to the ACD prior to Oct. 1, a new, two-year referral is not required until the existing two-year referral will be expiring. HNFS realigned all existing beneficiaries’ referral cycle dates per the new definition in the TRICARE Operations Manual. All families have been notified in writing of their new referral cycle dates. 
• Once the definitive diagnosis requirement is met, only the DSM-5 Diagnostic Checklist will be required at each subsequent two-year referral period.
• The provider who completes the DSM-5 Diagnostic Checklist does not have to be the same provider who originally diagnosed the beneficiary.

Supporting beneficiaries

In addition to informing enrolled beneficiaries about changes to their individual timelines and requirements, we called each enrolled family to offer support and education. Beneficiaries are encouraged to visit www.tricare.mil/ACD and www.tricare-west.com/go/ACD to learn about changes to the ACD. We continue to offer dedicated ACD customer service agents at 1-844-866-WEST (9378), option 5 Monday through Friday, 5 a.m. to 9 p.m. (Pacific time). 

For additional information about Autism Care Demonstration updates, visit www.health.mil/autism.