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Autism Care Demonstration: Key Changes Heading into August

Friday, July 16, 2021

As the phased implementation for TRICARE’s Autism Care Demonstration (ACD) heads into August, providers should begin to prepare for changes that go into effect on Aug. 1. Health Net Federal Services, LLC (HNFS) offers resources to assist you, including expanded web content and new printable guides you can share with your office staff. Be sure to visit www.tricare-west.com/go/ACD-provider to review our ACD timeline to help you track new requirements and their effective dates; access frequently asked questions; view detailed benefit content; and find the multiple resource guides now available to you.  

Treatment plans
The TRICARE Operations Manual, Chapter 18, Section 4 outlines detailed instructions on new requirements for ACD treatment plans that go into effect Aug. 1. To help providers navigate the new requirements, we offer a new printable ACD Treatment Plan Guide available. Please also review the aforementioned manual to ensure your ability to develop and submit a compliant treatment plan. 

Clinical necessity reviews
Effective with new treatment authorization requests as of Aug. 1, HNFS is required to perform clinical necessity reviews on all treatment plans before making coverage determinations for applied behavior analysis (ABA) services. Clinical necessity reviews, performed by qualified clinical reviewers (BCBAs, BCBA-Ds), follow a standardized approach that considers the individual beneficiary to ensure the treatment plan coincides with the most appropriate level of care. Clinical reviewers may request additional information or schedule a clinical consultation with the responsible ABA supervisor before making coverage determinations. ABA supervisors may need to submit updated treatment plans as part of the review process.

View our new Clinical Necessity Review Guide to learn more. 

New age-based outcome measures
Starting Aug. 1, beneficiaries must have complete, valid outcome measure scores in order for HNFS to process treatment authorization requests. TRICARE currently requires ACD participants to complete and submit scores for the Pervasive Developmental Disorder Behavior Inventory (PDDBI) (parent/teacher, when applicable); the Vineland, 3rd Edition (Vineland-3) and the Social Responsiveness Scale, Second Edition (SRS-2). 

As of Aug. 1, TRICARE will also require the Parenting Stress Index, Fourth Edition (PSI-4) Short Form (0–12 years old) or the Stress Index for Parents of Adolescents (SIPA) Profile Form (11–19 years old). Similar to other outcome measures, providers submit only the PSI-4 or SIPA scores (not the questions or calculations) to HNFS. 

The PDDBI and PSI-4/SIPA are required prior to HNFS authorizing treatment and then every six months. The Vineland-3 and SRS-2 are required prior to HNFS authorizing treatment and then annually. We offer new printable guides on each outcome measure.  

Submitting outcome measure scores to contractors
Outcome measure scores must be submitted to the regional contractor as part of the treatment authorization process. As such, HNFS is permitted to receive and appropriately review beneficiary medical records. Upon receipt, we will verify scores are complete and valid (i.e., scores fall within the publisher limits, as applicable) and our qualified BCBA/BCBA-D clinical reviewers will:

  • Evaluate the outcome measure scores submitted for the PDDBI, Vineland-3 and SRS-2 as part of the clinical review process and complete a clinical consultation with the ABA supervisor, as needed, to discuss changes in the scores over time.  

  • Use PSI-4/SIPA scores to evaluate for additional supports (i.e., case management) that may benefit the family.

Outcome measure authorizations
Again, all applicable outcome measure scores must be submitted to HNFS prior to treatment authorization. While the treating ABA provider is required to administer the PDDBI, HNFS may proactively authorize existing beneficiaries to other ABA providers with the ability to complete all additional ABA outcome measures (Vineland-3, SRS-2, PSI-4/SIPA) in order to meet access to care standards. 

Treating ABA providers who prefer to complete all ABA outcome measures (Vineland-3, SRS-2, PSI-4/SIPA) for their existing TRICARE patients can submit a request for authorization through a treatment plan update. Requests submitted outside of a treatment plan update will be canceled. 

Keep in mind:

  • If HNFS has already authorized a beneficiary to another ABA provider for the Vineland-3, SRS-2 and PSI-4/SIPA, the treating ABA provider may submit an authorization request to complete these through the treatment plan at the next reassessment renewal period. 

  • Treating ABA providers who do not have the ability or expertise to render the Vineland-3, SRS-2 and PSI-4/SIPA can defer to HNFS to authorize these outcome measures to another ABA provider. 

  • Treating ABA providers who do wish to complete all outcome measures for existing TRICARE patients must be able to complete all additional measures (Vineland-3, SRS-2, PSI-4/SIPA). In other words, outcome measure authorizations for the Vineland-3, SRS-2, PSI-4/SIPA will only be issued to one provider. HNFS will not authorize multiple providers for the same outcome measure and will not divide the Vineland-3, SRS-2, PSI-4/SIPA amongst multiple providers. 

  • A separate authorization will be issued specifically for Vineland-3, SRS-2, PSI-4/SIPA outcome measures. 

For additional information about Autism Care Demonstration updates, visit www.tricare-west.com/go/ACD-provider and www.health.mil/autism. Thank you for your continued partnership in caring for military service members, retirees and their families.