ACD Update – Key Changes Heading into Summer 2021

Tuesday, June 22, 2021

In late March, TRICARE announced sweeping changes to its Autism Care Demonstration (ACD), which provides applied behavior analysis (ABA) benefits to TRICARE-eligible beneficiaries diagnosed with autism spectrum disorder. Due to the extensive changes, TRICARE is implementing the revised ACD in phases, with all updates to be in place by Jan. 1, 2022.

We offer a detailed timeline on our website to help you track dates.

What you need to know for July and August:

National Provider Identifier (NPI). All ABA providers must have an NPI. While not a new requirement for the TRICARE West Region, Health Net Federal Services, LLC (HNFS) must verify this information for new providers as of July 1 and by Aug. 1 for existing providers. Please be sure your NPI record is up to date by visiting https://npiregistry.cms.hhs.gov.
Outcome measures. Beginning Aug. 1, all required outcome measures must be submitted prior to HNFS authorizing/reauthorizing treatment. Other changes impacting outcome measures as of Aug. 1 include: 1) All forms must include the name of the person completing the form and their relationship to the beneficiary; 2) Providers must submit the full publisher print report. If hand scoring, full calculations and related documents must be included. Scores imbedded into the treatment plan will no longer be accepted; and 3) One of two age-based measures – the Parenting Stress Index, Fourth Edition (PSI-4) or Stress Index for Parents of Adolescents (SIPA) will be required for new and renewing authorizations.
Active provider placement. Beginning Aug. 1, HNFS will assign all referrals to ABA providers based on the provider’s ability to provide care within TRICARE’s access to care (ATC) standards. ABA providers must complete the initial assessment within 28 days from the date HNFS verified the referral and initiate treatment within 28 days from the last date of service in the 14-day window allowed for the initial assessment. HNFS will confirm providers met ATC for assessment and treatment dates. We may need to collect additional information from providers, in particular, if a parent/beneficiary waives ATC standards for either period. Please reply promptly to these requests.
Reimbursement via electronic funds transfer (EFT). Effective Aug. 1, TRICARE requires HNFS to reimburse ABA sole providers and ACD Corporate Services Providers (ACSPs) for ACD services via EFT. If you are an ABA sole provider or ACSP who has not yet signed up for EFT, visit our EFT/ERA page to get started. New enrollments can take up to 45 days to process once all information is received.
Changes to CPT® codes. On Aug. 1, TRICARE will allow for the following CPT codes under the ACD: 97157, 97158, 99366 and 99368. Existing beneficiaries are not eligible for services under these codes until their next authorization renewal on or after Aug. 1. Additionally, for authorizations on and after Aug. 1, CPT 97151 will replace T1023 and the total number of units reimbursable for assessments and reassessments will change. Reimbursement rates are available at health.mil.
Medically Unlikely Edit (MUE). New MUE limits will apply to services billed under the ACD for authorizations that begin on or after Aug. 1. Look for a detailed crosswalk on our website in the coming weeks.
Parent training. Parent training is an important component of the ACD. Parent training ensures that parents and caregivers receive training that allows them to apply the same treatment protocols practiced with the beneficiary during a provider session at home. Beginning Aug. 1, providers rendering treatment following the assessment must initiate parent training (97156) within the first 30 days of the initial authorization period. Providers rendering treatment on all authorizations approved on or after Aug. 1 must conduct a minimum of six parent training sessions (97157, 97158) by the end of the authorization period. ABA providers must document the rendered dates of service and planned parent training sessions remaining in the authorization period in the treatment plan.
Treatment plans. Beginning Aug. 1, HNFS will review all treatment plans for clinical necessity prior to authorizing treatment. We may reach out to providers to complete a consultation as part of our clinical necessity review and request modifications to the treatment plan prior to authorization. We will be updating our online treatment plan guide to include the new requirements prior to Aug. 1. Look for the revised guide and additional information on the clinical necessity review process on our website.
Participation agreements. TRICARE requires all ACSPs and Sole Providers to re-sign participation agreements with their regional contractors. Please pay attention to the updated agreement notices sent by HNFS. We are required to notify DHA of any providers who have not returned new participation agreements by Aug. 1.
Family definition. Effective Aug. 1, the definition of ‘family’ under the ACD expands to include caregivers such as family nannies. In order to be considered eligible, nannies must meet specific requirements.

Questions? We encourage you to visit www.health.mil/autism and www.tricare-west.com/go/ACD-provider often as content and FAQs will be updated throughout the year. You can also sign up for ACD-specific email alerts at www.health.mil/autism.