Autism Care Demonstration: Diagnostic Evaluations and Symptom Severity

Friday, November 5, 2021

TRICARE beneficiaries must have a definitive autism spectrum disorder (ASD) diagnosis to be eligible for the Autism Care Demonstration (ACD). Meeting the eligibility requirements of a definitive diagnosis has different timelines for beneficiaries who enrolled prior to Oct. 1, 2021 compared with those who enroll after Oct. 1. Your understanding of the diagnostic evaluation requirement will help expedite the ACD authorization process. To learn more, visit our ACD Eligibility & Diagnostic Criteria page.  

For diagnosing/referring providers: Key information about diagnostic evaluations

Diagnostic evaluations are submitted to Health Net Federal Services, LLC (HNFS) only in these specific circumstances: 

1. Beneficiaries new to the ACD as of Oct. 1: Before an initial applied behavior analysis (ABA) assessment can be authorized, a copy of the diagnostic evaluation must be submitted to HNFS only if the beneficiary was first diagnosed over the age of 8 years and/or the first referral for ABA services is two years after the initial ASD diagnosis.
   
   
2. Beneficiaries who entered the ACD prior to Oct. 1: A diagnostic evaluation must be submitted to HNFS if the validated assessment tool used for diagnosis was the Gilliam Autism Rating Scale, Third Edition (GARS-3). In this case, the diagnosing provider must submit a diagnostic evaluation demonstrating other methodology used to supplement the parent questionnaire to render the diagnosis. 

There is no other TRICARE requirement to submit a diagnostic evaluation.

At no point are ABA providers responsible for collecting or submitting diagnostic evaluations. ABA providers should not request a copy of the diagnostic evaluation from referring providers on behalf of TRICARE. All referring providers should submit the diagnostic evaluation, when requested by HNFS, directly to the contractor. 

For ABA providers: Obtaining level of ASD symptom severity

HNFS understands ABA providers are required to obtain and document the beneficiary’s ASD symptom severity level in their treatment plan. Before contacting the referring/diagnosing provider to obtain the severity information, ABA providers should first attempt to obtain level of severity by: 

• Reviewing the initial assessment authorization. Commonly (but not always) ASD level of severity is included in the reason for referral. Note that not all authorizations will contain this information. 
  
  
• Requesting information from the family. If level of severity is not present on the assessment authorization, the ABA provider should request the level of severity from the family; they may have supporting documentation received during the diagnostic process that states the severity of symptoms. 

Please note: The severity in the treatment plan does not need to match the severity on the two-year referral. HNFS understands the severity reported from different sources may vary. 

ABA providers unable to obtain the information using one of the options above should then request the level of severity from the referring provider. Any format of symptom severity details is acceptable; a copy of the diagnostic evaluation is not required for ABA providers and should not be requested from the referring provider. 

We appreciate your cooperation with these guidelines.