Unlimited Parent/Caregiver Guidance via Telemedicine Provision Ends July 31

Monday, August 2, 2021

In late March of 2020, the Defense Health Agency (DHA) temporarily expanded the telemedicine options under TRICARE’s Autism Care Demonstration (ACD) to allow for unlimited applied behavior analysis (ABA) parent/caregiver guidance – billed under Common Procedural Terminology (CPT®) 97156 – via telemedicine. In order to account for CPT code changes taking effect Aug. 1, 2021, DHA recently informed Health Net Federal Services, LLC (HNFS) the temporary provision will end on July 31, 2021, with some exceptions for beneficiaries with existing authorizations. Please note: There may be a delay in processing claims with CPT 97156 services as we update our systems.

For existing authorizations approved prior to Aug. 1:

You may continue to render parent/caregiver guidance via telehealth through the expiration of the authorization. However, the following guidelines apply as of Aug. 1, regardless of the authorization end date:

CPT 97156 services are no longer unlimited. You may not exceed eight units per day or the maximum units/month authorized. Please do not send requests for additional units as we are unable to make changes to existing authorizations before the renewal cycle.
For dates of service on or after Aug. 1, 2021 only, TRICARE will allow for the same-day rendering of CPT 97156 via telemedicine and direct services (CPT 97153, 97155, 97156, 97157, 97158, and 99366).

For authorizations approved on or after Aug. 1 (includes updated ACD guidelines that take effect Aug. 1):

TRICARE will only reimburse for CPT 97156 services rendered via telemedicine if authorized.

CPT 97156 services may not exceed eight units per day or the maximum units/month authorized.
TRICARE will allow for the same-day rendering of CPT 97156 via telemedicine and direct services.
The first CPT 97156 session must take place within the first 30 calendar days of the treatment authorization.
Telehealth for CPT 97156 will only be authorized after the initial six-month treatment authorization period has completed.
A minimum of six parent/caregiver sessions must occur every six months (CPT 97156 and/or 97157).

As a reminder:

CPT 97156 services may only be rendered by the authorized ABA supervisor (or delegated to an assistant behavior analyst). Behavior technicians are not permitted to render CPT 97156.
TRICARE-authorized providers must comply with telemedicine guidelines outlined in TRICARE Policy Manual, Chapter 7, Section 22.1.

Find additional information about the ACD, visit our ACD provider web page and www.health.mil/autism.