Autism Care Demonstration: Six Commonly Missing Requirements in Treatment Authorization Requests

Tuesday, December 27, 2022

Health Net Federal Services, LLC (HNFS) has found that nearly 75% of Autism Care Demonstration (ACD) treatment authorization requests we receive do not include all the information TRICARE requires us to review before we can issue a benefit review determination. Visit our Clinical Necessity Reviews page for more information. When one of our clinical necessity reviewers needs to request missing information or meet with the applied behavior analysis (ABA) provider this may lead to delays in determinations.

Please review these six commonly missed requirements before submitting your next treatment authorization request.

1. Outcome measure explanations.
   • Does not include explanations for outcome measures that have remained the same over several treatment periods.
   • Does not include explanations for outcome measures that show a patient has been regressing.
2. Goals and treatment methods.
   • Does not include consistent or clear criteria in a goal’s baseline, mastery criteria or progress summary.
   • Does not clearly define or provide enough detail for goal progress.
   • Does not demonstrate that goal criteria relate to core ASD symptoms.
   • Does not include or only includes insufficient interventions for goals and behavior intervention plans.
3. Discharge criteria.
   • Does not include discharge criteria.
   • Does not include detailed discharge criteria.
   • Does not include discharge criteria that relates (is individualized and practical) to the patient.
4. Beneficiary history and background information.
   • Missing total time in treatment.
   • Missing statements explaining other diagnosis(es) or prescribed medication(s) (when applicable).
   • Missing school schedule or total time attending school.
5. Locations.
   • Does not include specific community location (store, park, etc.).
   • Does not include documentation that supports use of or an explanation for use of a school setting.
   • Does not include documentation that supports use of or an explanation for use of a community setting.
6. Parent training.
   • Does not include the number of sessions that were completed.
   • Does not include sufficient details supporting why parent training minimums were not met (for example, writing “only five parent training session were conducted over the past six months” and not providing an explanation for why the required six sessions were not conducted).
   • Does not include specific details in progress summaries (for example, only stating goal status without providing a detailed summary or not including new baselines for new goals). 

Clinical necessity reviewers look for all treatment plan requirements. If any area is missing, we will ask the ABA provider to make changes. ABA providers can help expedite the review process by clearly labeling and organizing treatment plan information and including all required elements.

Note: An updated treatment plan always requires a new parent/caregiver signature to confirm the parent/caregiver is aware of and agrees to the updated treatment.