Autism Care Demonstration Medical Documentation Requests

Wednesday, June 1, 2022

Under TRICARE’s Autism Care Demonstration (ACD), Health Net Federal Services, LLC (HNFS) reviews provider billing practices to verify the services Autism Corporate Services Providers (ACSP) and sole applied behavior analysis (ABA) providers bill are supported by clear and complete medical documentation. HNFS conducts medical documentation reviews to ensure claims are supported by corresponding documentation, progress notes contain all required elements, services documented comply with TRICARE billing guidelines, and no exclusions have been rendered. When requested, ACSP and sole ABA providers must submit medical records to HNFS on or before the due date as part of the medical documentation review process.

Medical documentation request review process

1. HNFS contacts the ACSP/sole ABA provider to establish initial contact and verify contact information for the audit.
2. HNFS sends written medical documentation request to the ACSP/sole ABA provider.
3. HNFS may contact the ACSP/sole ABA provider regarding the written request.
4. ACSP/sole ABA provider responds to HNFS written requests promptly. Note: Documentation not received by due dates indicated in written requests will negatively impact audit scores.
5. HNFS conducts a review to ensure medical documentation/records comply with ACD requirements.
6. HNFS sends ACSP/sole ABA provider a written summary detailing education requirements or findings resulting in recoupment. HNFS does not send a written notification when there are no findings.
7. (If applicable) HNFS assigns online training to ACSP/sole ABA provider to target any issues identified from the review. Note: ACSP provider groups may determine which individual providers from their group will complete assigned online training.
8. (If applicable) HNFS performs follow-up reviews within 180 days of an ACSP/sole ABA provider completing online training. If a provider does not show improvement, additional reviews may be conducted.

Important details regarding the review process and scoring

Medical documentation received after the due date is a negative score.

• A determination that indicates recoupment is necessary is a negative score.
• A final score of 75% or greater for all records is a passing score.
• Providers who do not achieve a final passing score and are not exhibiting compliance may require:
  • Outreach, education, additional training and/or probe audit(s)
  • Payment recoupment(s)
  • Referral to HNFS’ Program Integrity Department
  • Placement into prepayment review

Visit our Compliance & Audits section of the ACD web page for more information on ACD medical documentation reviews.