Autism Care Demonstration: Exclusions

Friday, January 28, 2022

While many services are available to TRICARE beneficiaries under the Autism Care Demonstration (ACD), there are defined exclusions which are not reimbursable and will not be authorized. Be sure to familiarize yourself with ACD exclusions to help expedite the authorization process and minimize financial impacts. Find the complete list of exclusions in the TRICARE Operations Manual, Chapter 18, Section 4.  

Through clinical necessity reviews and medical documentation review audits, we continue to see exclusions such as:

• Asynchronous (one-way) telehealth services
• Applied behavior analysis (ABA) services provided via telehealth that were not explicitly authorized to be rendered via telehealth in accordance with ACD guidelines
• ABA services rendered at sporting events, camps or other excluded settings. 
• Services rendered by behavior technicians (BTs) or assistant behavior analysts in a school setting 
• Shadow, aid or support services rendered in a school setting by the ABA supervisor. (Services in school settings must target specific behavior excess or deficit for a limited duration.) 
• Educational or vocational services
• Goals targeting activities of daily living
• ABA services using any aversive techniques or restraints
• Supervision or training of BTs
• Mileage to and from ABA appointments

Per provider contract agreements, network providers may not bill TRICARE beneficiaries for excluded services, or for covered services rendered without authorization when required, except in the following circumstances:

• The beneficiary did not inform the provider they were a TRICARE beneficiary.
• The beneficiary was informed the services were excluded and agreed in advance and in writing with the rendering provider to pay. 

For providers who seek to establish a written agreement with a beneficiary to render excluded services, we offer a “Request for Non-Covered Services” form. This specific form is not required; however, any signed written agreement must include the same elements. Be sure to keep the written agreement with the patient’s records. If you submit a claim, you will need to include the written agreement for the claim to process with patient responsibility for the non-covered service. 

Non-network providers should also inform beneficiaries in advance if a service is excluded, as the beneficiary can be held liable for 100% of billed charges. For covered services rendered outside of a required authorization, non-network providers who accept assignment (participating) cannot bill the beneficiary without in-advance written consent. Submit a copy of the written agreement with the claim to have it process with patient responsibility. Non-participating non-network providers may not bill beneficiaries more than 115% of allowable charges or 100% of billed charges, whichever is less, for non-authorized covered services.

We offer balance billing details on our Billing Tips page. For additional information on the Autism Care Demonstration, including exclusions and billing, visit our Autsim Care Demonstration web page.