Autism Care Demonstration: Providing Timely Responses to Treatment Plan Requests

Wednesday, October 12, 2022

Health Net Federal Services, LLC (HNFS) reviews Autism Care Demonstration (ACD) treatment plans as required by TRICARE Operations Manual, Chapter 18, Section 4. During these reviews, our clinical necessity reviewers examine treatment plan goals, patient progress and number of treatment hours reported. Sometimes a reviewer may need more information to address questions and/or findings. This can mean a letter faxed to the applied behavior analysis (ABA) supervisor or a request for a phone consultation (for more complicated issues). Quick, complete responses to requests can help patients avoid treatment delays.

What are common treatment plan request mistakes?

Common mistakes our clinical necessity reviewers encounter include:

• Patient progress. Not providing an explanation for a lack of patient progress.
  
• Goal criteria. Missing, unclear or not detailed enough.
  
• Discharge criteria. Missing, unclear or not individualized to the patient.
  
• Exclusions. Goals included that are excluded from coverage.
  
• Location. Missing or inadequate information about location or lacking a justification for providing services in school and community locations.
  
• Parent training. Information on sessions lacks details or is too general. 
• Behavior intervention plan. Not including a behavior intervention plan when concerning behaviors reported in summaries.

I received a fax from HNFS. What should I do?

Follow these tips for faxed request letters.

• Read the entire letter.
• Contact the clinical necessity reviewer with any questions about what the letter is requesting. 
• Address each item mentioned in the letter in your response.
  
• Send your complete response – including all information requested – to HNFS within 10 days of receiving HNFS’ request letter. Important: Responses not received by HFNS within 10 business days will result in canceled treatment requests.

I received a consultation request from HNFS. What should I do?

Follow these tips for phone consultation requests. 

• Contact the clinical necessity reviewer on the date and time listed in the request or call to reschedule.
• Request clarification on anything you do not completely understand or if you have remaining questions. 

Visit our Clinical Necessity Reviews page for more information about ACD clinical necessity reviews.