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Authorization Reviews and the Autism Care Demonstration

Friday, February 17, 2023

When you submit well organized authorization requests that meet TRICARE’s Autism Care Demonstration (ACD) requirements, you help Health Net Federal Services, LLC (HNFS) make coverage determinations more quickly. If any requirement is incomplete, then the request cannot proceed until resolved. Please review this refresher on submitting complete requests. 

Prescreening Treatment and Reauthorization Requests

For enrolled beneficiaries, once the applied behavior analysis (ABA) referral and ACD outcome measures (Vineland Adaptive Behavior Scales, Third Edition; Social Responsiveness Scale, Second Edition; Parenting Stress Index, Fourth Edition Short Form/Stress Index for Parents of Adolescents) are verified as current and valid, the request will go through treatment prescreening. For HNFS’ reviewers to pass authorization requests on for clinical necessity review, requests must meet the following minimum requirements for reviewers to consider requests ready for clinical necessity review: 

  • Current Procedural Terminology (CPT®) codes
    • List each location where you plan to use each CPT code. 
    • List the recommended units for each CPT code you are requesting. 
  • Treatment plans – Make sure all documented patient information is correct, including:
    • Statement of autism spectrum disorder (ASD) diagnosis
    • Date of birth is correct; legal name used and spelled correctly
    • Sponsor Social Security number (SSN) or Department of Defense (DOD) Benefits Number (DBN)
    • Treatment plan was updated (for renewals) within 60 days of current authorized treatment period expiring
  • Pervasive Developmental Disorder Behavior Inventory (PDDBI)
    • Valid PDDBI
    • Separate from the treatment plan; includes name of respondent and relationship to the beneficiary 
    • Completed in the publisher’s PDDBI parent and or teacher rating form; scores are complete and valid within publisher limits 
    • Initial treatment requires parent PDDBI; treatment renewal requires parent and teacher PDDBI with the teacher PDDBI completed by the ABA supervisor only

Clinical Necessity Reviews 

HNFS conducts clinical necessity reviews with a uniform approach that requires assessing the initial baselines, recommended goals, target areas, parent training goals, outcome measure scores, and recommendations in treatment plans. During this review stage, requirements that are frequently missing or lacking supportive detail include:

  • Outcome measures with stagnation or regression not having detailed explanations.
  • Discharge criteria that is not objective or measurable and not individualized with valid criteria based on treatment history and/or symptom impacts.
  • Goal criteria lack details or do not target core ASD symptoms. When treatment plans include goals excluded from TRICARE coverage then include a statement identifying the provider is aware they are excluded or will be discussed in consultation.
  • Goal progress summaries not included or inadequately report progress or status of goal or do not match baseline criteria.
  • Documentation requirements and justifications for school and community locations are missing or lack detail that would support justification or lack clarity on which goals will be targeted in each environment in the goal section and by which units will be used in each environment in the recommendation section.
  • Parent/caregiver training and progress summaries lack detail and description of parent/caregiver progress, with the ABA provider only stating the parent/caregiver goal status or that they met the six minimum parent training requirements. 

Resources Available at www.tricare-west.com  

HNFS offers numerous resources – including printable guides and comprehensive web pages – to help you navigate the ACD authorization process. Visit our ACD page to access resources and ACD-specific content today.