autism resources TRICARE providers

Autism Care Demonstration (ACD) and Applied Behavior Analysis (ABA)

The TRICARE Autism Care Demonstration (ACD) covers ABA services for all eligible TRICARE beneficiaries diagnosed with Autism Spectrum Disorder (ASD). The demonstration began July 25, 2014, and will continue through December 31, 2023.

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Contact us about ABA services at: (866) 323-7155

ABA NOTIFICATIONS

ACD CPT code changes effective January 1, 2019

Changes include:

  • Update Category III CPT codes to Category I CPT codes
  • Clarify that new authorizations are not required for this change
  • Require use of new CPT codes for claim payment for dates of service on or after 1/1/2019
  • Confirms continued exclusion of concurrent billing of ACD
  • Clarify reimbursement rate processes for the new Category I codes
  • Clarify requirements for session notes for certain treatment plan codes

The ACD adopted the new Category I CPT codes that directly transferred from the Category III codes. Specifically, the ACD has adopted 97151, 97153, 97155 and 97156. Providers should use the approved new codes for all services provided on or after January 1, 2019.

There are several key changes:

  • Certain codes that were previously untimed, are now timed
  • Codes were converted from 30 minute increments to 15 minute increments
  • There is no longer a billable code for supervision. The Defense Health Agency (DHA) will rely on the supervision requirements of the credentialing bodies, but supervision is no longer being paid under the ACD

Learn more

Statement for Texas behavior analysts regarding the new law for ABA providers:

“There has been a change to the law regulating Applied Behavior Analytic providers in the state of Texas effective September 1, 2018. Behavior analysts and assistant behavior analysts must be licensed by the Texas Department of Licensing and Regulation in order to participate in the ACD and provide services under that demonstration. For more detailed information regarding the changes to this law please refer to this website."

Statement for Texas assistant behavior analysts regarding the new law for ABA providers:

“There has been a change to the law regulating Applied Behavior Analytic providers in the state of Texas effective September 1, 2018. This change will specifically affect assistant behavior analysts with the designation of Qualified Autism Services Practitioner (QASP) or Qualified Autism Services Practitioner-Supervisor (QASP-S). Behavior analysts and assistant behavior analysts must be licensed by the Texas Department of Licensing and Regulation in order to participate in the ACD and provide services under that demonstration. The QASP/QASP-s will no longer be eligible for Texas licensure and as a result will not be eligible to participate in the TRICARE ACD as an assistant behavior analyst. Therefore, these providers will no longer be able to provide supervision to ABA recipients nor receive TRICARE reimbursement at the “assistant behavior analyst” level. However, they may continue to practice ABA services at the level of a “behavior technician” providing they meet the requirements outlined in the TRICARE Operations Manual Chapter 18, Section 4, Paragraph 6.3 and comply with applicable state legislation. For more detailed information regarding the changes to this law please refer to this website."

ABA certification and credentialing

All ABA providers must be TRICARE-certified. To become an ABA TRICARE-certified provider, please complete the appropriate form and fax to (608) 221-7544.

All behavior analysts must be credentialed if they choose to become a network provider. Apply to become a TRICARE network provider

TRICARE recognizes the following National Autism certification boards for ABA providers

  • Behavior Analyst Certification Board (BACB):
    1. Behavior analyst certification as a Board Certified Behavior Analyst (BCBA) or Board Certified Behavior Analyst-Doctoral (BCBA-D)
    2. Assistant behavior analyst certification as a Board Certified Assistant Behavior Analyst (BCaBA)
    3. Behavior technician certification as a Registered Behavior Technician (RBT)
  • Qualified Applied Behavior Analysis Certification Board (QABA)
    1. Assistant behavior analyst certification as a Qualified Autism Services Practitioner (QASP) or Qualified Autism Services Practitioner-Supervisor (QASP-S)
    2. Behavior technician certification as a Applied Behavior Analysis Technician (ABAT)
  • Behavioral Intervention Certification Council (BICC)
    1. Behavior technician certification as a Board Certified Autism Technician (BCAT)

Identifying ASD

Explore our tools and resources to aid in the identification and diagnosis of ASD.

Learn more

Billing, claims and reimbursement

ABA providers are considered outpatient specialty providers. Authorized ABA supervisors and ACSPs are allowed to bill for ABA services.

Claims processing

All claims must be submitted electronically with Wisconsin Physicians Service (WPS) in order to receive payment for services. Claims can take up to 30 days to process. All claims for benefits must be filed no later than one year after the date the services were provided. Network providers can submit new claims and check the status of claims online using provider self-service. Log in or register

CPT codes for ABA

In accordance with TOM Chapter 18 Section 4, prior authorization is required prior to rendering ABA services. Claims for services rendered without prior authorization will be denied. All claims must be submitted by BCBA/BCBA-D for services covered under the Autism Care Demonstration (ACD).

  • CPT 97151 - Behavior identification assessment and treatment plan
  • CPT T1023 - PDDBI assessment/Outcome measures completed and submitted by BCBA/BCBA-D
  • CPT 97153 - Adaptive behavior treatment by protocol
  • CPT 97155 - Adaptive behavior treatment by protocol modification
  • CPT 97156 - Family adaptive behavior treatment guidance

*Please note: For telemedicine, the GT modifier must be used.

Changes to CPT codes for ABA were implemented on 1/1/2019. Learn more

Autism Care Demonstration: Guide for providers

Topics covered include TRICARE certification requirements, Humana Military credentialing requirements,
referrals and authorizations, claims requirements, forms and key provider resources.

Provider guide

Referrals and authorization for ABA services

The quickest, most efficient way to request ABA services is online through provider self-service. Providers may also fax referrals and supporting documentation to (877) 378-2316.

Submit referral or authorization

ABA referrals and authorization forms

Referral and authorization process

  • Initial referrals are provided by the ASD diagnosing provider. If the initial diagnosis is made by a Physician-Primary Care Manager (P-PCM), the P-PCM must also submit a referral for a specialized ASD diagnosing provider who must confirm the diagnosis within one year. The specialized ASD provider must also complete the Vineland-3 and SRS-2 outcome measures within the first year of the initial diagnosis.
  • Upon receipt of the referral, Humana Military authorizes an initial ABA evaluation/assessment, treatment plan development and PDDBI outcome measure. At an initial evaluation with the authorized ABA supervisor, target symptoms are identified and a treatment plan is developed.
  • Once the initial evaluation/assessment, treatment plan and PDDBI (parent form) are submitted, Humana Military will authorize six months of ABA services based on the referral request and there is a TRICARE-authorized ABA supervisor with an opening to accept the beneficiary.
  • Treatment plans are reviewed for medical necessity twice annually to allow re-assessment and document progress in improving core deficits. Prior to the expiration of each six month authorization period, the authorized ABA supervisor or ACSP must request re-authorization of ABA services for the next six months from Humana Military (up to 60 days in advance). Providers must submit reassessments, updated treatment plans and PDDBI outcome measures for re-authorization.
  • Every two years from the initial authorization, a new referral for ABA services and a new referral for outcome measures from the P-PCM or specialized ASD diagnosing provider is required.

Continuing Medical Education (CME)

Screening for Autism in the Primary Care Setting: Clinical Practice Guideline Training for Humana Military TRICARE Providers

Providers can learn about the clinical practice guideline tool for screening and identification of Autism Spectrum Disorder (ASD) in the primary care setting. The overall purpose of the training is to describe the guideline algorithm and demonstrate the use of the interactive tool.

This activity has been approved for AMA PRA Category 1 Credit(s)TM

This activity is eligible for ANCC credit, see final CNE activity front matter for specific details.

Jointly provided by

PIM logo

Postgraduate Institute for Medicine and Hayes, Inc.

This educational activity has been funded by Humana Military.

*In order to receive credits for this course, providers must create an account.

Begin the course