Clinical necessity reviews

Clinical review process

Humana Military’s licensed clinical reviewers (Board Certified Behavior Analysts (BCBA) and Board Certified Behavior Analysts-Doctoral (BCBA-D)) perform clinical necessity reviews on all treatment plans prior to authorizing treatment. Clinical necessity refers to services that are appropriate to address the diagnosed condition. For Applied Behavior Analysis (ABA) services this means addressing Autism Spectrum Disorder (ASD) symptoms.

Clinical reviews evaluate the following (although not inclusive):

• A complete treatment plan
• Progress with goals and scores of outcome measures
• Level of clinical support
• Duration of time in ABA services
• Location of services
• Specific goals addressing core symptoms of ASD
• Recommended hours of ABA services requested

Once Humana Military has received a complete treatment authorization request from the ABA provider, the clinical review process will begin.

The clinical reviewer may request additional information needed to determine clinical necessity. If the additional information is not provided in a timely manner, this could potentially cause a gap in services.

Once the review is complete, the reviewer will authorize clinically necessary and appropriate treatment or request the provider submit an updated treatment plan for further review. In the event the provider is requested to submit an updated treatment plan, the clinical review process restarts when all information is received.