To enroll in the ACD, beneficiaries must meet the following:
Approved Primary Care Managers (PCM):
Approved specialists:
Step 1: Receive Autism Spectrum Disorder (ASD) diagnosis
Diagnosis must come from an approved ASD-diagnosing Primary Care Manager (PCM) or specialist.
Approved PCM and specialists types:
Step 2: Get a referral and pre-authorization
Your child must get a referral to the ACD and a pre-authorization for all Applied Behavior Analysis (ABA) services. This is required for all TRICARE plans, including incidents where TRICARE is considered secondary (Other Health Insurance [OHI]).
Are you requesting ABA services for the first time?
Step 3: Complete outcome measures
You and your child’s provider team must complete four baseline outcome measures before your child can get ABA services. This will help monitor your child’s progress.
Outcome measures
You must complete the four outcome measures every six months or every 12 months (depending on the measure). If you need assistance in finding a provider to complete the outcome measures, please contact us at
Step 4: Schedule an appointment
When you get your child’s authorization notice, schedule their ABA assessment with the provider listed in the authorization. If you would like to request a different provider, please call
Your ABA supervisor’s role:
Step 5: Work with your Autism Services Navigator (ASN)
TRICARE will assign your child an ASN if they are enrolled on or after Oct. 1 2021. Your child’s ASN acts as their primary clinical advocate.
The ASN will work with you to develop your child’s Comprehensive Care Plan (CCP).
Your child’s CCP will:
Humana Military follows a placement process to ensure beneficiaries have access to an Applied Behavior Analysis (ABA) provider within TRICARE’s access to care standards.
Here’s how it works:
The initial assessment may involve multiple visits and includes a direct observation of the beneficiary needing care. Information will be collected to help develop an individualized treatment plan which will include treatment recommendations and goals.
The assessment includes:
The beneficiary can obtain a second opinion from a different ABA provider if requested. A new referral is not required as long as it is within the two-year timeline.
Two “ongoing” treatment authorizations of direct service are not permitted. It is important to communicate with Humana Military on which provider the beneficiary would like to use to avoid delays in authorization approval for treatment.
TRICARE requires the following outcome measures for beneficiaries participating in the ACD:
What is an ASN?
An ASN is a licensed behavioral health professional or registered nurse who has experience in case management services.
The ASN role is to support the beneficiary and their family by:
How do I get an ASN?
Beneficiaries who are new to the Autism Care Demonstration (ACD) on or after Oct. 1, 2021 are eligible for an ASN. If the beneficiary was previously enrolled in the ACD prior to Oct. 1, 2021 and has not received services for more than 12 months, the beneficiary would be considered “new” to the ACD and will need to be assigned an ASN.
What can I expect?
Humana Military will assign the beneficiary an ASN once we verify the referral has all of the required documentation. The ASN will complete a welcome call once eligibility and referral requirements have been verified and will work with the parent/caregiver to complete a CCP. The CCP is a living document that the ASN and parent/caregiver will update throughout enrollment in the ACD.
Your care management dashboard
Humana Military will assign the beneficiary an ASN once we verify the referral has all of the required documentation. The ASN will complete a welcome call once eligibility and referral requirements have been verified and will work with the parent/caregiver to complete a CCP. The CCP is a living document that the ASN and parent/caregiver will update throughout enrollment in the ACD.
The diagnosing provider will submit a referral to Humana Military for ABA services. Referrals must specify Applied Behavior Analysis (ABA) services and include proof of a definitive diagnosis using the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5 (or current edition)), including initial date of diagnosis, through either a referral reflecting a diagnosis of ASD or a diagnostic evaluation. DSM criteria must be documented in a DHA-approved checklist.
For beneficiaries enrolled to the ACD prior to Oct. 1, 2021, TRICARE-authorized ASD-referring and diagnosing providers have the option of submitting a definitive diagnosis referring provider attestation which fulfills both the DSM-5 diagnostic checklist and validated assessment tool eligibility requirements for the two year PCM referral requirements.
Your provider should submit referral requests online for faster processing. The referral for ABA form and supporting documentation may be faxed when needed to
Referrals for ABA services are valid for two years. The referral due date will be provided in writing to help track when a new request will be required.
The two-year referral cycle starts with the initial verified referral for ABA. Prior to the end of the current two-year cycle, a new referral must be submitted by your TRICARE-authorized ASD-diagnosing or referring provider.
Referrals remain valid within the two-year timeline, even if you:
Once the initial assessment has been completed, the Applied Behavior Analysis (ABA) provider will submit a request for treatment. Treatment authorizations are approved in six-month increments.
Humana Military must verify the following:
The clinical review process will not be completed until all clinical documentation is provided. Beneficiaries can view authorization status by logging into their self-service account. Humana Military will not backdate and will deny reimbursement for services performed outside of the dates on the approved authorization.
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):
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.
TRICARE allows clinically-appropriate Applied Behavior Analysis (ABA) services to be rendered in various settings. ABA services must target the core symptoms of Autism Spectrum Disorder (ASD) and not be an excluded service under the Autism Care Demonstration (ACD). The clinical review process will be used to determine the appropriate location of ABA services.
Various service settings allowed:
Home
Clinic
Daycare
School setting
Community setting
Telemedicine
Good ABA practices:
Red flags:
If you are concerned that your Board Certified Behavior Analyst (BCBA) may have violated one or more of the Behavior Analyst Certification Board's (BACB) ethics requirements, you can report your issue of concern to the BACB's Ethics Department.
Discharge planning is an important part of treatment planning. This prepares beneficiaries for a successful transition once they have reached all treatment goals and Applied Behavior Analysis (ABA) services are no longer appropriate. The ABA provider will develop a discharge plan during the treatment planning process. Once the beneficiary is ready to be discharged from the ABA provider’s care, the ABA provider will submit a discharge plan to Humana Military.
The ABA provider should provide a minimum of a 45-day notice to both parents and Humana Military prior to discharge. As part of the transition, we will authorize parent training for a six month period.
Relocating while enrolled in the ACD:
Resources
Autism education:
Forms:
Additional resources:
Available Monday through Friday, 8 AM - 7PM (ET)
(866) 323-7155 (Phone)
(877) 378-2316 (Fax referrals)
(877) 200-0401 (Fax ECHO support)
