To enroll in the ACD, beneficiaries must meet the following:
Approved PCMs:
Approved specialists:
Step 1: Receive Autism Spectrum Disorder (ASD) diagnosis
Diagnosis must be from an approved ASD-diagnosing Primary Care Manager (PCM) or specialist.
Approved PCMs:
Approved specialists:
Step 2: Obtain a referral and pre-authorization
Your child must have a referral to the ACD and a pre-authorization for all Applied Behavior Analysis (ABA) services. This is required for all TRICARE plans, including when TRICARE is 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 complete four baseline outcome measures before your child can begin ABA services. This helps monitor your child’s progress.
Outcome measures
Completed every 12 months:
Completed every six months:
Outcome measures are completed every six months and/or every 12 months depending on the outcome 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 contact us at
Your ABA supervisor’s role:
Step 5: Work with your Autism Services Navigator (ASN)
TRICARE will assign your child an ASN who acts as their clinical advocate.
The ASN will work with you to develop your child’s Comprehensive Care Plan (CCP) and:
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 is 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 ABA services 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) are eligible for an ASN.
What can I expect?
Once eligibility and referral requirements are verified, an ASN is assigned to your child and they will complete a welcome call to enroll in the ACD and work with the parent/caregiver to complete a Comprehensive Care Plan (CCP). The CCP is a living document that the ASN and parent/caregiver update throughout enrollment in the ACD. The CCP is viewable on your care management dashboard including your assigned ASN contact information
Initial referrals are provided by the Primary Care Manager (PCM) or ASD-diagnosing provider. 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.
Your provider should submit referral requests online. Please be aware that failure to provide necessary clinical information may result in delays, terminations of authorized care and denials for pended claims.
Referrals for ABA services are valid for two years. The referral due date will be provided in writing to help track when a new referral will be required.
The two-year referral cycle starts with the initial verified referral for ABA services. 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 has licensed Board Certified Behavior Analysts (BCBA) and Board Certified Behavior Analysts-Doctoral (BCBA-D) clinical reviewers 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 begins. Services should not begin until an approved authorization is on file to avoid nonpayment of services.
The clinical reviewer may request additional information needed to determine clinical necessity. In the event the provider is requested to submit an updated treatment plan, the clinical review process restarts when all information is received. It is essential for ABA providers to monitor the self-service portal when additional information is requested to avoid a delay in authorizations. 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.
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 determines 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 ABA services, 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.
Resources
Autism education:
Forms:
Find local resources, support groups and services on military installations when available:
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)
