Providers can easily access beneficiaries care management profiles with information and resources on their current enrolled program(s).

Check out the care management dashboard!

Enroll in Electronic Funds Transfer (EFT) by April 30, 2025

All providers must enroll in Electronic Funds Transfer (EFT) services as the exemption period for ABA providers is ending. Claims will be denied if enrollment in EFT is not completed by the deadline of April 30, 2025, in accordance with TRICARE Operations Manual (TOM) Ch. 18, Sec. 3, Para. 8.11.2.

View the EFT and ERA enrollment package for the application, FAQs and more information. Please email your completed application to HMT5EFT@PGBA.com.

Referral for ABA services

1. Referral from an approved Autism Spectrum Disorder (ASD) - diagnosing  provider or diagnosing specialist which includes:
  • An ASD diagnosis with severity level
  • Date of initial ASD diagnosis
  • Request for ABA services

 

For beneficiaries, eight years or older and first diagnosed with ASD, a referral from a specialized ASD-diagnosing provider evaluation is required.

2. Completed DHA Diagnostic Statistical Manual (DSM)-5 checklist,  indicating the severity level of ASD symptoms

3. Results from a validated assessment tool:
  • Screening Tool for Autism in Toddlers and Young Children (STAT)
  • Autism Diagnostic Observation Schedule-Second Edition (ADOS-2)
  • Autism Diagnostic Interview-Revised (ADI- R)
  • Childhood Autism Rating Scale-Second Edition (CARS-2)
  • Gilliam Autism Rating Scale, Third Edition (GARS-3)
    • Completion of the GARS-3 alone is not sufficient for diagnostic documentation. A diagnostic evaluation must be submitted in addition to the GARS-3.

 

For beneficiaries younger than age 12 months, the authorized ASD-diagnosing or -referring provider may choose an appropriate age-based tool to complete the VAT requirement

4. Enrollment in the Exceptional Family Member program (EFMP) and the Extended Care Health Option (ECHO) if the beneficiary is a dependent of an Active Duty Service Member (ADSM) 

5. Acceptance of Autism Service Navigator (ASN) services

For a list of approved TRICARE ASD-diagnosing providers, review TOM Ch. 18 Sec. 3, Par. 11.13.  

Registered providers should use provider self-service to submit all referrals and authorization requests. 

Providers who do not have a provider self-service account should register for an account to submit referral and authorization requests online. 

Humana Military will authorize an initial assessment for outcome measures for Treatment Plan (TP) development and outcome measure completion upon receipt of all necessary documents. Failure to provide necessary clinical information may result in delays, terminations of authorized care and denials for pended claims.

ABA services request

ABA services must be pre-authorized before services can begin. Humana Military does not accept retrospective referrals and will not backdate late submissions. Providers can submit requests for ongoing treatment up to 60 days in advance. However, submitting requests less than 30 days before the current authorization expires may result in non-reimbursement for ABA services.

Licensed, Board-Certified Behavior Analysts (BCBA) and Board-Certified Behavior Analysts-Doctoral (BCBA-D) review all TPs for clinical necessity prior to authorizing treatment. The clinical reviewer evaluates:

  • Level of clinical support
  • Effectiveness of treatment implementation
  • Intensity, frequency and duration of treatment (dose response)
  • Duration of services and individualized discharge planning
  • Additional services being rendered
  • Baseline data, progress summaries and ongoing data collection
  • Recommended goals
  • Parent training goals
  • Behavior Intervention Plans (BIP)
  • Outcome measure scores
  • Discharge plan
  • CPT codes requested

Every two years, a referral from an approved ASD-diagnosing provider or specialist must be submitted with the ASD diagnosis, the beneficiary’s level of support and an approved DHA DSM-5 checklist. A two-year referral may be accepted up to six months in advance of its due date. 

If an ABA supervisor cannot complete the required outcome measures, please notify Humana Military at (866) 323-7155 to ensure completion of these outcome measures.

Outcome measures timeline - what to expect the first two years

Initial assessment

ABA supervisor completes

  • Initial assessment and treatment plan (TP)
  • Pervasive Developmental Behavior (PDDBI) parent form
  • Parent Stress Index, Fourth Edition (PSI-4) short form *
  • Stress Index for Parents of Adolescents (SIPA) *
  • Social Responsiveness, Second Edition (SRS-2) parent form 
  • Vineland-3 Parent, Teacher or Interview form

Every 6 months

ABA supervisor completes

  • Updated TP
  • PDDBI parent form
  • PDDBI teacher form
  • PSI-4, short form *
  • SIPA *

Annually

ABA supervisor completes

  • Updated TP
  • PDDBI parent form
  • PDDBI teacher form
  • PSI-4 short form *
  • SIPA *
  • SRS-2 parent form
  • Vineland-3 Parent, Teacher or Interview form

Every 2 years

Approved ASD diagnosing provider / specialist completes

  • An updated referral
  • An updated DSM 5 checklist

 

ABA supervisor completes

  • Updated TP
  • PDDBI parent form
  • PDDBI teacher form
  • PSI-4 short form *
  • SIPA *
  • SRS-2 parent form
  • Vineland-3 Parent, Teacher or Interview form

 *Complete only one based on beneficiary’s age