While TRICARE’S Autism Care Demonstration (ACD) offers Applied Behavior Analysis (ABA) services for beneficiaries with Autism Spectrum Disorder (ASD), there are defined exclusions, which will not be authorized and are not reimbursable.

Review TOM Ch. 18, Sec. 3 in its entirety for complete overview of the ACD policy and TRICARE requirements for ACD participation and policy exclusions.

Humana Military will not reimburse for the following, to include but not limited to:

Exclusions

 

Activities Concurrent billing Location Telemedicine Type of service and goals Other exclusions
  • Training and supervising a Behavior Therapist (BT)
  • Report writing outside of the use of CPT code 97151    
  • Emails and phone calls
  • Office and therapeutic supplies
  • Concurrent billing for all ABA CPT codes except when the beneficiary and family are receiving separate services, and the beneficiary is not present in the family session
  • Certain locations may be preauthorized at clinical review
  • Asynchronous telemedicine services 
  • Rendering CPT 97156 virtually within the first six months of treatment
  • Goals targeting activities of daily living
  • Vocational and/or educational goals
  • ABA services involving any aversive techniques or restraints 
  • Interventions considered psychotherapy such as Cognitive Behavior Therapy (CBT), Acceptance and Commitment Therapy (ACT), Prolonged Exposure, group psychotherapy, etc.
  • ABA services for diagnoses other than ASD 
  • ABA services for symptoms and behaviors that are not part of the core symptoms of ASD