ABA services require prior authorization. Authorized ABA supervisors must submit the initial assessment, treatment plan, PSI/SIPA, Vineland-3 (parent, teacher or interview form), SRS-2 (parent form) and PDDBI (parent form). Once submitted, Humana Military will review for clinical necessity and authorize six months of ABA services as appropriate based on the referral request. We encourage you to read and adhere to the policy outlined in the TRICARE Operations Manual (TOM), Chapter 18 Section 4. If you have questions or concerns about the policy, please contact DHA directly at dha.acd@mail.mil, or contact Humana Military at (866) 323-7155.
ABA providers are considered outpatient specialty providers. Authorized ABA supervisors and Autism Care Corporate Service Providers (ACSP) are allowed to bill for ABA services. View ABA maximum allowed amounts for more information.
In accordance with the TRICARE Operations Manual (TOM), Chapter 18 Section 4, prior authorization is required prior to rendering ABA services. Claims for services rendered without prior authorization will be denied. All claims must be submitted by BCBA/BCBA-D for services covered under the Autism Care Demonstration (ACD). Network providers can submit new claims and check the status of claims via provider self-service.
Providers should include the start and stop times on the individual claim lines when submitting claims, even when billing for multiple services rendered by the same rendering provider on the same day. These sessions must be separated out, even when the CPT code is the same. When the times are not submitted on the individual lines, claims processing is delayed as additional research is required to confirm the correct start and stop times and corresponding charges.
Autism Corporate Service Providers (ACSP) and sole providers participating within the Autism Care Demonstration (ACD) are required to complete ACD training annually. The training provides a comprehensive overview of the ACD reviewing topics such as eligibility and diagnosis, authorizations, documentation requirements and claims.
Providers must register for training on one of the posted dates available throughout the year. A 10% penalty will be applied to all claims billed under the provider Tax ID for providers who miss the annual training. Once the training has been completed, the penalty will be remedied. Emails will be sent to providers as reminders to assist in compliance.
Please contact Humana Military at (866) 323-7155 or log into provider self-service to update any provider information necessary.
Humana Military is required to perform clinical necessity reviews, as well as clinical consultations as necessary on all treatment authorizations. Clinical necessity reviews are conducted by a BCBA/BCBA-D. The review process examines a complete TP, baseline measures, recommended goals, target areas, parent training goals, outcome measures and any recommendations.
Step 1 – Administrative document review
The following information is required prior to initiating the clinical necessity review process:
Step 2 – Clinical necessity review
Clinical necessity reviews ensure the TP corresponds with the most appropriate level of care for the beneficiary. The clinical reviewer (BCBA/BCBA-D) considers the following areas for clinical necessity:
Step 3 – Clinical consultation and/or additional documentation
In the event that clinical consultation is required, Humana Military will complete a live phone review with the treating ABA supervisor to resolve areas regarding clinical necessity, exclusions or other areas that require consultation.
TPs that contain exclusions or missing information must be modified and resubmitted.
Applied Behavior Analysis (ABA) providers must comply with medical documentation and billing practices listed in the TRICARE Operations Manual (TOM), Chapter 18, Section 4; state and federal regulations; and provider participation agreements, policies and guidelines at all times. Providers who fail to demonstrate compliance are subject to additional education, payment recoupment, penalties, and/or more severe administrative actions as required by law and contract.
Audit frequency
An annual audit will be conducted for Autism Corporate Service Providers (ACSP) and sole ABA providers. A minimum of 30 records (if available) that include a combination of administrative records, medical documentation and one medical team conference progress note will be reviewed. Providers must submit medical records to Humana Military in response to any review requests on or before the due date specified. Medical records not received by the due date will negatively affect the audit score.
Reviews for new providers
Humana Military monitors all new network and non-network ACSP/Sole ABA providers during their initial 180 days of participation within the TRICARE East Region. After 180 days, we will review records for clinical documentation and claims submission for compliance. Providers must submit medical records to Humana Military in response to any review requests on or before the due date specified. Medical records not received by the due date will negatively affect the audit score. Audit results will be shared with new providers. Provider education will be provided as needed to address inconsistencies with the program requirements.
Administrative reviews
Humana Military conducts administrative reviews to uncover patterns of alleged fraudulent or abusive billing practices, which may include at a minimum, but are not limited to:
High-dollar, erratic, or inconsistent billing and coding patterns
Changes in billing frequency
Concurrent billing (i.e. billing for two services at the same time)
Misrepresentation of provider (i.e. filing for a non-rendering provider or non-authorized provider)
Claims patterns of “impossible days”
Patterns of high-claim error rates
Medical documentation reviews
Humana Military conducts medical documentation reviews to ensure compliance with TRICARE requirements. These reviews evaluate whether:
Claims are supported with medical documentation
Progress notes contain all required documentation elements
Documented services comply with ABS approved CPT codes
Any exclusions were present during session
What to expect after a failed audit
Providers that do not pass the annual or new provider audit (i.e. with a combined administrative and clinical score in excess of the standard) receive both verbal and written education. In the following 180-days, Humana Military conducts secondary, and possibly, tertiary audits.
Prepayment status occurs when suspect billing patterns persist or upon the failure of secondary or tertiary audits, following multiple audit and education cycles or when a provider is non-compliant (has not returned complete medical records after extensive outreach to the provider). The ACD audit team refers suspected fraud and waste cases to the program integrity department, upon identification of suspected ongoing fraudulent practices.
The purpose of a Medical Team Conferences (MTC) is for treating providers to periodically meet to discuss the beneficiary and the overall program and progress towards goals. The MTC includes face-to-face participation with a minimum of three qualified healthcare professionals from different specialties or disciplines. The parent/caregiver may also be present to collaborate or discuss the beneficiary’s case, but is not mandatory. The participants will be actively involved in the development, revision, coordination and implementation of clinical services necessary for the beneficiary.
Available Monday through Friday, 8 AM - 7PM (ET)
(877) 378-2316 (Referrals)
