Authorized ABA supervisors and Autism Care Corporate Service Providers (ACSP) bill for ABA services as outpatient specialty providers. View ABA maximum allowed amounts for more information.
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 documented and separated out, even when the same CPT code is billed. Times are not submitted on the individual lines, may result in a delay of claims processing.
Entering start and stop times in XpressClaim:
To enter start and stop time services, navigate to each line and enter the start and stop times in military format as a claim line note. See the XPressClaim (XPC) guide for more information on submitting claims.
Autism Corporate Service Providers (ACSP) and sole providers participating within the Autism Care Demonstration (ACD) are required to complete ACD training annually. This one hour training provides a comprehensive overview of the ACD reviewing topics such as eligibility and diagnosis, authorizations, documentation requirements and claims.
A 10% penalty will be applied to all claims billed under the provider Tax ID for providers who do not attend an annual training. Upon completion of the annual training, the penalty will be remedied. Reminder emails are sent to providers to assist in compliance.
ABA providers must comply with medical documentation and billing practices listed in the TOM, Ch. 18, Sec. 3; state and federal regulations and provider participation agreements, policies and guidelines. Providers who fail to demonstrate compliance are subject to additional education, payment recoupment, penalties, and more severe administrative actions as required by law and contract.
Audit frequency
An annual audit of 30 records is reviewed will be conducted for Autism Corporate Service Providers (ACSP) and sole ABA providers. that includes a combination of administrative records, medical documentation and one MTC progress note. 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 audits all new network and non-network ACSP/Sole ABA providers during their initial 180 days of participation within the TRICARE East Region 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, and provider education will be provided as needed to address inconsistencies with the program requirements.
Administrative reviews
Administrative reviews uncover patterns of alleged fraudulent or abusive billing practices, which may include at a minimum but are not limited to:
Medical documentation reviews
Medical documentation reviews ensure compliance with TRICARE requirements to whether:
What to expect after a failed audit
Providers that do not pass the audit receive both verbal and written education and may receive a secondary audit in the following 180 days.
Prepayment status occurs when suspect billing patterns persist or upon the failure of a secondary audit, following multiple audit and education cycles or when a provider is non-compliant. The ACD audit team refers all suspected fraud and waste cases to the program integrity department, upon identification of suspected ongoing fraudulent practices for further review.
The purpose of a MTC is for treating providers to coordinate and 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 required to do so. The participants will be actively involved in the development, revision, coordination and implementation of clinical services necessary for the beneficiary.
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