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 3, 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 documented and separated out, even when the same CPT code is billed. 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.
Entering start and stop times in XpressClaim:
To enter start and stop times for Applied Behavior Analysis (ABA)/Autism Care Demonstration (ACD) 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. The training provides a comprehensive overview of the ACD reviewing topics such as eligibility and diagnosis, authorizations, documentation requirements and claims.
Providers must attend training provided 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. Upon completion of the annual training, the penalty will be remedied. Reminder emails are sent to providers 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 has licensed Board-Certified Behavior Analysts (BCBA), and Board-Certified Behavior Analysts-Doctoral (BCBA-D) reviews all TPs prior for clinical necessity prior to authorizing treatment. The review process examines a compliant TP, baseline measures, recommended goals, target areas, parent training goals, outcome measures and any recommendations.
ABA services require prior approval and must be preauthorized. Humana Military does not accept retrospective referrals and will not backdate late submissions as outlined in TOM Ch. 18 Sec. 3.
Clinical necessity reviews ensure the TP corresponds with the most appropriate level of care for the beneficiary. The clinical reviewer evaluates:
Registered providers should use provider self-service to submit all authorization requests. Providers who do not have a provider self-service account should register for an account to submit referral and authorization requests online.
Providers can submit requests for ongoing authorization treatment up to 60 days in advance. However, submitting requests less than 30 days before the current authorization expires may risk non-reimbursement for ABA services until the new authorization is issued.
The following information is required for initiating an authorization:
Applied Behavior Analysis (ABA) providers must comply with medical documentation and billing practices listed in the TRICARE Operations Manual (TOM), Chapter 18, Section 3; 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:
Medical documentation reviews
Humana Military conducts medical documentation reviews to ensure compliance with TRICARE requirements. These reviews evaluate whether:
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 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 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, 8AM - 7PM (ET)
(877) 378-2316 (Referrals)
