While many services are available to TRICARE beneficiaries under the Autism Care Demonstration (ACD), there are defined exclusions which are not reimbursable and will not be authorized.

ABA services can be rendered in various settings, as clinically appropriate. ABA services must target the core symptoms of ASD and not be an excluded treatment location under the ACD. The clinical necessary review process determines the appropriate location of ABA services. All community settings must be authorized prior to rendering services. 

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

Activities
  • Training and supervising a Behavior Therapist (BT)
  • Report writing outside of the use of CPT code 97151 
  • Driving to and from ABA services appointments (i.e., beneficiary’s house, clinic or other locations). Mileage/time traveling is not to be billed to the TRICARE program   
  • Emails and phone calls
  • Office and therapeutic supplies

Concurrent billing
  • 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
  • Billing for ABA services while the beneficiaries are at another medical appointment, including another family member’s appointment
  • Two different ABA supervisors simultaneously billing the same CPT code 

Location
  • Community settings not authorized prior to rendering services
  • ABA services performed by BT or Assistant Behavior Analysts (BCaBA) in a school setting
  • ABA providers functioning as support aides or observers during care routines or activities (lunch, group activities, arts and crafts, etc.) in a school setting
  • Autism schools; if an autism school has a clinic setting, the clinic must have a separate TIN 

Telemedicine
  • Asynchronous telemedicine services 
  • ABA services not authorized prior to rendering services
  • Rendering CPT 97156 virtually within the first six months of treatment
  • Rendering CPT code 99366 and 99368 for Medical Team Conferences with audio only

Type of service and goals
  • Goals targeting activities of daily living
  • Vocational and/or educational goals
  • ABA services involving any aversive techniques or restraints 
  • Group ABA services billed as one-on-one services
  • Interventions considered psychotherapy such as Cognitive Behavior Therapy (CBT), Acceptance and Commitment Therapy (ACT), Prolonged Exposure, group psychotherapy, etc.
  • Non ABA services by ABA providers
  • ABA services written in the beneficiaries Individualized Education Program (IEP)
  • Other non-medical services such as changing of diapers

Other exclusions
  • ABA services for diagnoses other than ASD 
  • ABA services for symptoms and behaviors that are not part of the core symptoms of ASD
  • School tuition
  • Custodial care, personal care and/or childcare
  • ABA evaluation or intervention services provided directly by the beneficiaries’ responsible adult
  • ABA evaluation or intervention services provided by a clinic or agency owned by beneficiaries’ responsible adult
  • Durable Medical Equipment (DME) whose safety and efficacy has not been established
  • Services when the beneficiary is sleeping
  • Two ABA providers at same time under one CPT code

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.