Specific information is required by TRICARE to be included on all TPs prior to submission to Humana Military.

Required information for TPs

Identifying information

  • Name of beneficiary
  • Date of birth
  • Date of initial Applied Behavior Analysis (ABA) assessment completed
  • Date of initial TP completed
  • Either the DoD Benefit Number (DBN) or the sponsor’s Social Security Number (SSN)
  • Name of the referring provider

Reason for referral

  • Autism Spectrum Disorder (ASD) diagnosing/referring provider’s ASD diagnosis, including level of severity

Background information on the beneficiary including

  • Information that reports the beneficiary's condition, diagnoses and/or medications
  • School enrollment status and number of hours enrolled in school
  • Number of hours of other support services being received (Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST))
  • Age of the child and the year of their initial ASD diagnosis 
  • How long the beneficiary has been receiving ABA services

Summary of assessment activities

  • Objectively identify behavior deficits and excesses that impede the beneficiary’s safe, healthy functioning in all domains applicable and related to core symptoms of ASD
  • Include a list of assessment tools administered
  • Identify if the beneficiary is able to actively participate in treatment

TP goals

  • Clearly defined, measurable targets relevant to the DSM-5
    • Goals must address core symptoms of ASD only
      • Social communication and social interaction behavior
      • Restrictive, repetitive, and/or stereotypical patterns of behavior 
    • Goals cannot address daily living skills acquisition, educational or vocational activities, or address co-morbid related symptoms, or goals better served by other specialties such as PT/OT/ST
  • Goals and objectives must be measurable, objective, achievable, developmentally appropriate, and clinically significant
  • Goals must include baseline and ongoing measurement levels for each target behavior in terms of measurable behavior dimensions over time
  • Goals must have a description of interventions/techniques 
  • Identify the objective measure of assessment for each goal specified
  • May include long-term goals and short-term objectives

Parent/Caregiver goals

Parent participation and parent training goals are a requirement and must include the following:

  • Measurable objectives relevant to practicing learned skills with the beneficiary at home or clinic/office (school setting is excluded for parent training)
  • Goals must relate to increasing the parent/caregiver’s skills and capabilities and not to the beneficiary’s response or progress on the individual goals described in the TP

Goals may include: 

  • ABA principles
  • Treatment implementation and teaching new skills
  • Generalization and maintenance to other environments
  • Teaching daily living skills, academic skills, or other excluded areas outside of program hours 
  • Targeting new skills and behavior excesses in other environments
  • Preparation for increased implementation of taught skills outside of treatment

If parent/caregiver participation is not possible, include reasons why and describe when parent training will resume. Parent training may be conducted with the family member or caregiver as defined:

  • Natural parent 
  • Adopted parent
  • Stepparent
  • Grandparent
  • Responsible siblings over the age of 18 
  • Other legal guardian over the age of 18
  • Nanny:
    • Over the age of 18
    • Must be employed full time by the family or an agency on behalf of the family 
    • Documented in the service family care plan and submitted to Humana Military
    • Approved TP must identify the level of the nanny’s participation to include specific goals
    • Caregiver training does not exceed parent training (CPT codes 97156 and 97157)
  • No other individuals are considered family or caregivers under the ACD 

All attempts to mitigate parent/caregiver lack of involvement/participation must be documented by the ABA provider.

Implementation of the TP should begin with parent guidance sessions (CPT codes 97156 or 97157) especially if other ABA services are delayed.

ABA providers are required to render a minimum of one session of parent training within 30 days of the treatment authorization under CPT codes 97156 or 97157.

Telemedicine for parent training is allowed after the initial six months of treatment. 

Behavior Intervention Plans (BIP) for target behavior excesses

  • When the initial assessment or reassessment identifies interfering or dangerous behaviors related to ASD, TPs must include a BIP and a corresponding goal
  • BIPs must include an operational definition of the target behavior excesses, prevention and intervention strategies, schedules of reinforcement, and functional alternative responses
  • While safety protocols and de-escalation procedures are appropriate when necessary, restraints or similar techniques are excluded from the ACD and must be removed from the TP and BIP recommendations

Use of outcome measures

The Vineland-3, Social Responsiveness Scale (SRS-2), and the Pervasive Developmental Disorder Behavior Inventory (PDDBI) outcome measure scores, as well as TP goal progress are used to analyze beneficiary progress, monitor areas of stagnation and/or regression, and make TP decisions.

  • ABA providers should identify and document a direct relationship between score changes and TP changes to address no improvement or a regression
  • Scores improving into ranges considered significantly low or within age norms or average and above percentiles should be factored into treatment goal recommendations and discharge planning

The Parenting Stress Index (PSI-4) and Stress Index for Parents of Adolescents (SIPA) scores offer useful information for providers and care managers to determine needs for additional support training. 

While another provider may complete the Vineland-3, SRS-2, and the PSI-4/SIPA, treating ABA providers should fully review all scores.

Recommendations and units

Recommended units of service should be based on a combination of the symptom domains and level of support required, outcome measure scores, availability of the beneficiary, and the capability of the beneficiary to participate actively in ABA services.

Requested services must be submitted as units (other formats will not be accepted).

The TP must specify units for monthly parent/caregiver training hours

  • If parent/caregiver participation is not possible, specify the reason and mitigation efforts 
  • A minimum of six parent training sessions must be conducted over the six-month treatment authorization
  • TP updates must document the number of parent training units rendered of the current treatment authorization period and the projected planned dates for parent training in the last 60 days of the authorized period to demonstrate the sessions will be met as planned

The TP must identify the locations of service for each requested CPT code

Services rendered in a school setting will only be authorized to ABA supervisors 

  • Include details of timelines, specific treatment goals, and any explanations as appropriate
  • TP goals must directly coincide with active delivery of ABA services under CPT code 97153, targeted to the core symptoms of ASD
  • Academic/Educational goals are excluded in all settings, including the school setting
  • Include the current Individualized Education Program (IEP) or equivalent (provider services cannot duplicate services provided through the IEP) 
  • Pre-school is considered a school location
  • Daycare is not considered a school location and is permitted as a location of service

Community settings such as sporting events, camps and medical appointments are excluded from treatment

  • Certain community settings may be allowed but require prior approval through the clinical necessity review process 
  • Community settings must directly coincide to a specific generalization or behavior treatment related to the DSM-5 descriptions of ASD
  • Community setting must specify and describe the necessity of the location due to substantial levels of impairment in the core symptoms of ASD and/or severe behavior excesses, which may cause harm to the beneficiary

The TP must indicate a sole or tiered delivery model