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 DSM-5 symptom domains
    • Goals must address core symptoms of ASD only
      • Social communication and social interaction behavior
      • Restrictive, repetitive, and/or stereotypical patterns of behavior
  • 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
  • Must be measurable, objective, achievable, developmentally appropriate, and clinically significant
  • Describe objective, baseline and ongoing measurement levels for each target behavior/symptom in terms of frequency, intensity and duration
  • Include a description of interventions/techniques specific to each of the targeted behaviors/symptoms
  • Identify the objective measure of assessment for each goal specified
  • Specific to the child, objectively measurable within a specified timeframe, attainable in relation to the child’s prognosis and developmental status, relevant to child and family, and directly related to the core symptoms of ASD as defined by the DSM

Parent/Caregiver goals

  • Establish measurable objectives relevant to practicing skills with the beneficiary, either at home or in a clinic/office environment. (school settings are an exclusion for parent training)
  • Specifically aim to enhance the skills and capabilities of parent/caregivers and focus on the development of parent/caregiver skills, not the beneficiary’s individual progress as 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
    • GrandparentResponsible 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 treatment plan 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 treatment plan should begin with parent guidance sessions (CPT codes 97156 or 97157) especially if other ABA services are delayed.
  • A minimum of one session of parent training within 30 days of the treatment authorization under CPT code 97156 or 97157
  • Telemedicine for parent training is allowed after the initial six months of treatment

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.

Service recommendations

  • Recommendation of units of ABA are based upon a combination of the DSM-5, symptom domains and levels of support required by DSM-5 ASD criteria, outcome measure results 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)
  • Specific units for weekly 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 considered a community setting 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