Initial referral submitted with proof of definitive diagnosis
Initial referrals are provided by the Primary Care Manager (PCM) or ASD-diagnosing provider. Referrals must specify ABA services and include proof of a definitive diagnosis using the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5 (or current edition)), including initial date of diagnosis, through either a referral reflecting a diagnosis of ASD or a diagnostic evaluation. DSM criteria must be documented in a DHA-approved checklist.
The referral for ABA form and supporting documentation may be faxed when needed to (877) 378-2316. Please be aware that failure to provide necessary clinical information may result in delays, terminations of authorized care and denials for pended claims. Upon receipt of the referral, Humana Military authorizes an initial ABA assessment, treatment plan development and PDDBI outcome measure, given there is a TRICARE-authorized ABA supervisor with an opening to accept the beneficiary.
For beneficiaries enrolled to the ACD prior to Oct. 1, 2021, TRICARE-authorized ASD-referring and diagnosing providers have the option of submitting a definitive diagnosis referring provider attestation which fulfills both the DSM-5 diagnostic checklist and validated assessment tool eligibility requirements for the two-year PCM requirements.
Conduct initial assessment and submit new referral for treatment
During the initial assessment with an authorized ABA supervisor, target symptoms are identified and a Treatment Plan (TP) is developed. After the initial assessment is complete, the Board Certified Behavior Analyst (BCBA) must submit a new authorization request containing the TP, Parenting Stress Index (PSI) - 4 (short form) or Stress Index for Parents of Adolescents (SIPA), Vineland-3 (parent and teacher/interview form), Social Responsiveness Scale (SRS) -2 (parent form), and Pervasive Developmental Disorder Behavior Inventory (PDDBI) (parent form). If BCBA cannot complete the PSI/SIPA, Vineland-3, or SRS-2, please contact Humana Military to assist in ensuring completion of these outcome measures. Once submitted, Humana Military will authorize six months of ABA services based on the referral request.
Reassessment and re-authorization required
Treatment plans are reviewed for clinical necessity twice annually to allow reassessment and document progress in improving core deficits. Prior to the expiration of each six month authorization period, the authorized ABA supervisor or Autism Corporate Service Providers (ACSP) must request re-authorization of ABA services for the next six months from Humana Military (as early as 60 days in advance). Providers must submit updated treatment plans, PSI (short form) / SIPA and PDDBI (parent and teacher form) outcome measures for re-authorization.
Providers must submit Vineland-3 (parent, teacher or interview form) and SRS-2 (parent form) for re-authorization. If the BCBA is unable to complete the outcome measures, please contact Humana Military to assist in ensuring their completion.
New referral for ABA services required
The PCM or ASD-diagnosing provider must provide ASD diagnosis with level of support, diagnostic checklist and a validated assessment tool (if one of the approved tools has not already been submitted). These subsequent referrals may be accepted up to six months in advance.
If you have a beneficiary enrolled in a care management program, such as the ACD, you can access their care management profile via provider self-service. Care management profiles contain information and resources regarding the beneficiary’s current enrolled program(s).Log in to access now