Humana Military is required to perform clinical necessity reviews, as well as clinical consultations as necessary on all treatment authorizations. Clinical necessity reviews are conducted by a BCBA/BCBA-D. The review process examines a complete TP, baseline measures, recommended goals, target areas, parent training goals, outcome measures and any recommendations.
The following information is required prior to initiating the clinical necessity review process:
Clinical necessity reviews ensure the TP corresponds with the most appropriate level of care for the beneficiary. The clinical reviewer (BCBA/BCBA-D) considers the following areas for clinical necessity:
The clinical reviewer will evaluate all documentation received including, but not limited to:
In the event that clinical consultation is required, Humana Military will complete a live phone review with the treating ABA supervisor to resolve areas regarding clinical necessity, exclusions or other areas that require consultation.
TPs that contain exclusions or missing information must be modified and resubmitted.