Clinical necessity reviews

Clinical review process

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.

Step 1 – Administrative document review

The following information is required prior to initiating the clinical necessity review process:

• Beneficiary TRICARE/ACD eligibility
• A valid two-year referral for Applied Behavior Analysis (ABA) services
• A complete TP
• Outcome measure scores to include signatures from both parent/caregiver and ABA supervisor
  • Pervasive Development Disorder Behavior Inventory (PDDBI)
    • Parent/Caregiver
    • ABA Supervisor
    • Vineland-3
    • Social Responsiveness Scale, Second Edition (SRS-2)
    • Parenting Stress Index, Fourth Edition, Short Form (PSI-4-SF) or Stress Index for Parents of Adolescents Profile Form (SIPA)

Step 2 – Clinical necessity review

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:

• Level of clinical support
• TP
• Effectiveness of treatment implementation
• Intensity, frequency, duration of treatment (dose response)
• Duration of services and individualized discharge planning
• Additional services being rendered

The clinical reviewer will evaluate all documentation received including, but not limited to:

• Baseline data, progress summaries and ongoing data collection
• Recommended goals
• Parent training goals
• Behavior Intervention Plans (BIP)
• Outcome measure scores
• Exclusions
• Required TP information
• Discharge plans
• CPT code recommendations
• Community location recommendations
• Individualized Education Program (IEP) recommendations

Step 3 – Clinical consultation and/or additional documentation

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.