Provider compliance audits
Applied Behavior Analysis (ABA) providers must comply with medical documentation and billing practices listed in the TRICARE Operations Manual (TOM), Chapter 18, Section 4; state and federal regulations; and provider participation agreements, policies and guidelines at all times. Providers who fail to demonstrate compliance are subject to additional education, payment recoupment, penalties, and/or more severe administrative actions as required by law and contract.
Recoupment tip sheet for ABA providersAudit frequency
An annual audit will be conducted for Autism Corporate Service Providers (ACSP) and sole ABA providers. A minimum of 30 records (if available) that include a combination of administrative records, medical documentation and one medical team conference progress note will be reviewed. Providers must submit medical records to Humana Military in response to any review requests on or before the due date specified. Medical records not received by the due date will negatively affect the audit score.
Reviews for new providers
Humana Military monitors all new network and non-network ACSP/Sole ABA providers during their initial 180 days of participation within the TRICARE East Region. After 180 days, we will review records for clinical documentation and claims submission for compliance. Providers must submit medical records to Humana Military in response to any review requests on or before the due date specified. Medical records not received by the due date will negatively affect the audit score. Audit results will be shared with new providers. Provider education will be provided as needed to address inconsistencies with the program requirements.
Administrative reviews
Humana Military conducts administrative reviews to uncover patterns of alleged fraudulent or abusive billing practices, which may include at a minimum, but are not limited to:
- High-dollar, erratic, or inconsistent billing and coding patterns
- Changes in billing frequency
- Concurrent billing (i.e. billing for two services at the same time)
- Misrepresentation of provider (i.e. filing for a non-rendering provider or non-authorized provider)
- Claims patterns of “impossible days”
- Patterns of high-claim error rates
Medical documentation reviews
Humana Military conducts medical documentation reviews to ensure compliance with TRICARE requirements. These reviews evaluate whether:
- Claims are supported with medical documentation
- Progress notes contain all required documentation elements
- Documented services comply with ABS approved CPT codes
- Any exclusions were present during session
Contact Humana Military's dedicated Autism Care Demonstration (ACD) team
8 AM - 7 PM (ET)