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Referral and authorization process for Applied Behavior Analysis (ABA)

 

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Prior to initial assessment

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. 

For beneficiaries enrolled to the ACD prior to Oct. 1, 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 referral requirements.

Referral and authorization requests should be submitted online via provider self-service for faster processing. 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.

Prior to first request for treatment for ABA

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 is developed. After the initial assessment is complete, the BCBA must submit a new referral request for treatment and attach their initial assessment, treatment plan, PSI/SIPA, Vineland-3 (parent, teacher or interview form), SRS-2 (parent form), and PDDBI (parent form) to the new authorization request. Once submitted, Humana Military will authorize six months of ABA services based on the referral request.

Every six months

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 ACSP must request re-authorization of ABA services for the next six months from Humana Military (up to 60 days in advance). Providers must submit reassessments, updated treatment plans, PSI/SIPA and PDDBI outcome measures for re-authorization.

Annually

Re-authorization required

Providers must submit Vineland-3 (parent, teacher or interview form) and SRS-2 (parent form) for re-authorization.

Every two years

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). The ASD-diagnosing provider must provide the Vineland-3 (parent, teacher or interview form) and SRS-2 (parent form).