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Autism Care Demonstration Program Update for USFHP

Tricare has updated the Autism Care Demonstration (ACD) program effective January 29, 2018, TRICARE Operations Manual 6010.56-M, February 1, 2008 Chapter 18, Section 18 Department of Defense (DoD) Comprehensive Autism Care Demonstration.

We’d like to emphasize two areas that cover referrals and mandatory outcome measures.  JHHC requires that these outcome measures accompany the initial and concurrent requests for authorization. Please be aware that failure to submit these required documents may result in delayed authorizations or possible denial of services. If you need assistance locating providers who can assist with these outcome measures if you cannot complete them, please call JHHC USFHP at 410-424-4830 or 800-261-2429.

Referrals

A referral for Applied Behavior Analysis (ABA) services under the ACD is required. A physician-primary care manager (P-PCM) or a specialized Autism Spectrum Disorder (ASD) diagnosing provider may submit the referral for ABA services. The beneficiary must be diagnosed with ASD using DSM-5 criteria by an approved provider. The referral for ABA services must contain documentation of the age of the child and year of the initial ASD diagnosis, documentation of any comorbid psychiatric and medical disorders, and level of symptom severity (level of support required per DSM-5 criteria under ASD). The level of symptom severity must be submitted by the specialized ASD diagnosing provider. The diagnosing/referring provider must provide a copy of the referral for ABA services to the beneficiary’s parent(s)/caregiver(s). If the initial diagnosis is made by a P-PCM, the P-PCM must submit a referral for a specialized ASD diagnosing provider who must confirm the diagnosis of ASD within one year.

The specialized ASD diagnosing provider must complete the outcome measures as described below. If the specialized ASD diagnosing provider cannot complete the outcome measures requirement within one year of the initial diagnosis, then the specialized ASD diagnosing provider can contact JHHC for assistance locating a provider who can complete the outcome measures (see contact information above).

Outcome Measures

For all beneficiaries participating in the ACD, outcome evaluations must be completed and reported, using norm-referenced, valid, and reliable evaluation tools (see DoD form 1423). Outcome measures may be completed via telehealth (see the TPM, Chapter 7, Section 22.1 for requirements).

Pervasive Development Disorder Behavior Inventory (PDDBI)

This outcome measure must be completed at baseline and every six months. Only the Parent form is required at baseline. The Parent form and the Teacher form must be submitted every six months thereafter to align with the treatment plan submission and reauthorization. The teacher form may be completed by the teacher or the board-certified behavior analyst (BCBA/BCBA-D). Responsibility for the completion of the Teacher form by the BCBA/BCBA-D cannot be delegated except to a teacher who meets the requirements specified in the PDDBI manual. The Domain/Composite Score Summary Table must be submitted to JHHC with the initial request and at every six month renewal. Only authorized ABA supervisors are eligible to submit the PDDBI.

Vineland-3

This outcome measure must be completed at baseline (within one year of the initial diagnosis) and every two years thereafter to align with the Periodic ABA Program Review. The Parent form, the Interview form, or the Teacher form will be accepted. The Score Summary Profile, to include the Maladaptive Behavior Results Submission, must be submitted to JHHC. The Vineland must be completed and submitted by the specialized ASD diagnosing provider. If the specialized ASD diagnosing provider cannot complete the requirement, the following providers may be authorized to do so:

  • A TRICARE authorized independent provider (TRICARE authorized independent providers must use the assessment code for their discipline for reimbursement)
  • A BCBA/BCBA-D
  • Parents/caregivers may provide the TRICARE authorized independent provider or the authorized ABA supervisor a school-completed Interview or Teacher form for submission to JHHC to meet this requirement.

Note: The Vineland-2 can be accepted in lieu of the Vineland-3 until December 31, 2017.

SRS-2

This outcome measure must be completed at baseline (within one year of the initial diagnosis) and every two years thereafter to align with the Periodic ABA Program Review. The Parent form is required. The Total Score Results and Treatment Subscale Results must be submitted to JHHC. The SRS-2 must be completed and submitted by the specialized ASD diagnosing provider. If the specialized ASD diagnosing provider cannot complete the requirement the following providers may be to do so:

  • A TRICARE authorized independent provider (TRICARE authorized independent providers must use the assessment code for their discipline for reimbursement)
  • A BCBA/BCBA-D

If you have questions or need additional assistance please call the Behavioral Health Utilization Management team at 410 424-4830.