autism benefit comparison chart

7/30/2019 Autism Benefit Comparison Chart

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TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.TriWest Healthcare Alliance provides access to quality health care for 2.9 million members of America's military family

in the 21-state TRICARE West Region.

HO2372012-02052013

Applied Behavior Analysis (ABA) Therapy Under TRICARE Basic

Program

ECHO Autism Demonstration Project

TRICARE-authorized primary care provider or by a specialized ASDprovider defined as one of the following:

A physician board-certified or board-eligible in behavioraldevelopmental pediatrics, neurodevelopmental

pediatrics, pediatric neurology, or child psychiatry

A Ph.D. clinical psychologist working primarily with children

behavior plan and progress report.

Services will be authorized only for those beneficiaries diagnosed

by a TRICARE-authorized primary care provider or by aspecialized ASD provider defined as one of the following:

A physician board-certified or board-eligible in behavioraldevelopmental pediatrics, neurodevelopmental

pediatrics, pediatric neurology, or child psychiatry

A Ph.D. clinical psychologist working primarily with children

Provider Requirements

For services provided in conjunction with ABA under the TRICAREBasic benefit, the following are TRICARE-authorized provider

requirements when referred by and working under the supervision

of those identified in theTRICARE Policy Manual, Chapter 7,Section 3.18:

Have a current state license to provide ABA services; orAre currently state-certified as an Applied Behavioral

Analyst; or

Where such state license or certification is not available,are certified by the Behavioral Analyst Certification Board

(BACB) (www.bacb.com)as a Board Certified Behavior

Analyst (BCBA); andOtherwise meet all applicable requirements of TRICARE-

authorized providers.

Note: Individuals certified by the BACB as a Board Certified

Assistant Behavior Analyst (BCaBA) are not TRICARE-authorizedABA providers under the TRICARE Basic Program.

Provider Requirements

TRICARE currently authorizes only board-certified ABA therapistsfor ASD-related services. The Autism Demonstration allows tutors

supervised by an ABA therapist to deliver Educational

Interventions for Autism Spectrum Disorder (EIA) services toeligible beneficiaries.

For services provided in conjunction with ABA under the AutismDemonstration Project, the following are TRICARE-authorized

provider requirements for EIA Supervisors.

Have a current, state-issued license to provide ABA

services; or

Have a current State-issued certificate as a provider ofABA services; Or

Have a current certification from the BACB

(www.bacb.com)as either a BCBA or a BCaBA where

such state-issued license or certification is not available;

andOtherwise meet all applicable requirements as outlined in

theTRICARE Operations Manual, Chapter 20, Section 9,
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Services of Tutors are not covered under the TRICARE Basic

program benefit.

paragraphs 5.2, 5.3 and 5.4.

Authorized supervisors will be required to direct and oversee

tutors who will provide hands-on services to children with autism.Tutors must be qualified and specially trained to work with

children with special needs as outlined in the TRICARE Operations

Manual, Chapter 20, Section 9, paragraph 5.3.

Qualified tutors who are not otherwise available under the ECHO

program will be available to deliver EIA services to eligible

beneficiaries under the demonstration project while under a

supervisory agreement with an ABA therapist.

Benefit Maximum

No fiscal year caps apply to ABA services under TRICARE Basic.

All applicable deductibles, copayments and cost-shares apply.

Benefit MaximumThere is a $36,000 fiscal year (Oct-Sep) ECHO benefit cap that

applies to all ECHO benefits, except ECHO Home HealthCare(EHHC).

The benefit cap applies for each ECHO beneficiary in a family.

Claims and Reimbursement

Claims for ABA services will be submitted electronically by aTRICARE-authorized provider on a Centers for Medicare and

Medicaid Services (CMS)-1500 form.

90887 - Conducting progress meetings, Interpretation orexplanation of results of psychiatric, other medical

examinations and procedures, or other accumulated

data to family or other responsible person, or advisingthem how to assist patient will be reimbursed at the lesser

of providers billed charges orCHAMPUS MaximumAllowable Charge (CMAC).

99080 - Development of an updated treatment plan will

be reimbursed at the lesser of providers billed charges or

Claims and Reimbursement

Claims for ABA services will be submitted electronically by aTRICARE-authorized provider on a Centers for Medicare and

Medicaid Services (CMS)-1500 form.

ECHO claims are reimbursed for the amount authorized to thefiscal year benefit limit:

90887 - Conducting the required quarterly progressmeetings with the TRICARE beneficiarys caregivers will be

reimbursed at the lesser of providers billed charge orCMAC.

99080 - Development of the required EIA progress report

(EPR) and updated behavior plan. This will be completed


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CMAC.S5108 is used for the following services with reimbursement

at the lesser of providers billed charges or $31.25 per 15

minute unit:o Functional Behavioral Assessment and Analysis and

initial treatment plano One-on-one ABA interventions with an eligible

beneficiary, training of immediate family members to

provide services in accordance with the treatment

plan; and monitoring of the beneficiarys progress

toward treatment goal

NOTE: CPT Code 99199 and HCPCS Code

H2019 are not allowed for ABA Therapy under the TRICARE BasicProgram benefit.

and billed in the 5th month of the 6-month authorizationperiod. The reimbursement rate will be at the lesser of

providers billed charge orCMAC.

H2019 - EIA services provided directly by an EIA Tutor willbe reimbursed at the lesser of providers billed charge or

$12.50 per 15-minute unit.

S5108 is used for the following services with reimbursementat the lesser of providers billed charges or $31.25 per 15

minute unit:

o Functional Behavioral Assessment and Analysis andinitial treatment plan

o Supervision of tutors implementing ABA interventionswith an eligible beneficiary, training of immediatefamily members in accordance with the treatment

plan; and monitoring of the benef iciarys progresstoward treatment goal

Case Management

For complex cases, a case manager may be assigned uponrequest.

Case Management

A team of ECHO nurses is available as a point of contact for allECHO beneficiaries, sponsors and providers. ECHO nurses are

responsible for all ECHO care authorization requests.

Documentation Requirements Provider Certification

The application process for direct Applied Behavior Analysis

(ABA) therapy begins with the completion of the AppliedBehavioral Analyst Certification application, which can be

downloaded from TriWest.com/Provider>Find a

Form>Certification>Applied Behavioral Analyst Certification Form.

If you are certified as a BCBA, please submit a copy of your BCBAcertification, a copy of state licensure in ABA Therapy, if

applicable and a copy of your resume with your application.

Include a copy of the Declaration of Professional Liability

Documentation Requirements Provider Certification

The application process for the Autism Demonstration Project

begins with the completion of the Autism Services Demonstrationcertification application for each BCBA or BCaBA. You can

download this application from TriWest.com/Provider>Find a

Form>Certification>Autism Services Demonstration Certification.

Include each supervisors BCBA or BCaBA certification

application and resume.

Include a copy of the Declaration of Professional Liability

Insurance page under the autism groups name with a minimum
http://www.triwest.com/en/provider/resource-library/forms/AutismProviderCertApp.pdfhttp://www.triwest.com/en/provider/resource-library/forms/AutismProviderCertApp.pdfhttp://www.triwest.com/en/provider/resource-library/forms/AutismProviderCertApp.pdf


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Insurance page under the autism groups name with a minimum

coverage of $1 million/$3 million and IRS form W-9.

All BCBAs interested in providing services under the TRICARE basicprogram must be certified by TriWest. Application and further

information can be found on TriWest.com.

NOTE: Providers for the TRICARE Basic Program benefit will only be

certified on an as-needed basis for geographically-based

shortages or continuity of care.

coverage of $1 million/$3 million and IRS form W-9.

A resume must also be attached for each Tutor, and the Tutors

names should be listed on page five of the application.

If any of these items are missing or expired, the certification

process will be delayed.

NOTE: Providers for the ECHO Autism Demonstration Project

benefit will only be certified on an as-needed basis for

geographically-based shortages or continuity of care.

autism benefit comparison chart

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