Autism Care Demonstration Provider Frequently Asked Questions

Transcription

1 Autism Care Demonstration Provider Frequently Asked Questions Why are there differences between what is published on the tricare.mil website and what UnitedHealthcare Military & Veterans (UnitedHealthcare) has communicated? The Defense Health Agency (DHA) is actively listening to the input they are receiving from providers, beneficiaries and other stakeholders in genuine effort to make these services work for all. DHA will often publish information on tricare.mil to inform stakeholders of upcoming program changes. However, under the rules of government contracting, UnitedHealthcare Military & Veterans (UnitedHealthcare) as a managed care support contractor must wait until proposed changes are reflected and changed in formal TRICARE policy and then communicated to us through our contracting officer. UnitedHealthcare can then respond, implement and publish these changes once that process has been completed. Therefore, we ask that you revisit this page frequently for any updates that may have been formulated in TRICARE Policy. What is the Comprehensive Autism Care Demonstration (ACD)? This new program combines all TRICARE-covered Applied Behavior Analysis (ABA) services under one demonstration and provides TRICARE reimbursement for ABA and related services to TRICARE-eligible beneficiaries diagnosed with Autism Spectrum Disorder (ASD). This demonstration incorporates ABA services provided under the TRICARE Basic program (i.e., the medical benefits authorized under 32 CFR 199.4, for both Active Duty Family Members/Non-Active Duty Family Members including retiree dependents), terminating December 31, 2014; the Enhanced Access to Autism Services Demonstration, (i.e., the supplemental ABA benefits authorized for certain Active Duty Family Members (ADFMs) under 32 CFR 199.5), terminating December 31, 2014; and the ABA Pilot (i.e., the supplemental ABA benefits authorized for certain Non-Active Duty Family Members (NADFMs) including retiree dependents), terminating December 31, Why was a new autism demonstration created? TRICARE is seeking to simplify the autism benefit for the beneficiary and the providers and have combined three programs into one comprehensive program. The features of this program are: One benefit Everyone gets the same ABA coverage Expanded time period for testing You have a year to get the ADOS-2, if needed No caps No $36,000 annual cap, no lifetime cap, and no maximum age Simplified diagnostic criteria Specialized Autism Spectrum Disorder Diagnosing Providers can waive the initial ADOS-2 testing requirement that had been implemented with the ABA Pilot in July Expanded testing options Board Certified Behavior Analysts choose the testing tool or other metric to measure progress. Which providers can diagnose a beneficiary with an ASD? TRICARE Operations Manual (TOM), Chapter 18, section 18, paragraph 5.0 states that the physician-pcm (primary care manager) can render a provisional diagnosis and submit a referral for ABA evaluation and a referral to an ASD specialty Frequently Asked Questions Autism Care 1

2 provider who will confirm the diagnosis within one year of the start of ABA service. Specialized Autism Spectrum Disorder Diagnosing Providers are board certified or board eligible in Behavioral Developmental Pediatrics, Neurodevelopmental Pediatrics, Pediatric Neurology, Adult or Child Psychiatry or Licensed Clinical Psychology (doctoral level). What is the effective date? All new beneficiaries meeting criteria will be enrolled in ACD as of October 20, Beneficiaries currently in one of the legacy programs will transfer to ACD when their current authorization expires, but not later than December 31, Who is eligible? Any TRICARE beneficiary over the age of 18 months with a qualifying diagnosis of Autism Spectrum Disorder , under the Diagnostic Statistical Manual version 5 (DSM-5) that is provided by a Specialized Autism Spectrum Disorder Diagnosing Provider. How will the new demonstration impact patients currently receiving ABA services under the TRICARE Basic Program, the Enhanced Access to Autism Services Demonstration or the ABA Pilot? Beneficiaries currently receiving ABA services will continue with their current provider(s) in most situations. DHA and UnitedHealthcare are committed to avoiding disruption in service. Therefore, we are not asking that the provider submit a new Treatment Plan (TP). Instead, UnitedHealthcare will compare the current TP to the new codes. When current authorizations expire and no later than December 31, 2014, a new authorization will be generated for ACD to assure no reduction in hours. Is prior authorization required for the Autism Care Demonstration (ACD)? Yes, authorizations are required for ABA service requests see TOM, Chapter 18, section 18, paragraph The elements required in the request are located in para and Claims may not be submitted and services may not be delivered without an authorization for care. Is there a specific referral form providers should use to request ABA services under ACD? Providers should utilize the Referral/Authorization Request Form found on the United Healthcare portal ( using the following path: Providers >Find a Form>Medical-Surgical Referrals & Authorizations>Referral>Authorization Request Form. Will I need to submit a new TP and request for authorization? If the beneficiary has never been seen for ABA services under TRICARE, the P-PCM will initiate a referral for services. The BCBA will receive an authorization to: complete a Functional Behavioral Assessment develop a Treatment Plan (TP) submit an authorization request based on the needs of the child and level of participation of the family Frequently Asked Questions Autism Care 2

3 If the beneficiary has been receiving ABA services under the ABA Basic, or the Enhanced Access to Autism for ADSM or the ABA Pilot for NADSM, then no new TP or authorization request is required. UnitedHealthcare will take your most current treatment plan, attempt to cross walk it to the new codes for ACD and issue a new authorization for the ACD program to become effective when your current authorization expires. Beneficiaries will not receive less service than has been provided previously. The new authorization will cover twelve months of service. If you believe that additional codes are indicated that UnitedHealthcare has not captured, then UnitedHealthcare welcomes a new TP and authorization request from you to capture the beneficiary needs. Providers are expected to utilize the criteria in TOM, Chapter 18. The underlying principle supported by the Behavior Analyst Certification Board (BACB) and by TRICARE is that each request needs to be individualized to each beneficiary s functioning and individual needs and to your level of participation. A single template requesting the same services for all beneficiaries is not consistent with this individualized care and cannot be accepted. If the provider accepts the new authorization as cross-walked by UnitedHealthcare based on the prior TP, then the provider will submit a new assessment, TP and authorization request in six months that is consistent with the requirements in TOM, Chapter 18. What is the psychometric testing requirement? For new eligible beneficiaries enrolled in the Comprehensive Autism Care Demonstration program, according to TOM, Chapter 18, section 18, paragraph 5.1 ABA services may be initiated once a provisional diagnosis is provided by the P- PCM. There is a period of up to one year in which either the Autism Diagnostic Observation Scale (ADOS-2) must be administered by a qualified provider including a BCBA, BCBA-D, or a diagnostic evaluation must occur by a Specialized ASD Diagnosing Provider. Either of these actions will provide a confirming diagnosis of Autism Spectrum Disorder. This requirement does not apply to beneficiaries currently enrolled in the Pilot or the Enhanced Access to Autism Demonstration program or using ABA Basic who will transition to the new ACD. Existing beneficiaries will be deemed to have met all diagnosis, referral and assessment requirements. If a beneficiary has already completed the Vineland II and the ADOS 2, can those results be incorporated into the current ABA assessment? For initial evaluations: Yes, Vineland II and ADOS 2 or a diagnostic evaluation satisfies the diagnostic requirement if provided in the past 12 months. Is there an age limit for this benefit? At this time, TOM, Chapter 18, section 18, paragraph beneficiary must be at least 18 months of age; the duration of the program will be related to beneficiary response to the treatment plan (TP), progress towards TP goals and discharge criteria stated in TOM, Chapter 18, section 18, 8.3. TRICARE has defined no upper limit to age limit at this time. Frequently Asked Questions Autism Care 3

4 Can beneficiaries select any provider for Certified ABA provider for services? Yes, at a minimum, providers must be TRICARE certified. Different cost share/responsibilities will be applied depending on the network status of the provider. Access may be impacted if the selected provider has capacity to accept the beneficiary to provide the needed services. If that occurs, go to our website to search for a BCBA and follow the links for behavioral health providers found on LAWW or call for help finding other providers. Please refer to tricare.mil for any information on cost shares and co-pays as they apply to each individual situation. These are found on the comparison grid prepared by TRICARE on that page. If I have questions regarding benefits, authorization, billing or beneficiary eligibility, who do I call? Customer Service call center is available Monday-Friday, 7:00am to 7:00 pm local time. For pending and closed authorization status, eligibility status and claims status inquiries, providers can use the services available on 24 hours/day-7 days/week. In network providers have access to the automated self-service feature for claims and eligibility status 24 hours/day-7 days/week by calling and following the prompts. January 1, 2015, customer services will direct all provider calls related to claims and eligibility status to Education and training related to this process can be obtained through the provider advocate assigned to your state. When do we start using the new codes? Once you have received an authorization for ACD services. Do existing beneficiaries receiving services today need to return to their doctor and have a new diagnosis before they can receive services in the new program? No, they do not need to return to their PCM for a new diagnosis. TOM, Chapter 18, section 18, paragraph 7.2 identifies that beneficiaries currently receiving care in the ABA Basic, Enhanced Access to Autism Demonstration and the ABA pilot will be deemed to have met all diagnosis, referral and assessment requirements of this section With this program, there will be no annual $36,000 benefit cap as there had been for the Pilot and the Autism Demo under ECHO for ABA services. What will be the criteria to base a request for additional 1:1 services? The functional behavioral assessment and the child and parents progress towards treatment goals will serve to determine the clinical appropriateness and reasonableness of the services requested. Refer to TOM, Chapter 18 section 18, paragraph 8.2.5, 8.2.6, , and 8,3. Does that also mean we can request more BCBA supervision hours if we are requesting more 1:1 services? Yes. Supervision is only under the Tiered Model. If more 1:1 services are requested and approved, additional supervision of the Behavior Technician and BCaBA is required. Please refer to TOM, Chapter 18, section 18, paragraph BCaBA & TOM, Chapter 18, section 18, paragraph which stipulates the minimum supervisory requirements based on the requested hours of services supported by the behavioral treatment plan, anticipated goals and patient response. Frequently Asked Questions Autism Care 4

5 Depending on the Assessment and Treatment Plan request, authorization for services may be valid for up to 1 year. Should I send authorization requests now for all of my learners for a period of 1 year? Or do we need to get another referral from the child's primary care physician first? For Existing beneficiaries All beneficiaries presently enrolled to the Pilot or the Enhanced Access to Autism Demo must be transitioned to the Comprehensive Autism Care Demonstration by December 31, Any existing authorizations under these 2 programs will expire on or before December 31, 2014 and must be reauthorized under the ACD on or before December 31, For these beneficiaries currently in care with an authorization, no new referral is required from the P-PCM and no new authorization request is required. UnitedHealthcare will generate a new authorization for ACD based on the most recent TP. This authorization will cover services for 1 year. If the provider believes additional services are needed beyond what is on the authorization generated by UnitedHealthcare, then a new TP and request for authorization may be submitted. In all cases where an authorization extends longer than 6 months, a new functional behavioral assessment and treatment plan is required after 6 months of the Initial Assessment and Treatment Plan in order to continue billing for care. The Functional Behavioral Assessment (FBA) must be performed after 6 months and one day and the FBA and TP must be sent to UnitedHealthcare within 30 days after 6 months and one day for review. FBA and TP not sent within this 30 day period will result in the status of the authorization to be changed to denial and claims rejection for services rendered after 6 months, one day. New Beneficiaries If the diagnosis is rendered by a P-PCM, a P-PCM referral to an ASD Specialty provider for diagnostic evaluation &/or ADOS-2 is required to confirm diagnosis within one year of the onset of treatment. Must have a referral from P-PCM or ASD specialty provider for ABA evaluation and TP development. ABA provider submits a request for Initial Assessment and Initial TP. Once the TP is developed, please submit a Functional Behavioral Assessment (FBA), and the TP with all the elements stated in TOM, Chapter 18, Section 18 paragraph 8.2. Include the ADOS-2 if that has been completed. You should not routinely ask for authorization for 1 year. The length of request should be consistent with your assessment, treatment plan and family engagement. Frequently Asked Questions Autism Care 5

6 In all cases where an authorization extends longer than 6 months, a new functional behavioral assessment and treatment plan is required after 6 months of the Initial Assessment and Treatment Plan in order to continue billing for care. The FBA must be performed after 6 months and one day and the FBA and TP must be sent to UnitedHealthcare within 30 days after 6 months one day for review. FBA and TP not sent within this 30 day period will result in the status of the authorization to be changed to denial and claims rejection for services rendered after 6 months and one day. What qualifies as a comprehensive review? Under TOM, Chapter 18, section 18, paragraph the UnitedHealthcare Case Manager and the Behavioral Health Medical Director team will conduct a comprehensive review of the treatment plan, patient response to the TP as evidenced by progression towards the treatment goals, parent engagement and progression towards training goals and applying ABA goal attainment criteria stated in TOM, Chapter 18, section 18, paragraph 8.3. As a group practice, can we load all of our BCBA s under all of our kids? According to TOM, Chapter18, Sec 18, paragraph 5.2, it specifies that only one BCBA is authorized at a time for ABA services for each beneficiary. This is also in line with the BACB guidance regarding coordination of care. Another BCBA may cover for the primary BCBA during times of absence; however, the primary BCBA is responsible for the overall plan. Are there out-of-pocket costs for the beneficiary? Yes. Please review tricare.mil to see what out-of-pocket costs apply depending on the services rendered and the status of the beneficiary. Are there benefit duration limits? There are no duration limits for ABA services specified in TRICARE policy. Care may be authorized for up to one year at a time depending on the functional status and needs of the beneficiary at the time of the request which will serve to determine continuation or a change in services. What types of providers are covered under the ACD? Board Certified Behavior Analysts (BCBA), Board Certified Behavior Analysts Doctorate (BCBA-D), Board Certified Assistant Behavior Analysts (BCaBA) and Behavior Technicians (RBT/BT). What is the role of the BCaBA under the new ACD program? The role of the BCaBA will continue to be an important function in this program. BCBAs/BCBA-Ds are the only authorized ABA providers who may bill TRICARE using the American Medical Association s (AMA) new Current Procedural Terminology (CPT) Category III codes for Applied Behavior Analysis (ABA) services (published and Frequently Asked Questions Autism Care 6

7 effective July 1, 2014). Under the direction/supervision of a BCBA/BCBA-D who is reviewing and providing personal sign off and approve each assessment and treatment plan, the BCaBA will be able to provide the following: Conduct a Behavioral Assessment (CPT 0359T. This must be reviewed and signed off on by a BCBA/ BCBA-D. (It is billed by and under the BCBA-BCBA-D with the BCBA/BCBA-D as the rendering provider on the claim) Design and oversee the TP intervention of a Behavior Technician (CPT 0359T. This must be reviewed and signed off on by the BCBA/BCBA-D. (It is billed by and under the BCBA/BCBA-D with the BCBA/BCBA- D as the rendering provider on the claim) Assist in providing Family Training (CPT 0370 Billed by and under the BCBA/BCBA-D with the BCBA/BCBA-D as rendering provider on the claim) Assist in supervising the Behavior Technicians (CPT 0360T/0361T) under the direction/supervision of a BCBA/BCBA-D. (Billed by and under the BCBA/BCBA-D with the BCBA/BCBA-D as the rendering provider on the claim) Assist with providing protocol modification (CPT4 0368T/ 0369T. Billed by and under the BCBA/BCBA-D with the BCBA/BCBA-D as the rendering provider on the claim) Provide direct one-on-one ABA (CPT 0364T/0365T, billed by and under the BCBA/BCBA-D with BCaBA as the rendering provider on the claim). What billing codes should be used for ABA services? TRICARE has adopted the American Medical Association s (AMA s) new Current Procedural Terminology (CPT) Category III codes for ABA services, published and effective on July 1, These include: 0359T for the initial ABA assessment and initial ABA treatment plan (TOM 12.1) 0364T and 0365T for the adaptive behavior treatment by protocol (12.2) 0360T and 0361T for the observational behavioral follow-up assessment supervised fieldwork (12.3) 0368T and 0369T for adaptive behavior treatment by protocol modification (12.4) 0370T for family adaptive behavior treatment guidance (12.5) Does the annual audit requirement for BCaBAs and Behavior Technicians (RBT/BT) mirror the other Autism Demonstration's audit? The annual audit will be similar and has been revised to include changes regarding certification and supervision of the BCaBA s and RBT/BT s. Can I participate in the Autism Care Demonstration and not join the TRICARE network? Yes you can. If a provider isn t a TRICARE contracted network provider, they must become a TRICARE Certified Provider before providing services to TRICARE beneficiaries under the Autism Care Demonstration. Frequently Asked Questions Autism Care 7

8 How do I become a network provider for TRICARE? A provider can their interest in joining the TRICARE autism provider network to TRICARE_autism@optum.com. One of the TRICARE Network Managers will then contact the provider to begin the contracting process. How do I become a provider under the Autism Care Demonstration? If you are currently a contracted TRICARE autism provider, your existing participation agreement covers all TRICARE autism programs and you will receive a revised Payment Appendix. What will happen if I bill the wrong code (bill for codes for the new program when I should have billed for the Pilot codes)? Will my claim be denied? Yes, claims with the incorrect codes will be rejected. Claims for the new Comprehensive Autism Care Demonstration must use the new codes. Claims for ABA Basic, Pilot or ECHO Demo must use the old codes until the authorization is transitioned to the new Comprehensive Autism Care Demonstration. Current authorizations must be transitioned by December 31, Once transitioned to new authorizations, providers can use the new codes immediately for dates of service after October 20th, Starting with date of service January 1, 2015, all ABA claims should be billed with the new authorized Comprehensive Autism Care Demonstration code. When do we start using the new codes? As soon as the new ACD authorizations are received by you. Do all paraprofessionals now need the new certification? According to the most recent published information, beginning January 1, 2015 all newly hired ABA Behavior Technicians (RBT/BT) must have their Registered Behavior Technician (RBT) certification by the Behavior Analyst Certification Board (BACB). Currently employed Behavior Technicians (formerly Tutors ) are encouraged, but are not required, to have the RBT certification. What are the rates of reimbursement? Refer to TRICARE Reimbursement Manual, Chapter 13. Where can I find more information about the new program? Read TRICARE Operations Manual, Chapter 18 and the TRICARE Reimbursement Manual, Chapter 13 and visit UnitedHealthcare and Optum will also be providing webinars to bring information to the provider community and will also publish updates on our Provider and Beneficiary pages of as we obtain them. Frequently Asked Questions Autism Care 8

9 Will families enrolled in ECHO only have to pay their usual co-pay? Will that meet the 10% co-pay that is required now? Yes when using the Tiered Delivery Model for adaptive behavior treatment. According to the most current published information from DHA, active duty family members (ADFM) must register for the Extended Care Health Option (ECHO) to participate in the Autism Care Demo. The intent of this requirement is to assure that there are no delays to accessing supplementary benefits available under ECHO. The monthly ECHO fees will satisfy the cost share for supervised ABA. We see that all of our newly hired BT s will need to complete the Registered Behavior Technician training and we want to know what new documentation and procedures are required for this? We also want to know how long you anticipate the new process of credentialing will be now that we will need to complete the RBT? For current information on the Registered Behavior Technician certification please visit the BACB website For newly BT s hired after January 1, 2015, the RBT certification process is completed prior to requesting to join the United Healthcare Military & Veteran autism provider network. After the completed BT attestation form has been received, please allow at least two weeks for our systems to be updated. You may not assign a new RBT to deliver service and submit claims for those services until after we have received a completed provider application and attestation. Claims received for services provided by an RBT who is not TRICARE certified will not be accepted. I know a co-pay payment is required by clients, but are there any exceptions allowed due to financial hardship? I have forms that I have used in the past for this to document clients who would not be able to otherwise access services due to a financial hardship. Is this something Tricare will accept? No, TRICARE does not allow copayment or cost shares to be waived under any circumstance. How do we bill for Treatment Plan (TP) updates? TP updates are required every six months (six months and one day for billing) and are billed with 0359T. TOM, Chapter 12, Section 1.2. How will we bill when delegating supervision assignments while a BCBA is out of the office? The authorization from UnitedHealthcare is loaded to the group Tax ID so claim payment will not be impacted if a substitute BCBA is submitted on the claim. A new authorization is not required when an alternative BCBA covers for the assigned BCBA who is out of the office. However, the substitution should be an infrequent occurrence since TRICARE policy requires the assignment of a single BCBA to oversee services. 0359T can we bill this code more than once a year? Can we bill for reassessment every 6 months? Yes, this code can be billed every six months. Services must be at least six months and one day apart. Exactly six months or less will be rejected if billed. Frequently Asked Questions Autism Care 9

10 Can we bill BCaBA for RBT/BT hours and also under the BCBA 0370T? No. 0370T is only allowed for payment to a BCBA or BCBA-D. Do we have to do a new contract with these new CPT codes and rates? A new Payment Appendix with the new procedure codes and the reimbursement will be mailed to network autism providers. For progress monitoring, work done in the absence of the beneficiary, etc. what code do we bill this service under? TRICARE does not allow for reimbursement of these types of services in the absence of the beneficiary. There are no codes available for reimbursement. Are there a maximum number of units allowed for the autism procedure codes? The autism procedure codes are listed in the TOM, Chapter 18 Section 18 Paragraphs The maximum allowed units can be found on Tricare.mil under Limits on Number of Services without Override Code. Column C shows the limit which is the daily limit. Requests for units in excess of the daily limit will be administratively denied. It is important to note although this site shows you the maximum units allowed, it does not suggest or assure that the maximum allowed by TRICARE will be authorized for each beneficiary. What is requested and authorized is directly dependent on the individualized TP, the clinical needs of each beneficiary, and the level of participation of the family based on the individualized TP. Submitting a single template authorization request that is the same for 100% of the beneficiaries the provider serves would be an inappropriate use of TRICARE funds. When a BCBA or BCBA-D is supervising a Behavior Technician/BCaBA can both the BCBA (0360T/0361T) and the Behavior Technician/BCaBA bill (0364T/0365T)? No, only the BCBA would be reimbursed for this supervision time (billed with 0360T/0361T); concurrent one on one intervention services (billed with 0364T/0365T) during the same time will not be reimbursed and do not need to be submitted at all. Entering the session time of service on the claim is required and allows for claims to be adjudicated in a timely manner. Codes 0368T and 0369T are the codes billed for team meetings in which the BCBA or BCBA-D has direct one-onone time with the beneficiary demonstrating a new or modified protocol to the Behavior Technician or parent/caregiver. Can the Behavior Technician also bill under 0364T/0365T for the same time the BCBA bills? No, only the BCBA or BCBA-D can bill for the time spent demonstrating a new or modified protocol (billed with 0368T/0369T); concurrent one on one intervention services provided by the Behavior Technician during the same time will not be reimbursed and do not need to be submitted at all. Entering the session time of service on the claim is required and allows for claims to be adjudicated in a timely manner. Frequently Asked Questions Autism Care 10

11 How are codes 0364T and 0365T billed when a beneficiary received interventions from multiple Behavior Technicians in one day? If Behavior Technician A provides one-on-one interventions with the beneficiary in the morning and Behavior Technician B provides one-on-one interventions with the beneficiary in the afternoon, each Behavior Technician will bill 0364T for the initial 30 minute they are with the beneficiary and 0365T for the remaining time they are with the beneficiary. It is very important to enter the session times for each Behavior Technicians on the claim in order for the claim to be processed in a timely manner. How many units will be authorized for parent training? The number of units authorized is based on the individualized TP, the clinical needs of the child and the level of engagement of the family members. Do beneficiaries need to be enrolled in the ECHO program? According to currently published information, the Active Duty Family Members (ADFM) need to be enrolled in the ECHO program in order to expedite access to supplemental services available under ECHO. Please explain how we should request 0368T and 0369T (Adaptive Behavior by Protocol Modification) so it will be authorized. The Behavior Modification code is used when the child is not responding to the TP and the BCBA needs to engage in a session to assess and modify the existing TP. This will need to be supported in their record documentation supporting the need to use this code. UnitedHealthcare recognizes that modifications cannot be anticipated. UnitedHealthcare will authorize 3 units a month which are available if needed in order to reduce the need for you to submit additional requests for services. Provider requests will only be required if more than 3 units a month are required. Can you provide guidance on rounding up and down on the 30-minutes codes? For example how would a 45- minute session be billed? As an ABA practitioner, you should follow guidance of the BACB and recommended professional guidelines. Is the 5% supervision requirement based on 5% per beneficiary or 5% overall interventions provided by the BT? How is the 5% supervision requirement determined in a situation where multiple BTs work with one beneficiary? According to TOM, 6.3.5, the requirement is that supervision occurs for a minimum of 5% of each BT/RBT for the 1:1 services provided. This is based on the time the BT/RBT provides direct service, not on a per beneficiary basis. Again, it is not calculated on the number of hours provided to the beneficiary, but on the number of hours of direct service per BT/RBT. To make it easier for the provider, UnitedHealthcare will administratively enter up to 8 units per month of supervision on each authorization so you do not need to calculate that on the authorization request. However, remember to conduct the supervision based on the hours provided in total be each BT/RBT and then bill UnitedHealthcare for the beneficiary who was seen when supervision occurred. Frequently Asked Questions Autism Care 11

12 TOM 15.4 and 15.5 requires that UnitedHealthcare conduct audits to assure that the supervision requirement is met and the 6 month progress measurement is conducted. Can more than the 5% supervision be requested and approved? Supervision is calculated to a minimum of 5% of the BT/RBT time delivering service. There may be reasons to increase this time based on the complexity and clinical needs of the child and family. You may submit a revised treatment plan and authorization request reflecting the clinical justification if the hours that were administratively authorized are not sufficient. Can ABA services be provided in the school and in the classroom and be reimbursed by TRICARE? Yes, if it is not otherwise provided by the school. TRICARE has allowed for ABA services to be delivered in the natural environment for the purposes of assisting in modifying behavior appropriate to that setting. Behavioral Reinforcement should not be used as a replacement for Personal Care Assistance (PCA) for classroom behavior or as a substitute to other behavioral services that occur and are provided within the school setting. However, if the Functional Behavioral Assessment and Treatment Plan indicate Behavioral Reinforcement is needed to address specific behaviors in the school setting, then this is an appropriate use of TRICARE benefits. The TP should indicate what percentage of services are needed in the school, vs. services in the home or in the office. Parent Education / Training should occur in the home environment where the parent/child interaction naturally occurs. In all cases where a beneficiary has an Individual Education Plan (IEP) through the school, it is also expected that the assessment will consider that plan and the BCBA will coordinate services accordingly. Frequently Asked Questions Autism Care 12