Austim Care Demonstration Request for Reauthorization of Applied Behavior Analysis Treatment Process Full Text

Note: Two-Year Referral Verification, Eligibility and Referral Requirements, Clinical Necessity Review Requirements, and Clinical Necessity Review have overlapping and/or concurrent steps.

1. HNFS receives 2-year referral.
   
   
2. HNFS will verify the referral was received within the last 6 months of 2-year referral cycle.
   
   
   • If Yes – HNFS will verify if ABA referral requirements have been met.
      
     • If Yes – Request canceled (ACD referral verified – no PCM action is required). Move on to the second bullet under step 3 in “Eligibility and Referral Requirements.”
       
       
     • If No – HNFS will request additional information from the ABA provider, which must be received within 10 business days.
       
       
       • Received within 10 business days – Go back to step 1 in this section and restart the steps to continue the process.
         
         
       • Not received within 10 business days – HNFS will cancel the request (no valid military hospital/clinic or PCM referral) until additional information received. Once received, go back to step 1 in this section and restart the steps to continue the process.
          
   • If No – HNFS cancels the request as a duplicate referral submission. Once time frame is correct, go back to step 1 in this section and restart the steps to continue the process.

1. ABA provider requests reauthorization of treatment.
   
   
2. HNFS verifies beneficiary eligibility, including ECHO enrollment for ADFMs.
   
   
3. HNFS verifies TRICARE plan type qualification.
   
   
   • (Concurrent step) If Yes – HNFS verifies DSM-5 Diagnostic Checklist for 2-year referral cycle.
     
     
   • (Concurrent step) If Yes – HNFS verifies referral for 2-year referral cycle.
     
     
   • (Concurrent step) If Yes – HNFS verifies enrollment. Note: HNFS will verify a VAT for anyone enrolled in the ACD before Oct. 1, 2021.
     
     
     • If all three concurrent steps have been met, HNFS has verified that eligibility and referral requirements have been met. Move on to step 1 in the “Clinical Necessity Review Requirements” section.
       
       
     • If any of the three concurrent steps have not been met, HNFS will cancel the request for not meeting ACD requirements and send correspondence to the family with a statement to submit required documentation. When HNFS receives the required documentation, return to step 3 in this section and restart the steps to continue the process. 
       
       
     • If only the previous bullet applies (for those linking from "If Yes – Request canceled [ACD referral verified – no PCM action is required]" in the Two-Year Referral Verification section):
       
       
       • If Yes – Move on to step 1 in the “Clinical Necessity Review Requirements” section.
         
         
       • If No – Once HNFS receives referral, go back to step 1 in the “Two-Year Referral Verification” section.
          
   • If No – HNFS cancels the request (data entry error). If HNFS’ receives additional information, return to step 3 in this section and restart the steps to continue the process.

1. (Concurrent steps involved) HNFS does a 60-day verification (last 60 days of authorization and minimum beneficiary identifiers).
   
   
   • (Concurrent step) If Yes – HNFS verifies PDDBI (Parent and Teacher Forms) with applicable scores.
     
     
   • (Concurrent step) If Yes – HNFS verifies CCP (if assigned an ASN).
     
     
   • (Concurrent step) If Yes – HNFS verifies outcome measures: Vineland-3, SRS-2, and PSI-4-SF/SIPA.
     
     
     • If all three concurrent steps have been met, move on to step 1 in the “Clinical Necessity Review” section.
       
       
     • If any of the three concurrent steps have not been met, HNFS will request additional information that must be received in 10 business days.
       
       
       • Received within 10 business days – Proceed to step 1 in the “Clinical Necessity Review” section.
         
         
       • Not received within 10 business days – HNFS will cancel the request for not meeting ACD requirements and send correspondence to the ABA provider and family. The process will end here. 

1. HNFS begins clinical necessity review.
   
   
2. HNFS determines if a clinical consultation or if additional information is required.
   
   
   • If Yes – The clinical consultation must be completed within 10 business days, and/or the additional information must be sent to HNFS within 10 business days. The treatment plan must be resubmitted to HNFS.
     
     
     • If the clinical consultation is not completed within 10 business days, HNFS will cancel the request and send correspondence to the ABA provider and beneficiary, and the process will end here.
        
     • If the additional information is not received within 10 business days, HNFS will cancel the request and send correspondence to the ABA provider and beneficiary, and the process will end here.
         
     • If the resubmitted treatment plan is not received within 10 business days, HNFS will cancel the request and send correspondence to the ABA provider and beneficiary, and the process will end here. 
        
   • If No – HNFS will complete a benefit review (certified in total, modified, or denied), and the process will end here.