The requirements for referrals and necessary documentation
for prior authorization may vary across insurance companies. BTEC strongly
recommends that families check with their individual carrier regarding coverage
of ABA therapy.
beneficiaries are required to have a diagnosis of Autism Spectrum Disorder
(ASD). ASD diagnosing and referring providers include: TRICARE-authorized
Physician-Primary Care Manager
(P-PCM) or by a specialized ASD diagnosing provider. TRICARE authorized P-PCMs
for the purposes
of the diagnosis and referral include: TRICARE authorized family practice,
and pediatric physicians. Authorized specialty ASD diagnosing providers
physicians board-certified or board-eligible in developmental-behavioral
neurodevelopmental pediatrics, child neurology, adult or child psychiatry,
clinical psychologists, or board certified doctors of nursing practice (DNP). *Diagnoses and referrals from Nurse
Practitioners (NPs), Physician Assistants (PAs), or other providers not having
the above qualifications are not accepted by TRICARE.
for ABA services under the ACD is required prior to beginning services. A P-PCM
or specialized ASD diagnosing provider should submit the referral for ABA
866-323-7155 TRICARE EAST ABA Dept.
for ABA services must contain documentation of the age of the child and year of
the initial ASD diagnosis, documentation of any co-morbid psychiatric and
medical disorders, and level of symptom severity (level of support required per
DSM-5 criteria under ASD).If the
initial diagnosis is made by a P-PCM, the P-PCM should also submit a referral
for a specialized ASD diagnosing provider who must confirm the diagnosis of ASD
within one year.
OTHER FL INSURANCE AND FL MEDICAID PLANS:
requirements may vary by company, the following general guidelines apply:
* Documentation confirming a diagnosis of ASD
signed by an MD.
* Documentation of any other mental health or
signed by an MD (most insurers will not accept referrals signed by ARNPs or PAs),
recommending ABA therapy for the treatment of Autism (F84.0) is generally
accepted by most insurers. The following referral forms may also be downloaded and
contain the required documentation:
ALL DOCUMENTATION TO BTEC’s REFERRAL LINE AT 850-435-7704