In a recent webinar entitled “TRICARE® Extended Care Health Option (ECHO)” participants were able to gather more information about the supplemental services for active duty family members with qualifying mental and physical disabilities provided through TRICARE® ECHO.
Question: I had a couple questions regarding the Applied Behavioral Analysis (ABA) referral process and what type of medical equipment is covered by ECHO and what is not. There seems to be a lack of communication between the child’s Primary Care Manager (PCM) and United Health Care (UHC) when sending in a referral for ABA therapy. Does the ECHO Case Manager have the correct verbiage and time line to share with the families on what the PCM needs to state on the referral prior to sending to UHC to begin the process for ABA services? A lot of my clients have shared with me that if the PCM does not write the referral on a prescription pad and if the correct verbiage is not written on the referral that UHC will kick the referral back. This causes a lot of confusion for the clients and the process to begin the services for their child with Autism takes longer.
Also, is there a list of medical equipment that ECHO does cover when Tri-care does not? Such as hearing aids, wheel chairs etc.
Advice: The ACD policy requires that prior to coverage of ABA, the beneficiary must be diagnosed with ASD using DSM-5 criteria and issued a referral for ABA by a TRICARE-authorized Physician-Primary Care Manager (P-PCM) or by a specialized ASD diagnosing provider whether they work in the purchased care or direct care system. The medical record and the referral must contain documentation of the Autism Spectrum Disorder (ASD) diagnosis and documentation of co-morbid psychiatric and medical disorders. We also require that ASD symptom severity be documented on the referral, but plan to delete this requirement from the referral itself in the next policy update which we expect sometime in FY 2017.
Referrals made for TRICARE Prime beneficiaries from the Direct Care system (the MTF) providers are made electronically in Composite Health Care System (CHCS). These electronic referrals are sent to the regional managed care support contractor for processing. The regional contractor then sends an authorization letter specifying the ABA provider/practice information and the authorization number to each beneficiary. The Active Duty Family Member (ADFM) parent/caregiver is to call the phone number of the ABA practice on the authorization letter to schedule the appointment for ABA. If the provider cannot see the patient within 28 days, then the ADFM parent/caregiver should directly telephone the regional contractor at the phone number specified in the authorization letter for help getting an appointment with another ABA provider able to see the beneficiary within the 28 day access standard.
For Purchased Care under TRICARE Prime, each regional contractor, in this case UHC, defines their referral requirements. If UHC requires the referral be written on a paper prescription pad, then this is the process that must be followed. Under TRICARE Standard plans, referrals per se are not used, but rather a prior authorization process if followed. Each regional contractor specifies the process per contractual requirement. The process may involve filling out a regional contractor online form requesting authorization, faxing in this information on a form or telephoning the regional contractor to request for authorization. Regardless of each regional contractor’s process, prior authorization is required for ABA services under the ACD. Each authorization is for six months.
I hope this answers your question. Each regional contractor is available per the phone numbers provided in the presentation to assist family members with the referrals and authorizations. Please encourage the families you assist to call the regional contractor whenever there are problems or challenges accessing ABA through the ACD as we do not want beneficiaries to wait to access ABA services.
Expert: Theresa A. Hart, RNC MS, Nurse Consultant/Program Manager, Perinatal, Pediatrics and Special Medical Programs Defense Health Agency Clinical Support Division
For more advice from Ms. Hart, watch and listen to the professional development training on TRICARE® Extended Care Health Option (ECHO) to learn about the ECHO program.
The new blog series provides monthly advice from subject matter experts on issues surrounding military caregiving for service providers and families. We take questions and concerns from military helping professionals and families and provide the necessary feedback from credible experts in the field of study. Whether you are a provider or a caregiver, what questions do you have? We want to hear from you.
This MFLN-Military Caregiving concentration blog post was published on September 16, 2016.