Martin’s Point Health Care runs one of the six Uniformed Services Family Health Plans — TRICARE Prime delivered through a civilian health system’s own network rather than through a regional contractor. Its service area is the northern tier: Maine, New Hampshire, Vermont, upstate and western New York, the northern tier and western Pennsylvania, and northeastern and central Ohio.
Martin’s Point answers the question that matters most about USFHP and ABA directly, in its own provider training: "The US Family Health Plan is contracted with the Defense Health Agency to administer the Autism Care Demonstration benefits in accordance with TRICARE’s Program Manuals." So the rules are the ACD’s — the TRICARE Operations, Policy, Reimbursement and Systems Manuals — but the plan is the entity that certifies providers, authorizes services and pays claims. That combination is what an intake team has to hold in its head.
Martin’s Point describes its USFHP as "one of six Department of Defense-sponsored TRICARE Prime options nationwide," offering the full TRICARE Prime benefits package to eligible military retirees and their families, certain active-duty family members, and dependents aged 21 to 26 through TRICARE Young Adult. Care is delivered through Martin’s Point’s own civilian provider network rather than through TRICARE’s.[1][3]
TRICARE’s own USFHP listing gives the service area as Maine, New Hampshire, Vermont, upstate and western New York, the northern tier and western Pennsylvania, and northeastern and central Ohio — which matches the plan’s description of "Maine, New Hampshire, Vermont, upstate and western New York, northern Pennsylvania, and parts of Ohio." Three of those states are partial, so confirm by ZIP rather than by state name. The standard USFHP limits apply: members get most care from a plan-network PCP, cannot use TRICARE network providers, and cannot use military hospitals and clinics except for emergency care.[1][3]
Martin’s Point can authorize ABA under the ACD only where the beneficiary is a dependent of an active duty service member enrolled in the US Family Health Plan and registered for ECHO; a retiree or retiree family member enrolled in TRICARE Prime or TRICARE Select; covered under the Transitional Assistance Management Program; covered under TRICARE For Life; a TRICARE Young Adult participant; a NATO or Partnership for Peace participant; or a Continued Health Care Benefit Program participant. For active duty families, EFMP enrollment is the prerequisite for ECHO, and ECHO registration is the prerequisite for the ACD.[2][4]
Diagnostically, the beneficiary must have an ASD (F84.0) diagnosis from a TRICARE-authorized PCM or specialized ASD diagnosing provider, with the diagnosis made under the TRICARE basic benefit. The enrollment packet needs a referral or diagnostic evaluation stating the diagnosis, the date of the initial ASD diagnosis, a completed DSM-5 diagnostic checklist, and complete results of an approved validated assessment tool.[2][4]
The validated assessment tool list is closed: the STAT, the ADOS-2, the ADI-R, the CARS-2 or the GARS-3 — with the caveat that "completion of the GARS alone is not sufficient for diagnostic documentation" and an approved diagnosing provider must submit a diagnostic evaluation alongside it. A general observation interview alone is not a valid diagnostic tool. Two exceptions are published and worth knowing: for beneficiaries younger than 12 months the diagnosing provider may choose an appropriate age-based tool, and the plan may accept a diagnosis through source verification on a case-by-case basis where the diagnosing provider was not TRICARE-authorized but would otherwise have qualified and the diagnosis meets the requirements.[2][4]
The initial referral must include a complete assessment, the level of support needed, and the ASD diagnosis. ABA supervisors complete the initial assessment under CPT 97151, and that assessment includes the required outcome measures — the PDDBI, Vineland-3, SRS-2 and either the PSI-4 or the SIPA. Treatment plans are then updated every six months, documenting progress on behavior targets, adjusting goals, and carrying the outcome measures required for that interval.[2][6]
The cadence Martin’s Point publishes matches DHA’s: the PSI-4 or SIPA and the PDDBI every six months, and the Vineland-3 and SRS-2 annually. Reauthorizations must be submitted at least 30 days before the current authorization expires, with progress reports and updated outcome measures.[2][6]
Two requirements here have no commercial analogue and both belong on an intake checklist. Parent/caregiver involvement is mandatory: "Six parent/caregiver training sessions are required every six months to teach treatment protocols." And discharge is regulated — discharge criteria include meeting ABA goals or a lack of measurable progress across several assessments, and if the corporate services provider or sole provider terminates services with a beneficiary for any reason, they must notify the contractor a minimum of 45 calendar days before termination.[2][6]
No. The Autism Care Demonstration chapter of the TRICARE Operations Manual (Revision C-57, June 24, 2026) never mentions electronic visit verification. Its proof-of-service rule is the progress note. Each session note needs the beneficiary’s full name, “The date and time of session to include start and end time,” the location, the length of the session, the rendering provider’s legible name, type and dated signature, the authorized ABA supervisor’s name and the names of everyone present. Paid claims must also show the rendering provider and NPI “per unique claim line (i.e., every session must be identified as its own unique line on any claim submitted).”[8]
The TRICARE Operations Manual (Ch. 18 Sec. 3, Revision C-57, June 24, 2026) makes graphs one of two accepted formats, not a requirement. Each reassessment and treatment plan (TP) update must describe “progress toward short and long-term treatment goals for the identified targets in each domain utilizing either graphic representation of ABA TP progress or an objective measurement tool consistent with the baseline assessment.” The update is due every six months and must include: the date and time it was completed; the ABA provider who did it; an “Evaluation of progress on each treatment target (i.e., Met, Not Met, Discontinued)”; the interventions that did not work and how the TP changed; and new targets, objectives and goals, with changes based on “the cumulative six month assessment of the PDDBI and other outcome measures.” Parent/caregiver engagement is a required goal, reassessed every six months. The authorized ABA supervisor and the parent/caregiver both sign. The reassessment, PDDBI included, must be “conducted, completed, and submitted no later than 30 calendar days prior to the end of the current authorization.”[8]
The manual names USFHP Designated Providers among the contractors it binds (it excludes them only from the Autism Services Navigator and a few education provisions). So this TP-update standard applies to the plan’s ABA reviews too. Ask the plan whether it adds a form or template of its own.[8]
Master’s degree or higher in a relevant field, state licensed and/or BACB certified.[2]
Bachelor’s degree with appropriate state licensure or BACB/QABA certification, working under a qualified ABA supervisor.[2]
RBT, ABAT or BCAT certification, operating under the direct supervision of an authorized ABA supervisor.[2]
Cardiopulmonary resuscitation and basic life support certification must be completed and maintained through approved courses.[2]
Providers with felony convictions or crimes against children are ineligible. Supervisors provide a criminal history review; assistants and technicians provide federal, state and county reports covering the last 10 years.[2]
Corporate services providers and sole providers must maintain $1 million per claim and $3 million in aggregate.[2]
Martin’s Point lists as non-reimbursable: behavior technician training, non-ABA services, travel time unless authorized, academic services and school-based ABA, services provided by family members, and services rendered by a non-authorized ABA provider. Note the tension worth resolving in writing before you schedule anything: the plan’s training lists school-based ABA among the exclusions, while DHA’s ACD Q&A says technician-delivered school ABA is not covered but a BCBA may be authorized for a focused, time-limited, contractor-approved goal. Treat school delivery for a Martin’s Point member as a plan-level question and get the answer from the plan, not from another contractor’s guidance.[2][5][7]
On claims: all claims must be submitted electronically with the correct HIPAA taxonomy codes and the ABA provider’s valid NPI. Contractors audit provider records annually, monitor documentation and billing compliance, and watch for high-dollar claims and inconsistent billing — providers with irregularities face recoupment or additional monitoring. ABA is coordinated care, not a silo: providers are expected to coordinate with OT, PT and speech, and to align ABA with the comprehensive care plan.[2][5][7]
Costs are TRICARE Prime costs, because USFHP carries Prime out-of-pocket amounts. ABA bills as outpatient specialty care and one copayment covers all ABA services on a single day — currently $0 for active duty family members and $39 for retirees and others for network specialty care. There are no yearly or lifetime dollar caps on ABA under the ACD.[2][5][7]
Filing limit: Martin’s Point’s provider manual says participating providers “must submit service claims within 60, 90, 120, or 180 calendar days of the date of each service, in accordance with the provider’s participating agreement.” Its dispute table shows 120 days from the date of service “unless otherwise stated in Provider Agreement.” For non-participating providers, “timely filing requirements for a clean claim is one year from the date of service.” A non-participating corrected claim is due within 65 calendar days of the first remittance. Secondary (COB) claims are due “within 120 calendar days from the remittance date of the primary payer’s payment or denial,” on paper with the primary’s EOP. Members may not be billed for a claim filed late.[12]
Corrections and disputes: send a corrected claim, not a dispute, when you are changing codes, modifiers, dates or charges. Participating providers request adjustments within 60, 90, 120 or 180 days of the original remittance, per contract; non-participating providers within 60 days. A first-level dispute on the Provider Claims Dispute Form is due within 120 days of the original claim remittance. A second-level dispute is due within 30 days of the plan’s first-level response. A claim denied for lack of authorization is not disputed. For USFHP, submit the retro authorization request online (“USFHP Retro Authorization Requests: These requests must be submitted via ProAuth”). The manual publishes no clean-claim payment deadline or weekly cutoff. Provider Inquiry: 1-888-732-7364.[12]
Martin’s Point’s ACD training says nothing specific on either point, but it says which rules govern: “The US Family Health Plan is contracted with the Defense Health Agency to administer the Autism Care Demonstration benefits in accordance with TRICARE’s Program Manuals,” naming the TRICARE Operations Manual 6010.62-M and the TRICARE Policy Manual 6010.63-M. Its own provider standards require ABA supervisors to be “state-licensed, and/or certified” by the BACB, and require reauthorizations at least 30 days before the authorization expires.[2][8][9]
The DHA manuals answer both visitor questions. On licensure, the ACD chapter requires ABA providers to meet the licensing or certification requirements “extant in the State, county, municipality, or other political jurisdiction in which ABA services are provided under the ACD.” The TRICARE Policy Manual’s telehealth section pays only when the service is “within a provider’s scope of practice under all applicable state(s) law(s) in which services are provided and or received.” On telehealth, 97151, 97153, 97155, 97157 and 97158 “may not be conducted via TH,” and 97156 parent/caregiver sessions may be done by telehealth only after the first six-month authorization period per authorized provider. So an out-of-state BCBA cannot assess or deliver direct ABA remotely, and can deliver remote parent training only after six months and only if licensed or otherwise authorized where the child is. On back-dating, the ACD referral rule is that “A retroactive referral shall not be accepted.”[2][8][9]
This page is not legal advice. TRICARE Operations Manual Ch. 18 Sec. 3 ¶ 8.8 (Revision C-57, June 24, 2026) sets the ACD discharge rules. ABA ends on loss of TRICARE eligibility, or when the ABA supervisor, the contractor or the family determines that the child met the treatment-plan goals, made “no measurable progress” after successive review periods and repeated plan changes, has gains that do not generalize, or “can no longer participate in ABA services (due to medical problems, family problems, or other factors that prohibit participation).” It also ends if the diagnosing provider or PCM changes the diagnosis or no longer believes ABA is clinically necessary.[8]
How it must end: “Termination of ABA services under any circumstance must not occur abruptly by the authorized ABA supervisor. All termination plans must be submitted at least 45 calendar days prior to the termination of services.” The contractor “shall work with the ABA provider to ensure a smooth transition,” and if a supervisor ends services abruptly the contractor must “report the authorized ABA supervisor to the appropriate credentialing/licensure board.” Discharge planning belongs in every treatment plan, a discharge summary with the reason is required (it is not billable), and when direct ABA is no longer clinically necessary the contractor uses parent training to fade services over one six-month authorization. For a child whose aggression a setting cannot manage, the manual’s answer is a planned transition with 45 days’ notice, not an abrupt stop.[8]
TRICARE Operations Manual Ch. 18 Sec. 3 (Revision C-57) assigns each ACD code to a provider level. 97151 (assessment and treatment-plan updates): the authorized ABA supervisor “or as delegated to an assistant behavior analyst”; not by telehealth. 97153: the BT, the assistant behavior analyst or the supervisor, paid no lower than $12.50, $18.75 and $31.25 per 15 minutes respectively; capped at 32 units a day and 160 a week; not by telehealth. 97155: the supervisor or a delegated assistant, at least once a month by the supervisor personally; not by telehealth. 97156: the supervisor may delegate caregiver teaching to an assistant, “but only the authorized ABA supervisor may bill for this service using this code”; up to 8 units a day, home or clinic only. 97157 and 97158: the supervisor. In school, only 97153 “rendered by the authorized ABA supervisor (not delegated to the assistant)” is authorized.[8]
No credential modifier (HM, HN, HO, HP) is set in the chapter. Instead, every claim line must carry “the NPI of the rendering provider per unique claim line,” and remote parent sessions carry modifier GT or 95. When 97153 and 97155 are billed for the same time the contractor “shall pay the higher rate and deny the other.” For a family changing agencies, a second-opinion assessment authorization may overlap an approved one, but “Two ‘ongoing’ treatment authorizations of direct services (CPT codes 97153, 97155, 97156, 97157, and 97158) are not permitted.”[8]
The AMA CPT Editorial Panel accepted six new adaptive behavior codes, revised 97151–97158 and deleted 0362T and 0373T, effective January 2027. The AMA's CPT 2027 HCPAC vote document lists the new codes as 97148 and 97149 (supporting assessment of harmful behavior, two technicians), 97159 and 97160 (treatment of harmful behavior, two technicians), 97173 (treatment with analysis delivered by the physician or QHP) and 97180 (non-face-to-face services by the physician or QHP). The codes are national; what each payer decides is which ones it authorizes and pays, and how.[14][15][16]
The TRICARE Operations Manual's Autism Care Demonstration chapter (Chapter 18, Section 3, Revision C-57, June 24, 2026) still describes only the Category I codes 97151–97158, and no revision addressing the 2027 code changes had been posted as of November 1, 2026. Watch for a TOM revision before January 1, 2027, and confirm with the regional contractor which codes an authorization spanning January 1 should carry.[14][15][16]
The Autism Care Demonstration is audited every year. The TRICARE Operations Manual tells the regional contractor to audit, "on an annual basis," at least 30 records for each ABA provider group, combining administrative-record and medical-documentation reviews with one medical team conference session note. For the TRICARE Overseas Program and USFHP the audit "must include a minimum of 10% of records" for each group.[16]
Findings lead first to outreach and education, then to "progressively more severe administration action, commensurate with the seriousness of the identified problems." The contractor "shall recoup all claims determined to be insufficient per supporting documentation for claims payment," and recoups claims for session notes "that describe the rendering of non-ABA services" and for a supervisor whose BACB, BICC or QABA certification or state license carries a restriction. One penalty is automatic: 97155 "must be completed at least one time per month by the authorized ABA supervisor," and a provider who misses it faces "a 10% penalty on all ABA claims for that beneficiary for the entire six-month authorization."[16]
The questions that decide whether a family can start with Martin’s Point US Family Health Plan, and what they have to bring. Each maps onto something intake should ask on the first call.
No age limit and no yearly or lifetime dollar cap on ABA under the demonstration. Eligibility rather than age is the gate: Martin’s Point can authorize ABA only where the beneficiary is a dependent of an active duty service member enrolled in the US Family Health Plan and registered for ECHO; a retiree or retiree family member on TRICARE Prime or Select; covered under TAMP; covered under TRICARE For Life; a TRICARE Young Adult participant; a NATO or Partnership for Peace participant; or a Continued Health Care Benefit Program participant. Age does decide the stress measure — the PSI-4 below, the SIPA for adolescents.[2][4]
The ACD clocks apply: a diagnosis more than two years old requires an updated diagnostic assessment, and the referral runs two years. The enrollment packet must carry the date of the initial ASD diagnosis alongside the referral or diagnostic evaluation, so capture that date at intake rather than at reauthorization. Reauthorizations must be submitted at least 30 days before the current authorization expires, with progress reports and updated outcome measures. USFHP families have no Autism Services Navigator, so the renewal calendar is your team’s to keep.[2][4][3]
The diagnosis must come from a TRICARE-authorized PCM or specialized ASD diagnosing provider and must be made under the TRICARE basic benefit — the ACD’s closed list of family practice physicians, pediatricians and pediatric or family nurse practitioners on the primary-care side, and developmental-behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology, adult or child psychiatry, doctoral-level licensed clinical psychologists and qualifying DNPs on the specialist side. One published mercy: the plan may accept a diagnosis through source verification on a case-by-case basis where the diagnosing provider was not TRICARE-authorized but would otherwise have qualified and the diagnosis meets the requirements. Worth asking about before you turn a family away. LCSW: no. TRICARE Operations Manual Ch. 18 Sec. 3 ¶ 11.13.1 (Revision C-57) lists every authorized ASD diagnosing and referring provider, and licensed clinical social workers are not on it. The manual names LCSWs only as possible Autism Services Navigators and as providers of parent-mediated programs, not as diagnosers.[8][2][4]
The closed validated-tool list in this directory, and it is worth memorising: the STAT, the ADOS-2, the ADI-R, the CARS-2 or the GARS-3 — with the caveat that “completion of the GARS alone is not sufficient for diagnostic documentation” and an approved diagnosing provider must submit a diagnostic evaluation alongside it. A general observation interview alone is not a valid diagnostic tool. For beneficiaries younger than 12 months the diagnosing provider may choose an appropriate age-based tool. On top of that sit the four ACD outcome measures, which the ABA supervisor folds into the initial 97151 assessment: the PDDBI and the PSI-4 or SIPA every six months, the Vineland-3 and the SRS-2 annually.[2][6]
Required, and the enrollment packet is specific: a referral or diagnostic evaluation stating the diagnosis, the date of the initial ASD diagnosis, a completed DSM-5 diagnostic checklist, and complete results of an approved validated assessment tool. The initial referral must also include a complete assessment and the level of support needed. For active duty families, EFMP enrollment is the prerequisite for ECHO and ECHO registration is the prerequisite for the ACD. Two plan-level requirements with no commercial analogue belong on the same checklist: six parent/caregiver training sessions are required every six months to teach treatment protocols, and a provider terminating services with a beneficiary for any reason must notify the contractor at least 45 calendar days in advance.[2][4]
One code, after six months. Martin’s Point’s ABA provider training administers the ACD “in accordance with TRICARE’s Program Manuals” and does not restate this rule, so the answer is the DHA rule. The DHA rule applies to USFHP: TRICARE Operations Manual Ch. 18, Sec. 3 names USFHP designated providers among the contractors it binds and carves them out only of specific paragraphs (such as the navigator rules in 6.0–6.9). It says 97151, 97153, 97155, 97157 and 97158 “may not be conducted via TH,” that 97156 parent/caregiver sessions “may be conducted via TH only after the first six-month authorization period per authorized provider,” that remote sessions “must include the GT or 95 modifier on claims,” and that “all services provided via TH must adhere to State laws governing TH services.” Asynchronous telehealth is excluded. Plan the first six months fully in person.[8][2]
Martin’s Point publishes no USFHP-specific ABA decision clock (the 72-hour/7-day decision times on its site are for its Medicare Advantage plans), so the DHA ACD rule for USFHP governs: the plan completes clinical-necessity review of a compliant treatment plan “within the five business days for authorization processing standards.” Martin’s Point’s own lead times: “Reauthorizations: Submit at least 30 days before the authorization expires, with progress reports and updated outcome measures,” and prior authorization requests generally “should be submitted at least 14 calendar days prior to date of service.” The DHA rule lets reauths go in as early as 60 calendar days before expiry, and late submissions are not backdated.[2][10][11]
“The US Family Health Plan is primary to the Medicaid program and secondary to all commercial health insurance plans such as Aetna, CIGNA, or Anthem. Federally sponsored health plans (e.g., Federal Blue Cross and Mail Handlers) are employee benefits and are primary to the US Family Health Plan.” Bill the commercial plan first, then submit to Martin’s Point with the primary EOB “within 120 calendar days from the remittance date of the primary payer’s payment or denial”; a claim without it is denied (“OHI must process claim first, resubmit with primary EOB”). Under the DHA ACD rule, “For Other Health Insurance (OHI), beneficiaries receiving ABA services must obtain a referral and prior authorization” — get the USFHP ABA authorization even when the commercial plan is primary.[12][11]
Coverage decides whether Martin’s Point US Family Health Plan pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Authorized ABA supervisors hold a master’s degree or higher in a relevant field and are state licensed and/or BACB certified. Assistant behavior analysts hold a bachelor’s degree with appropriate state licensure or BACB/QABA certification and must work under a qualified ABA supervisor. Behavior technicians must hold RBT, ABAT or BCAT certification and must operate under the direct supervision of an authorized ABA supervisor. Supervisors, assistants and technicians must also clear criminal history background checks — a felony conviction or a crime against children is disqualifying — and maintain CPR/BLS certification. Behavior technician training is not a reimbursable service.[2]
Excluded, with one exception, under the DHA rule. Martin’s Point’s ABA provider training does not state a same-time rule itself, but the plan administers ACD benefits “in accordance with TRICARE’s Program Manuals,” and TRICARE Operations Manual Ch. 18, Sec. 3 — which names USFHP designated providers among the contractors it binds — is explicit: concurrent billing is excluded for all ACD Category I codes “except when the family and the beneficiary are receiving separate services and the beneficiary is not present in the family session,” with documentation showing two separate rendering providers and locations. If 97153 and 97155 are billed concurrently, the contractor “shall pay the higher rate and deny the other.”[2][8]
Set by the DHA rule. Martin’s Point’s ABA provider training administers the ACD “in accordance with TRICARE’s Program Manuals” and does not restate this rule. The DHA rule applies to USFHP: TRICARE Operations Manual Ch. 18, Sec. 3 names USFHP designated providers among the contractors it binds and carves them out only of specific paragraphs (such as the navigator rules in 6.0–6.9). Ceilings: 97151 up to 32 units for the initial assessment and up to 24 units per later authorization, used within 14 calendar days of the first 97151 date of service; 97153 denied above “32 units (eight hours) per day or 160 units (40 hours) per week”; 97155 not authorized above eight units (two hours) a day; 97156 denied above eight units a day; 97157 and 97158 authorized at four to six units a day, with groups of no more than eight.[8][2]
All claims must be submitted electronically, must use the proper HIPAA taxonomy codes for the provider type (behavior analyst, assistant behavior analyst, behavior technician), and must carry the ABA provider’s valid NPI. Services rendered by a non-authorized ABA provider are not reimbursable. Records are audited annually and irregular billing draws recoupment or added monitoring.[2]
The plan’s ABA provider training lists academic services and school-based ABA as non-reimbursable, alongside services provided by family members, non-ABA services and travel time unless authorized. DHA’s ACD guidance is narrower rather than contradictory — technician-delivered school ABA is not covered, while a BCBA may be authorized for a focused, time-limited, pre-authorized goal after clinical necessity review. Because Martin’s Point administers the demonstration itself, treat any school or community request as a plan-level decision and obtain it in writing before scheduling.[2][5]
Ask the plan: Martin’s Point USFHP provider services, 888-241-4556, before scheduling school or community sessions
Not published. The plan’s ABA provider training sets documentation expectations at the plan level — treatment plans updated every six months documenting progress on behavior targets, annual record audits, monitoring of documentation and billing compliance, with recoupment or additional monitoring for irregularities — but does not state who signs an individual session note or by when.[2]
Blocked on: Martin’s Point USFHP provider services, 888-241-4556 — ask for the session-note standard the annual audit is run against.
Within limits set by the TRICARE Operations Manual. BTs deliver 97153. Assistant behavior analysts may deliver 97153, and 97151, 97155 and 97156 when the supervisor delegates them, but 97156 is billed only by the authorized ABA supervisor. Every claim line carries the rendering provider’s NPI; no HM/HN/HO/HP modifier is required by the chapter.
No. The TRICARE Operations Manual’s ACD chapter (¶ 11.13.1) limits ASD diagnosing and referring providers to pediatricians, family medicine physicians, pediatric or family nurse practitioners, and specialists: board-certified or board-eligible developmental-behavioral or neurodevelopmental pediatricians, child neurologists and child psychiatrists, doctoral-level licensed clinical psychologists and qualifying board-certified DNPs. LCSWs are not on the list.
Participating providers file within the 60, 90, 120 or 180 days their agreement sets. The dispute table shows 120 days from the date of service unless the agreement says otherwise. Non-participating providers have one year. Secondary claims are due within 120 days of the primary payer’s remittance. A first-level dispute is due within 120 days of the original remittance, and a second-level dispute within 30 days of the first response.
No. The TRICARE Operations Manual’s Autism Care Demonstration chapter has no electronic visit verification requirement. Proof of service is the session progress note, with start and end times, location, length, the rendering provider’s signature and the supervisor’s name, plus one claim line per session carrying the rendering provider’s NPI.
Graphs are one of two accepted formats, not a requirement. The TRICARE Operations Manual asks each six-month reassessment and treatment plan update to show progress on every target “utilizing either graphic representation of ABA TP progress or an objective measurement tool consistent with the baseline assessment.” It must also mark each target Met, Not Met or Discontinued, name the interventions that changed, and carry the PDDBI and the other outcome measures due that period. The supervisor and the parent sign it, and it goes in at least 30 days before the authorization ends. The manual binds USFHP Designated Providers, so the same standard applies here.
Yes. Martin’s Point states that the US Family Health Plan is contracted with the Defense Health Agency to administer Autism Care Demonstration benefits in accordance with TRICARE’s program manuals. The ACD has been in effect since 2014 and expires Dec. 31, 2028 unless extended.
The STAT, ADOS-2, ADI-R, CARS-2 or GARS-3. The GARS-3 alone is not sufficient — an approved ASD diagnosing provider must also submit a diagnostic evaluation. A general observation interview alone is not a valid diagnostic tool. For children under 12 months the diagnosing provider may choose an appropriate age-based tool.
Six parent/caregiver training sessions every six months, to teach treatment protocols. Parent/caregiver involvement is mandatory and the treatment plan must document it.
The plan’s own ABA provider training lists academic services and school-based ABA among non-reimbursable services, while DHA’s ACD guidance allows a narrow BCBA pathway for focused, time-limited, pre-authorized goals. Because the plan administers the demonstration itself, get its written answer before scheduling a school session.
At least 45 calendar days’ notice to the contractor before terminating services, for any reason. Discharge criteria are meeting the ABA goals or a lack of measurable progress across several assessments.
Only parent training (97156), only after the first six-month authorization, and only where the BCBA is licensed or otherwise authorized for the child’s location. Martin’s Point administers the ACD under the TRICARE manuals, which require compliance with licensing law where services are provided and received and bar telehealth for the assessment and direct ABA codes. The ACD does not accept retroactive referrals, so get the authorization first.
TRICARE Prime amounts, since USFHP has the same out-of-pocket costs as Prime. ABA bills as outpatient specialty care and one copayment covers all ABA on a single day — currently $0 for active duty family members and $39 for retirees and others in network. There is no annual or lifetime cap on ABA.
Not under the DHA rule the plan administers. TRICARE Operations Manual Ch. 18, Sec. 3 says 97156 “may be used only in a home or clinic/office-based setting” (97157 only in a clinic or office). A daycare can be authorized for direct ABA when clinically necessary, but hold parent training at home, in the clinic, or by telehealth after the first six-month authorization. Confirm any daycare plan with the USFHP plan in writing.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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