A TRICARE card is not a commercial card, and an intake team that treats it like one will get the case wrong. ABA is not part of the TRICARE basic medical benefit at all. It is covered under the Comprehensive Autism Care Demonstration — a separate demonstration program, currently authorized to run through Dec. 31, 2028, with its own eligibility chain, its own mandatory outcome-measure regime, and its own rules about where a session may happen.
In the TRICARE East Region the demonstration is administered by Humana Military. The practical consequence for intake: nothing starts until an approved ASD diagnosing provider issues a referral with a DHA-approved DSM-5 checklist, and nothing continues unless four standardized instruments keep arriving on schedule. Missing paperwork here does not slow the case down — it stops it.
DHA is explicit that ABA sits outside the medical benefit: occupational therapy, physical therapy, speech therapy, psychological services, psychological testing and prescription drugs are covered by the TRICARE medical benefit, while ABA "is a benefit covered under the ACD," which is "separate from the TRICARE medical benefit." The demonstration is run under 10 U.S.C. § 1092 demonstration authority, not as a standard covered service, and it has been extended more than once — the Aug. 4, 2022 Federal Register notice carried it from its Dec. 31, 2023 sunset to Dec. 31, 2028. That end date is the current one; there is no later extension notice on the Federal Register docket as of this review.[1][6][12]
Because it is a demonstration, the rules are unusually prescriptive and unusually enforced. Humana Military states plainly that "claims for services rendered without prior authorization will be denied," and that every participating ABA provider must attend annual training — a 10% penalty is applied to all claims billed under the provider Tax ID for providers who do not. Annual record audits (35 records) are conducted for Autism Corporate Service Providers and sole ABA providers. None of this has a commercial-plan analogue.[1][6][12]
Two conditions gate the door: the child must be enrolled in a TRICARE health plan, and must be diagnosed with ASD by an approved diagnosing provider. Humana Military names the covered diagnosis as Autism Spectrum Disorder (F84.0) under DSM-5. Eligible categories include dependents of active duty members, retirees and TRICARE-eligible Reserve Components, member-plus-family coverage under TRICARE Reserve Select and TRICARE Retired Reserve, TAMP and TRICARE For Life, TRICARE Young Adult, NATO dependents, and CHCBP participants.[1][2][12]
Who may diagnose is a closed list, and it is the single most common intake failure. Approved primary care providers are limited to family practice physicians, pediatricians, and pediatric or family nurse practitioners. Approved specialists are board-certified or board-eligible physicians in developmental-behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology, or adult or child psychiatry, plus doctoral-level licensed clinical psychologists and Doctors of Nursing Practice meeting specific criteria. Two age rules ride on top: if the first ASD diagnosis comes at age 8 or later, it must come from a specialized ASD diagnosing provider; and a child diagnosed more than two years before ABA is requested must get an updated diagnostic assessment.[1][2][12]
For active duty families there is a second, non-clinical gate that intake should ask about on the first call: the service member must enroll the child in their branch’s Exceptional Family Member Program, and the child must register for the Extended Care Health Option. If the ECHO path is not completed, ABA cannot be authorized regardless of the clinical picture.[1][2][12]
The referral itself is a defined document, not a note. Per Humana Military it "must include a definitive diagnosis of ASD using the DSM-5 (or current edition) criteria by a PCM or specialized ASD diagnosing provider," the DSM-5 criteria "must be documented in a DHA-approved checklist in the referral," and a validated assessment tool must accompany the referral and confirm the diagnosis.[8][12][1]
On receipt of a complete referral, Humana Military authorizes an initial assessment, treatment-plan development and the outcome measures, provided a TRICARE-authorized ABA supervisor has an opening to accept the beneficiary.[8][12][1]
The ABA supervisor completes the initial assessment and treatment plan and submits them with the baseline outcome measures. A treatment authorization is then issued for six months.[8][12][1]
The supervisor submits an updated treatment plan plus the PDDBI parent and teacher forms and the PSI-4 short form or SIPA, and requests reauthorization before the current period expires.[8][12][1]
This is the ACD’s signature requirement and it has no commercial equivalent. Four instruments are required and the required ones "must be received prior to issuing a treatment authorization." The cadence: the PDDBI at baseline and every six months (the ABA supervisor completes the teacher form); the Vineland-3 at baseline and annually; the SRS-2 parent form at baseline and annually; and the PSI-4 short form (ages birth through 12) or the SIPA (ages 11 to 19) at baseline and every six months. DHA states families "must complete the four outcome measures every six months or every 12 months" depending on the measure.[9][3][1]
The submission mechanics get authorizations bounced as often as the scores do. Humana Military requires outcome measures to be completed no earlier than 90 days before their due date; requires the full publisher print report or hand-scored protocols; and states that "the scores cannot be imbedded within the TP or any other clinical documents." The name of the person completing the form and their relationship to the beneficiary must match and appear on all forms. For the Vineland-3, all composite scores must be submitted — communication, daily living, socialization, motor skills, adaptive behavior composite, and both maladaptive behavior composites.[9][3][1]
What happens if they are not submitted is unambiguous. Humana Military will assist a family who cannot complete a measure through an ACD team associate, "however, if the barriers cannot be resolved, ABA services will not be able to be authorized." Outcome measures can be performed by TRICARE-authorized ASD diagnosing providers or, when Humana Military authorizes it, by the ABA provider without an additional PCM referral — and when the ABA provider administers one, bill it under CPT 97151 with a 99 modifier to distinguish it from an assessment.[9][3][1]
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).”[18]
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.”[18][8]
Humana Military’s BCBA reviewers check “Baseline data, progress summaries and ongoing data collection,” along with goals, parent training goals, behavior intervention plans, outcome measure scores, the discharge plan and the CPT codes requested. Requests for ongoing treatment may go in up to 60 days ahead. Filing less than 30 days before the current authorization expires “may result in non-reimbursement.” The six-month package is the updated TP, the PDDBI parent and teacher forms, and the PSI-4 short form or the SIPA. Once a year it also includes the SRS-2 and the Vineland-3.[18][8]
School is the setting that surprises people. DHA states that "ABA services rendered by a behavior technician in the school setting aren’t covered." A Board Certified Behavior Analyst may be authorized where there is a clinically necessary and appropriate goal, subject to clinical necessity review, with pre-authorization required and the contractor approving the goals, which "must be focused and time-limited." Community settings are similar but narrower: parents are generally expected to generalize mastered skills on their own, and a BCBA "may be authorized for certain community settings" only after checking with the contractor. Humana Military lists "community locations not being authorized prior to rendering services" as a common documentation failure.[2][10][11]
The goal-level exclusions bind in every setting. Humana Military excludes goals targeting activities of daily living, vocational and/or educational goals, ABA involving aversive techniques or restraints, ABA for diagnoses other than ASD, and ABA for symptoms and behaviors that are not part of the core symptoms of ASD. Training and supervising a behavior technician, report writing outside CPT 97151, emails and phone calls, and office and therapeutic supplies are not payable either.[2][10][11]
The ACD adopted only the Category I codes that transferred from Category III: 97151, 97153, 97155, 97156, 97157 and 97158, plus 99366 and 99368 for medical team conferences. Other codes are not covered. Authorized ABA supervisors and ACSPs bill as outpatient specialty providers; claims must be submitted electronically, EFT enrollment is required, and timely filing is one year from the date of service. Start and stop times belong on the individual claim lines, even when the same code is billed twice in a day by the same rendering provider.[7][12][4]
Three traps recur. Concurrent billing is excluded for all ACD Category I codes except where the family and the beneficiary receive separate services and the beneficiary is not present in the family session — documentation must show two separate rendering providers and two separate locations (which may be two rooms in the same building). If 97153 and 97155 are billed concurrently, the higher rate is paid and the other is denied. And all 97151 units must be used within 14 calendar days of the first date of service for 97151, or the claim is denied; delays outside the provider’s control go through the appeals process.[7][12][4]
On what the family pays: ABA is treated as outpatient specialty care and a single copayment covers all ABA services received on one day. Under TRICARE Prime, active duty family members pay $0 for network specialty care in both Group A and Group B; retirees and all others pay $39. Under TRICARE Select, active duty family members pay $39 network (Group A) or $33 (Group B), and retirees and all others pay $52 network or 25% non-network. There are no yearly or lifetime caps on ABA, and the amounts count toward the family catastrophic cap. Verify current-year figures on the TRICARE cost page before quoting them.[7][12][4]
Humana Military’s ABA FAQ answers the two-agency question directly. A family may see more than one authorized ABA supervisor, “however only one authorized ABA supervisor is approved to provide ABA services for a beneficiary at a time”; a supervisor brought in for consultation does not take over, and the primary supervisor “is the sole provider authorized to bill for ABA services.” The DHA manual carves out the assessment: “A second opinion authorization (for 32 units of CPT code 97151) may be permitted to overlap with another approved authorization. Two ‘ongoing’ treatment authorizations of direct services (CPT codes 97153, 97155, 97156, 97157, and 97158) are not permitted.” So agency B may be authorized to assess a child while agency A keeps treating, but agency B cannot hold treatment units until agency A’s treatment authorization ends. Humana Military publishes no separate East transfer-of-care procedure; request the second-opinion or change-of-provider authorization through provider self-service or the ABA line at (866) 323-7155.[18][12][8][16]
Nothing is back-dated. Humana Military: “ABA services must be pre-authorized before services can begin. Humana Military does not accept retrospective referrals and will not backdate late submissions”; its 2026 East Region provider handbook says “All ABA authorizations must be preauthorized; retrospective authorization is not allowed,” and the DHA manual says “A retroactive referral shall not be accepted.” Reauthorizations may be filed up to 60 days ahead, and filing less than 30 days before expiry “may result in non-reimbursement.”[18][12][8][16]
The licence has to cover the state the child is in. Humana Military’s 2026 East Region provider handbook, under “Multi-state licensure requirements,” says virtual-health providers “must also meet licensure requirements in the state where they practice and where the beneficiary is located at time of service,” that “It’s the provider’s responsibility to confirm that they are licensed in every state where they practice and where the virtual health patient is located,” and that “Claims review will validate compliance to this requirement.” The DHA manuals behind it say the same. 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.” 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.” It accepts BACB certification for an ABA supervisor only where a state-issued licence or certification is not available. Whether the child’s state requires its own licence is that state’s law, so check it state by state.[16][17][18]
The ACD adds a second limit that applies whatever the licence. Under TRICARE Operations Manual Ch. 18, Sec. 3, 97151, 97153, 97155, 97157 and 97158 “may not be conducted via TH.” Only 97156 parent/caregiver sessions may be done by telehealth, and only “after the first six-month authorization period per authorized provider”; “all services provided via TH must adhere to State laws governing TH services.” In practice an out-of-state BCBA cannot assess, treat or modify protocols remotely for a TRICARE child. They can deliver remote parent training only after the first six months, and only if licensed or otherwise authorized where the family is.[16][17][18]
DHA publishes the Autism Care Demonstration fee schedule. Its ABA Maximum Allowed Amounts file, effective May 1, 2026, sets a maximum per 15-minute unit for 97151, 97153, 97155 and 97156 in each TRICARE locality, split by credential: one rate for 97151 and one for 97156 (BCBA-D, BCBA or assistant behavior analyst), four tiers for 97153 (BCBA-D, BCBA, assistant behavior analyst, behavior technician) and three for 97155 (BCBA-D, BCBA, assistant behavior analyst). A companion table prices 97157 and 97158 at the non-physician, non-facility rate for CPT 90853 divided by three, and lists 99366 and 99368 at their CMAC rates. Earlier years' files sit on the same DHA page. These are maximums: look up the locality where care is delivered before quoting a family or modelling revenue. Examples from the May 1, 2026 file: Alabama pays 97151 $31.56, 97153 by a behavior technician $16.82 and 97155 by a BCBA $31.25; Boston pays 97151 $37.73, 97153 by a behavior technician $20.11 and 97155 by a BCBA $33.48.[14][15]
The DHA rule is in TRICARE Operations Manual Ch. 18, Sec. 3 (Revision C-57). Daycare itself is an allowed setting for direct ABA: “The daycare setting is not considered an academic setting and therefore may be authorized per clinical necessity as determined by the contractor.” Parent training is not. The same chapter says “CPT code 97156 may be used only in a home or clinic/office-based setting. School settings are prohibited,” and “CPT code 97157 may only be used in a clinic/office-based setting.” So a daycare (POS 99) can host authorized 97153 or 97155 sessions that target core ASD symptoms, but a 97156 caregiver session held at the daycare is outside the rule. Hold it at home or in the clinic, or by telehealth after the first six-month authorization with a GT or 95 modifier.[18][10][12]
Humana Military’s own ACD material adds nothing that widens this. Its progress-note rules list “daycare (non-preschool)” as a place of service the note must record, and its ABA FAQ lists 97156 among the adopted codes without a setting exception. If a family can only meet at the daycare, ask Humana Military in writing before you schedule it.[18][10][12]
Humana Military’s ABA FAQ: “All claims for benefits must be filed no later than one year after the date the services were provided,” and “Per the contract, claims can take up to 30 days to process.” Its 2026 East Region handbook asks network providers to “file TRICARE claims electronically within 90 days of the date care was provided.” ABA claims must go in electronically to PGBA, with EFT enrollment. The DHA standard behind the 30 days is TRICARE Operations Manual Ch. 1, Sec. 3: the contractor “shall process 98% retained and adjustment claims accurately and to completion within 30 calendar days from the date of receipt.”[12][16][19][18]
What goes on the claim: the handbook says “Both billing NPIs and rendering provider NPIs, when applicable, are required,” and providers treating beneficiaries on a referral “should also include the referring provider’s NPI on transactions, if available.” The ACD chapter requires the rendering provider’s name and NPI on every claim line and the HIPAA taxonomy of each provider type: 103K00000X behavior analyst, 106E00000X assistant behavior analyst, 106S00000X behavior technician.[12][16][19][18]
Disputes run on two 90-day clocks. An administrative review (allowed amount, coding, timely-filing denials, penalties for no authorization) “must be postmarked or received within 90 calendar days of the date of beneficiary’s EOB or the provider remittance.” An appeal covers only denials as not covered or not medically necessary, must be filed within 90 calendar days of the denial, and “Network providers are not a proper appealing party” unless they file for the family with a signed Appointment of representative form.[12][16][19][18]
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.[18]
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.[18]
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.[18]
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.”[18]
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.[22][23][24]
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.[22][23][24]
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.[24]
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."[24]
The clinical policy above is national, but three state-level layers change what a family's card actually buys: the state autism mandate (what fully-insured plans must cover), the carrier's state Medicaid plans (which follow the state Medicaid rules, not this commercial policy), and plan funding type (self-funded ERISA plans can carve benefits differently). Here's the picture in the states we cover:
Fully-insured TRICARE East (Humana Military) plans issued in Georgia sit under the state mandate above. State Medicaid baseline: Georgia Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in North Carolina sit under the state mandate above. State Medicaid baseline: North Carolina Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Indiana sit under the state mandate above. State Medicaid baseline: Indiana Medicaid (IHCP) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Virginia sit under the state mandate above. State Medicaid baseline: Virginia Medicaid (DMAS) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Tennessee sit under the state mandate above. State Medicaid baseline: TennCare (Tennessee Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Ohio sit under the state mandate above. State Medicaid baseline: Ohio Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in New Jersey sit under the state mandate above. State Medicaid baseline: NJ FamilyCare (New Jersey Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Maryland sit under the state mandate above. State Medicaid baseline: Maryland Medicaid (Medical Assistance) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Colorado sit under the state mandate above. State Medicaid baseline: Health First Colorado (Colorado Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Utah sit under the state mandate above. State Medicaid baseline: Utah Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Arizona sit under the state mandate above. State Medicaid baseline: AHCCCS (Arizona Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in New York sit under the state mandate above. State Medicaid baseline: New York Medicaid (NYS DOH / eMedNY) guide →
Fully-insured TRICARE East (Humana Military) plans issued in New Mexico sit under the state mandate above. State Medicaid baseline: New Mexico Medicaid (Turquoise Care) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Missouri sit under the state mandate above. State Medicaid baseline: MO HealthNet (Missouri Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Texas sit under the state mandate above. State Medicaid baseline: Texas Medicaid (THSteps-CCP) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Massachusetts sit under the state mandate above. State Medicaid baseline: MassHealth (Massachusetts Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Florida sit under the state mandate above. State Medicaid baseline: Florida Medicaid — Behavior Analysis Services (AHCA) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Kansas sit under the state mandate above. State Medicaid baseline: KanCare (Kansas Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Nebraska sit under the state mandate above. State Medicaid baseline: Nebraska Medicaid (Heritage Health) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Idaho sit under the state mandate above. State Medicaid baseline: Idaho Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Iowa sit under the state mandate above. State Medicaid baseline: Iowa Medicaid (IA Health Link) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Oklahoma sit under the state mandate above. State Medicaid baseline: Oklahoma Medicaid (SoonerCare / SoonerSelect) - Oklahoma Health Care Authority guide →
Fully-insured TRICARE East (Humana Military) plans issued in Michigan sit under the state mandate above. State Medicaid baseline: Michigan Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Hawaii sit under the state mandate above. State Medicaid baseline: Hawaii Medicaid (Med-QUEST / QUEST Integration) guide →
Fully-insured TRICARE East (Humana Military) plans issued in California sit under the state mandate above. State Medicaid baseline: Medi-Cal (California Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Pennsylvania sit under the state mandate above. State Medicaid baseline: Pennsylvania Medicaid (Medical Assistance) guide →
Fully-insured TRICARE East (Humana Military) plans issued in New Hampshire sit under the state mandate above. State Medicaid baseline: New Hampshire Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Wisconsin sit under the state mandate above. State Medicaid baseline: Wisconsin Medicaid (ForwardHealth) guide →
Fully-insured TRICARE East (Humana Military) plans issued in South Carolina sit under the state mandate above. State Medicaid baseline: South Carolina Healthy Connections Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Kentucky sit under the state mandate above. State Medicaid baseline: Kentucky Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Washington sit under the state mandate above. State Medicaid baseline: Washington Apple Health (Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Connecticut sit under the state mandate above. State Medicaid baseline: Connecticut Medicaid (HUSKY Health) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Illinois sit under the state mandate above. State Medicaid baseline: Illinois Medicaid (HFS) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Louisiana sit under the state mandate above. State Medicaid baseline: Louisiana Medicaid (Healthy Louisiana) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Oregon sit under the state mandate above. State Medicaid baseline: Oregon Health Plan (Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Minnesota sit under the state mandate above. State Medicaid baseline: Minnesota Medical Assistance (EIDBI) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Maine sit under the state mandate above. State Medicaid baseline: MaineCare (Maine Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Vermont sit under the state mandate above. State Medicaid baseline: Vermont Medicaid (Green Mountain Care / DVHA) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Alabama sit under the state mandate above. State Medicaid baseline: Alabama Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in South Dakota sit under the state mandate above. State Medicaid baseline: South Dakota Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Nevada sit under the state mandate above. State Medicaid baseline: Nevada Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Montana sit under the state mandate above. State Medicaid baseline: Montana Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Alaska sit under the state mandate above. State Medicaid baseline: Alaska Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in North Dakota sit under the state mandate above. State Medicaid baseline: North Dakota Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Arkansas sit under the state mandate above. State Medicaid baseline: Arkansas Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Rhode Island sit under the state mandate above. State Medicaid baseline: Rhode Island Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Wyoming sit under the state mandate above. State Medicaid baseline: Wyoming Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in West Virginia sit under the state mandate above. State Medicaid baseline: West Virginia Medicaid (BMS) guide →
Fully-insured TRICARE East (Humana Military) plans issued in District of Columbia sit under the state mandate above. State Medicaid baseline: District of Columbia Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Mississippi sit under the state mandate above. State Medicaid baseline: Mississippi Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Delaware sit under the state mandate above. State Medicaid baseline: Delaware Medicaid (DMAP / Diamond State Health Plan) guide →
The questions that decide whether a family can start with TRICARE East (Humana Military), and what they have to bring. Each maps onto something intake should ask on the first call.
None. DHA states plainly that the Autism Care Demonstration carries no age limit, no time limit and no yearly or lifetime dollar cap on ABA. What ages out is the diagnosing pathway, not the benefit: if the first ASD diagnosis comes at age 8 or later it must come from a specialized ASD diagnosing provider rather than a primary care provider. Separately, whether the child is still a TRICARE-eligible dependent is its own eligibility question — the ACD gates on plan enrollment, not on age.[1][12]
Two clocks, and both belong on the intake form. First, the diagnosis: a child diagnosed more than two years before ABA is requested must get an updated diagnostic assessment — so ask for the date of the initial ASD diagnosis, not just the diagnosis. Second, the referral: it runs two years, and every two years an approved ASD diagnosing provider must issue a new referral with an updated DHA-approved DSM-5 checklist. Neither is the ABA provider’s to sign, which is why the two-year renewal is a diary item to set on day one rather than a task to discover at reauthorization. Outcome measures carry their own window: they must be completed no earlier than 90 days before their due date.[1][12][9]
A closed list, and the single most common intake failure on a TRICARE case. Approved primary care providers are limited to family practice physicians, pediatricians, and pediatric or family nurse practitioners. Approved specialists are board-certified or board-eligible physicians in developmental-behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology, or adult or child psychiatry, plus doctoral-level licensed clinical psychologists and Doctors of Nursing Practice meeting specific criteria. A physician assistant or an unlisted specialty cannot diagnose or refer for the ACD, whatever their scope elsewhere. And a first diagnosis at age 8 or later must come from the specialist half of the list. 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.[18][1][2][12]
Two instruments-and-forms requirements, on different clocks. At the door, the referral must carry “a definitive diagnosis of ASD using the DSM-5 (or current edition) criteria,” those criteria “must be documented in a DHA-approved checklist in the referral,” and a validated assessment tool must accompany the referral and confirm the diagnosis. Then, for the life of the case, four standardized outcome measures are mandatory and “must be received prior to issuing a treatment authorization”: the PDDBI at baseline and every six months (the ABA supervisor completes the teacher form), the Vineland-3 at baseline and annually, the SRS-2 parent form at baseline and annually, and the PSI-4 short form (birth through 12) or the SIPA (ages 11 to 19) at baseline and every six months. Submission mechanics bounce as many authorizations as scores do: measures completed no earlier than 90 days before their due date, the full publisher print report or hand-scored protocols, scores that “cannot be imbedded within the TP or any other clinical documents,” a respondent name and relationship that match across all forms, and — for the Vineland-3 — all composite scores including both maladaptive behavior composites. Where the ABA provider administers a measure, bill CPT 97151 with a 99 modifier.[12][9][3][1]
Required, defined, and renewable on a two-year clock. The referral is a document rather than a note: it must include a definitive DSM-5 ASD diagnosis by a PCM or specialized ASD diagnosing provider, the DSM-5 criteria documented in a DHA-approved checklist, and a validated assessment tool confirming the diagnosis. On a complete referral Humana Military authorizes the initial assessment, treatment-plan development and the outcome measures, provided an authorized ABA supervisor has an opening; a six-month treatment authorization follows the completed assessment and baseline measures. For active duty families a second, non-clinical gate applies and intake should ask about it on the first call: the sponsor must enrol the child in their branch’s Exceptional Family Member Program, and the child must register for the Extended Care Health Option. Without the ECHO path, ABA cannot be authorized regardless of the clinical picture. “Claims for services rendered without prior authorization will be denied.”[8][12][1]
One code, after six months. The DHA rule Humana Military works under (TRICARE Operations Manual Ch. 18, Sec. 3) says 97151, 97153, 97155, 97157 and 97158 “may not be conducted via TH,” and that parent/caregiver sessions under 97156 “may be conducted via TH only after the first six-month authorization period per authorized provider,” must “include the GT or 95 modifier on claims,” and must follow state telehealth law and TPM Ch. 7, Sec. 22.1. Asynchronous telehealth is excluded outright. Humana Military adds the documentation consequence: the progress note must record the place of service as home, clinic/center, daycare (non-preschool), school, community or telemedicine, and GPS coordinates do not satisfy that.[18][10][1]
Every ABA service is pre-authorized, and there is no published expedited track. The DHA rule the contractor works under: it “shall complete 100% clinical necessity reviews for ABA services for all compliant TPs within five business days for authorization processing standards.” Humana Military authorizes the initial assessment “upon receipt of all necessary documents,” and missing clinical information “may result in delays, terminations of authorized care and denials.” The clock that matters is reauthorization: “Humana Military does not accept retrospective referrals and will not backdate late submissions. Providers can submit requests for ongoing treatment up to 60 days in advance. However, submitting requests less than 30 days before the current authorization expires may result in non-reimbursement.” Diary every six-month auth for day 60 before expiry, and never later than day 30.[18][8][16]
“TRICARE is the secondary payer to all health benefits and insurance plans, except for Medicaid, TRICARE supplements, the Indian Health Service and other programs or plans as identified by Defense Health Agency (DHA).” With Medicaid, TRICARE pays first (“In any double coverage situation involving Medicaid, CHAMPUS is always the primary payer”). Otherwise “the provider must bill the OHI first,” then file with TRICARE showing the other plan’s payment. OHI normally waives TRICARE referrals and authorizations, but ABA is on Humana’s list of services that “require prior authorization even when OHI coverage exists” — get the ACD authorization too. TRICARE will not pay amounts the other plan denied “because the beneficiary failed to meet some other requirement of coverage,” so follow the primary plan’s PA rules as well.[16][20][18]
Coverage decides whether TRICARE East (Humana Military) 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.
Assistant behavior analysts and behavior technicians must receive supervision in accordance with their certifying and licensing bodies. Behavior technicians may not conduct the ABA assessment or establish the treatment plan. Only one authorized ABA supervisor is approved to provide ABA for a beneficiary at a time; a consulting supervisor does not take over the plan or the billing. Supervision itself is not a payable service — training and supervising a behavior technician is an express exclusion.[12][11]
Excluded for all ACD Category I codes except where the family and the beneficiary receive separate services and the beneficiary is not present in the family session — documentation must show two separate rendering providers and two separate locations (two rooms in the same building qualify). If 97153 and 97155 are billed concurrently, the higher rate is paid and the other is denied. Where 97151 and 97156 fall on the same date and time with different rendering providers, modifier HS (beneficiary not present) or HR (beneficiary present) must be applied or the claim denies for concurrent billing.[12][7]
The ceilings are DHA’s, set in TRICARE Operations Manual Ch. 18, Sec. 3, which Humana Military’s ABA FAQ names as the governing reference. 97151 (assessment): the contractor authorizes “up to 32 units (eight hours) for the initial request of ABA services to complete an initial ABA assessment and TP development (to include administration, scoring, and review of the PDDBI),” then “up to 24 units (six hours) for reassessments and TP updates for every subsequent authorization” — i.e. one reassessment per six-month authorization. 97151 “must be used within 14 calendar days of the first date of service for CPT code 97151 and is a use or lose concept”; Humana Military states that if all 97151 cannot be completed in 14 days “the claim will be denied,” with the appeals process for delays outside the provider’s control. Outcome measures are authorized separately as 97151 with modifier 99. Per-day denials: 97153 above “32 units (eight hours) per day or 160 units (40 hours) per week”; 97155 above eight units (two hours) per day; 97156 above eight units (two hours) per day.[18][12][9]
Progress notes must carry the name and credentials of the rendering ABA supervisor, assistant behavior analyst or behavior technician, with a dated signature. Notes are not submitted with claims but are pulled in ABA quality audits and compared against the claims. Required elements include beneficiary name, date and start/end times with session length, place of service, participants and their relationship to the beneficiary, clinical status as DHA defines it, a narrative session summary, techniques used, response to treatment and progress toward goals. A treatment plan alone does not satisfy the 97151 note requirement.[10]
The note must record the place of service as home, clinic/center, daycare (non-preschool), school, community or telemedicine — GPS coordinates do not satisfy this. ABA rendered by a behavior technician in a school is not covered; a BCBA may be authorized for focused, time-limited, contractor-approved goals after clinical necessity review. Community locations must be authorized before services are rendered. Educational, vocational and activities-of-daily-living goals are excluded in every setting. Code-level limits come from TRICARE Operations Manual Ch. 18, Sec. 3: the daycare setting “is not considered an academic setting and therefore may be authorized per clinical necessity,” but 97156 “may be used only in a home or clinic/office-based setting” and 97157 “only in a clinic/office-based setting.”[2][10][11][18]
Only authorized ABA supervisors or Autism Care Corporate Services Providers may bill. Claims must be submitted by the rendering practitioner and the rendering and billing providers must match — a mismatch is one of the documentation failures Humana Military calls out. HIPAA taxonomies: behavior analyst 103K00000X, assistant behavior analyst 106E00000X, behavior technician 106S00000X.[12][10]
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.
At least 45 calendar days. The TRICARE Operations Manual says termination “must not occur abruptly” and that “All termination plans must be submitted at least 45 calendar days prior to the termination of services.” A supervisor who stops abruptly is reported to the credentialing or licensure board. This is the payer rule, not legal advice.
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.
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.
Yes, but not through the regular medical benefit. ABA is covered under the Comprehensive Autism Care Demonstration, a separate program currently authorized through Dec. 31, 2028 and administered in the East Region by Humana Military. Every ABA service requires prior authorization.
Four: the PDDBI (baseline and every six months, with the ABA supervisor completing the teacher form), the Vineland-3 (baseline and annually), the SRS-2 (baseline and annually), and the PSI-4 short form for ages birth through 12 or the SIPA for ages 11 to 19 (baseline and every six months). They must be received before a treatment authorization will issue.
The authorization does not issue. Humana Military will put an ACD team associate on resolving the barrier, but states that if the barriers cannot be resolved, ABA services will not be able to be authorized.
No. DHA states that ABA rendered by a behavior technician in the school setting is not covered. A BCBA may be authorized where there is a clinically necessary, focused and time-limited goal, but only with pre-authorization and contractor approval of the goals.
Every two years. An approved ASD diagnosing provider must issue a new referral and an updated DHA-approved DSM-5 checklist; the ABA provider cannot supply either. Treatment authorizations themselves run in six-month increments.
The copayment or cost-share for their plan, with one copayment covering all ABA services on the same day. Active duty family members in TRICARE Prime pay $0 for network specialty care; retirees and others pay $39. Select amounts run $33 to $52 network depending on category and group. There is no yearly or lifetime cap on ABA.
Yes. Under TRICARE Operations Manual Ch. 18, Sec. 3, the initial assessment and treatment plan are authorized for up to 32 units (eight hours) of 97151, including the PDDBI, and each later reassessment for up to 24 units (six hours) per authorization, which is once every six months. The units must be used within 14 calendar days of the first 97151 date of service or the claim is denied. Outcome measures are authorized separately as 97151 with modifier 99.
No. Humana Military does not accept retrospective referrals and will not backdate late submissions, and its 2026 provider handbook states that retrospective authorization is not allowed. Get the authorization before the first session, and file reauthorizations 30 to 60 days before the current one expires.
The assessment, yes; treatment, no. DHA allows a second-opinion authorization for 32 units of 97151 to overlap another approved authorization, but two ongoing treatment authorizations for direct services are not permitted. Humana Military approves only one authorized ABA supervisor to provide ABA for a child at a time. If the family moves to the new agency, the new treatment authorization cannot start until the old one ends.
Only parent training (97156), only after the first six-month authorization, and only if the BCBA is licensed where the child is. Humana Military requires virtual-health providers to be licensed both where they practice and where the beneficiary is located at the time of service, and checks this in claims review. The assessment and direct ABA codes cannot be delivered by telehealth under the ACD at all.
DHA publishes the rates. The ABA Maximum Allowed Amounts file effective May 1, 2026 sets a per-15-minute maximum by locality and credential, for example Alabama: 97151 $31.56, 97153 by a behavior technician $16.82, 97155 by a BCBA $31.25. Look up the locality where care is delivered on health.mil.
No. DHA’s ACD rule says 97156 “may be used only in a home or clinic/office-based setting,” and 97157 only in a clinic or office. A daycare can be authorized for direct ABA (97153, 97155) when it is clinically necessary, but parent training belongs at home, in the clinic, or by telehealth after the first six-month authorization.
One year from the date of service, per Humana Military’s ABA FAQ. Its 2026 handbook asks network providers to file electronically within 90 days. Humana Military says claims can take up to 30 days to process under its contract.
Humana Military’s 2026 handbook says providers treating beneficiaries on a referral “should also include the referring provider’s NPI on transactions, if available.” Billing and rendering NPIs are required, and the ACD requires the rendering provider’s NPI and taxonomy on every line.
90 calendar days. Administrative reviews (payment amount, coding, timely filing, missing authorization) are due within 90 days of the EOB or remittance; appeals of not-covered or not-medically-necessary denials within 90 days of the denial. Network providers can appeal only on the family’s behalf with a signed Appointment of representative form.
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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