TRICARE West ABA coverage under TriWest.

The TRICARE West Region changed hands on Jan. 1, 2025: TriWest Healthcare Alliance replaced the prior contractor, and six states — Arkansas, Illinois, Louisiana, Oklahoma, Texas and Wisconsin — moved from East to West on the same date. If your intake notes still route West cases to the old contractor, or route Texas to the East, you are sending referrals into a void. TRICARE resolves the boundary by ZIP code, so confirm by ZIP rather than by state.

What TriWest administers is the Comprehensive Autism Care Demonstration, not a commercial ABA benefit. The clinical rules are DHA’s and they are the same in both regions, but TriWest publishes them in unusual operational detail — including a place-of-service map, per-day unit ceilings and a concurrent-billing matrix — which makes the West the easiest region in which to get the operational layer right before the first session.

The region moved — get the contractor right first

TRICARE is managed in three regions. Humana Military holds the East; TriWest Healthcare Alliance holds the West under contracts that began Jan. 1, 2025. Six states that had been in the East — Arkansas, Illinois, Louisiana, Oklahoma, Texas and Wisconsin — moved to the West on that date. DHA publishes a ZIP-code lookup on its Regions page rather than a flat state list, so treat ZIP as the authority.^[10][12][1]

On the provider side, TriWest separates certification from network status: a TRICARE-certified provider with a signed Participation Agreement is a non-network participating ACD provider; adding a signed Network Agreement and TriWest credentialing makes you in-network. TriWest certifies ABA providers within 10 business days of a complete application. ACD requests and documents go through the online referral management system on the Availity provider portal, with a dedicated ACD fax line as the fallback, and TriWest staffs a separate ACD customer service line at 833-818-2525 — including up to 180 days of eligibility assistance for families who are new to the ACD or were told their documentation was incomplete.^[10][12][1]

Eligibility, diagnosis and the two-year referral cycle

Four things must be true before anything is authorized: the beneficiary is enrolled in a TRICARE health plan; a TRICARE-authorized ASD diagnosing provider has made a definitive ASD diagnosis; active duty family members are registered for the Extended Care Health Option; and the active duty sponsor is enrolled in their branch’s Exceptional Family Member Program. TriWest may grant provisional 90-day ECHO eligibility while registration completes — but if proof of EFMP enrollment is not complete within 90 days, the beneficiary is disenrolled from ECHO and loses ABA eligibility. ECHO carries its own annual $36,000 cap, and ECHO cost-sharing is separate from ABA deductibles and copayments.^[2][3]

Three diagnosis rules catch people out. If the beneficiary has never had ABA and the initial ASD diagnosis is more than two years old, an updated evaluation is required. If the first diagnosis comes at age 8 or older, the beneficiary must first be evaluated by a specialized ASD diagnosing provider. And an adult beneficiary who ages out of a diagnosing provider’s pediatric scope may only be diagnosed and referred by a clinical psychologist.^[2][3]

Referrals last two years. TriWest accepts a new referral within six months of the current one expiring, and recommends getting it no more than six months in advance. The DSM-5-TR ASD criteria checklist must be completed at ACD enrollment and every two years after — and only approved TRICARE diagnosing providers may complete it, not ABA providers. The diagnostic evaluation and the validated assessment tool are one-time requirements and are not repeated at the two-year renewal.^[2][3]

Outcome measures and the clinical necessity review

TriWest states the rule flatly: all beneficiaries need complete and valid outcome measure scores for ABA service requests to be approved. The PDDBI parent form is due before treatment and every six months; the PDDBI teacher form, completed by the treating ABA supervisor, is required with the first reassessment and every six months after. The Vineland-3 and the SRS-2 are due before treatment starts and annually. The PSI-4 short form (birth through 12 years 11 months) or the SIPA (11 through 19 years 11 months) is due before treatment and every six months — for ages 11 to 12 years 11 months either is acceptable; above that, only the SIPA. TRICARE West will accept outcome measures administered up to one year before ABA starts for a beneficiary new to the ACD.^[2][7][9]

Only the scores go in, not the questionnaires: submit the full publisher report or a clearly written hand-scored protocol with summary score sheets, labelled as parent or teacher form, with the respondent’s name and relationship to the beneficiary. Outcome measures other than the PDDBI may be authorized to the ABA provider without a separate diagnosing-provider referral, under CPT 97151 with modifier 99 and one unit per measure — but they must be requested through a treatment plan update, and requests made outside that update are cancelled. They are also not split between providers.^[2][7][9]

The review itself is substantive. TriWest’s clinical team reviews the treatment plan against goals, requested hours, location of services and outcome measure scores, and weighs level of support needed, treatment effectiveness, dose response, duration and discharge planning. If changes are required, the provider has 10 calendar days to submit a modified plan for a second review. Reauthorization requests may be filed up to 60 days in advance but no later than 30 days before the current authorization expires.^[2][7][9]

Does TRICARE require electronic visit verification (EVV) for ABA?

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).”^[19]

Does TRICARE West require graphs at the six-month reassessment?

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.”^[19][2]

TriWest’s ACD Provider Guide (September 2026 file) puts it the same way: “The ABA supervisor should update the behavior plan when needed and show progress in graphs or summaries for goals. This includes tracking skills learned or reducing problem behaviors.” The updated plan “must follow the same structure as the initial plan.” It lists new behaviors and goals and any changes based on the PDDBI and other outcome measures. It explains the barriers where scores have not improved, and it covers parent/caregiver training goals, generalization and discharge planning. It must also show how many parent/caregiver sessions took place in the period: at least six are required every six months. If the update goes in 60 to 30 days before the end date and fewer than six have happened, it should say how many more are planned.^[19][2]

Place of service: the map TriWest actually publishes

Codes, ceilings and the 97155 penalty

TriWest publishes the per-day ceilings: 97153 may not exceed 32 units (8 hours) per day or 160 units (40 hours) per week; 97155 and 97156 may not exceed eight units per day; 97157 and 97158 may not exceed six units per day with a maximum of eight participants per group. 97151 is approved at 32 units for the initial assessment and 24 units per reassessment period, with the PDDBI administration, scoring and analysis inside that allowance, and must be completed within 14 days of the first service date.^[2]

The rule with teeth is 97155. At least one 97155 session per month must be performed by the authorized ABA supervisor and cannot be delegated to an assistant behavior analyst. If it is not, a 10% penalty is applied to all ABA claims for that beneficiary for the entire six-month authorization period — waivable only if no direct-service codes were performed that calendar month. Team meetings and IEP meetings do not count, and BACB-required supervision of technicians is not billable at all; claims for supervision are denied or recouped.^[2]

Medical team conferences (99366 with the beneficiary, 99368 without) require at least three qualified health professionals from different specialties who have seen the beneficiary face-to-face within the last 60 days, and the Autism Services Navigator must be present for the entire conference for the ABA provider to be paid. One unit is authorized per six-month treatment authorization.^[2]

What the family pays, and who the navigator is

Cost-shares follow the TRICARE plan type and are charged at specialty outpatient office-visit rates. One copayment covers all ABA services on the same day, there is no annual cap for ABA services, and ABA deductibles and copayments are separate from ECHO cost-sharing. Providers may not bill beneficiaries more than 100% of the posted rates, and network providers may not bill for non-covered care unless the family was told in advance and agreed in writing. As currently published, TRICARE Prime active duty family members pay $0 for network specialty care and retirees and others pay $39; Select runs $33 to $52 network depending on category and group, with 20% or 25% non-network.^[2][11][8]

Every ACD participant in the West is assigned an Autism Services Navigator — a care manager who is the family’s main point of contact, builds the comprehensive care plan, and carries documentation through a permanent change of station. Navigators are health advocates: they do not review treatment plans for clinical necessity and do not decide coverage. Worth knowing for intake: USFHP members and overseas beneficiaries do not get an ASN.^[2][11][8]

Second opinions, changing providers and back-dating

TriWest writes the two-agency rule out. A second-opinion assessment “follows the same rules and requirements as the first assessment,” needs no new referral inside the two-year referral window, and a “second opinion, or change in provider, can also be requested as long as it is within two years of the current referral.” But “only one provider can give treatment at a time, and only one treatment authorization approval may be active at one time. If the family decides to pursue services with second opinion provider’s recommendations, the first provider’s authorization will end just before the second provider’s authorization starts.” The family should tell the current provider when it plans to hold the final session, and the first provider submits a discharge report. The DHA manual behind it: a second-opinion authorization for 32 units of 97151 “may be permitted to overlap with another approved authorization,” while two ongoing treatment authorizations are not. A provider ending services on its own must give 45 days’ notice.^[2][19]

Nothing is back-dated: TriWest states “authorizations cannot be backdated” and that there is no expedited review, so late submissions “will not be reviewed and may cause a gap in authorization.” The DHA manual adds that “A retroactive referral shall not be accepted.”^[2][19]

How do you get a TRICARE West authorization for an ABA assessment?

The ABA provider does not request the first assessment authorization. TriWest issues it once the child is enrolled in the ACD, and it is the diagnosing provider’s referral that starts the clock. The sequence below comes from TriWest’s ACD provider guide and the TRICARE West “Steps to Obtain ABA Services” page.^[2][5][16]

Can a BCBA licensed in another state treat a TRICARE West child by telehealth?

TriWest does not run its own cross-state rule; it sends providers to state law. Its West Region telehealth FAQ asks “Can providers provide telehealth services for beneficiaries across state lines?” and answers: “Requirements differ from state-to-state. Refer to respective state-specific guidance. All providers must abide by state-specific credentialing requirements.” Its ACD guide adds that supervisors and assistants “must maintain any licenses or certifications required by their respective state licensing board.” The DHA rule TriWest works under covers both ends of the call. The TRICARE Policy Manual tells contractors to instruct telehealth providers to follow licensing rules “in both the jurisdiction (site) in which they are practicing as well as the jurisdiction (site) where the patient is receiving care.” It 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 compliance with the licensing requirements of the jurisdiction “in which ABA services are provided.”^{[17][2][18][19]}

The ACD then limits what can be remote at all. 97151, 97153, 97155, 97157 and 97158 “may not be conducted via TH.” 97156 parent/caregiver sessions may be done by telehealth only after the first six-month authorization period per authorized provider, and must follow state telehealth law. An out-of-state BCBA therefore cannot assess or deliver direct ABA remotely for a TRICARE West child. They can do remote parent training only after the first six months, and only if the child’s state allows them to practise there.^{[17][2][18][19]}

What is TRICARE's fee schedule for ABA?

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: Nebraska pays 97151 $43.99, 97153 by a behavior technician $23.55 and 97155 by a BCBA $31.25; Idaho pays 97151 $32.14, 97153 by a behavior technician $17.13 and 97155 by a BCBA $31.25.^[14][15]

Can 97156 parent training be billed in a daycare under TRICARE West?

TriWest answers this in its ACD provider guide. Daycare (non-preschool) is a listed setting, POS 99, open to “All ABA provider types that are authorized in the beneficiary’s treatment plan.” It is approved only “if therapy is actively addressing the core symptoms of ASD,” and the plan must explain “why a home or center setting can’t be used.” But the 97156 limit is separate: “CPT code 97156 (Family Adaptive Behavior Treatment Guidance) may only be rendered up to eight units (2 hours) per day and may only be used in a home or clinic-based setting.”^[2][19]

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 in the West a daycare can host authorized 97153 or 97155 work, but 97156 cannot be billed there. Move the caregiver session home or to the clinic, or deliver it by telehealth (POS 02, GT or 95) once the first six-month treatment period is over.^[2][19]

How long does TriWest credentialing take for TRICARE West?

TriWest publishes the first step’s clock and not the rest. TRICARE certification: TriWest “will certify ABA providers for TRICARE within 10 business days from the receipt of a complete application,” and its ACD provider guide says certification “typically takes 10-15 days from receipt of a completed application packet.” Behavior technician certification “takes up to 10 days.” The DHA rule sets the same 10-business-day standard for technicians.^{[1][2][20][21][19][22]}

Credentialing for network status comes after that. Per the ACD guide, “Once certification is completed, any rosters with ABA supervisors will be sent to Credentialing for completion.” Only ABA supervisors (BCBA, BCBA-D, LBA or clinical psychologist) need credentialing; everyone else needs only certification. A certified supervisor can see families as a non-network participating provider, “however, these claims may not pay until the provider is fully credentialed,” and “A group’s contract is executed upon completion of credentialing all ABA supervisors listed on the initial roster.” To join the network you start with the Provider Contract Request form at JoinOurNetwork.TriWest.com.^{[1][2][20][21][19][22]}

Neither TriWest nor the DHA credentialing chapter (TRICARE Operations Manual Ch. 4, Sec. 1) states how long credentialing or contracting takes; TriWest says only that it follows URAC credentialing standards. Plan on the 10–15-day certification plus an open-ended credentialing step, submit every supervisor on the first roster, and check status with credentialing@triwest.com.^{[1][2][20][21][19][22]}

Timely filing, payment time and appeals on TRICARE West ABA claims

TriWest: claims go to PGBA “No later than one year (365 days) after services are provided,” and “TriWest strongly recommends filing claims within 30 days of the date of service.” With other insurance, the claim goes to PGBA “within 90 calendar days from the date of the Other Health Insurance (OHI) adjudication.” On payment, the DHA standard in TRICARE Operations Manual Ch. 1, Sec. 3 is that the contractor “shall process 98% retained and adjustment claims accurately and to completion within 30 calendar days from the date of receipt.”^{[23][24][25][19]}

Every line needs the rendering provider: the ACD chapter requires paid claims to “identify the name of the rendering provider for each ABA service delivered, to include the NPI of the rendering provider per unique claim line,” and “All claims for ABS CPT codes must include the HIPAA taxonomy designation of each provider type.”^{[23][24][25][19]}

Disputes: a claim reconsideration (allowed amount, OHI, timely filing, no-authorization penalties, denial codes) “must be submitted no later than 90 days from the date of the remittance” on TriWest’s reconsideration form. Appeals cover policy-limitation and medical-necessity denials, must be in writing, and must be “received within 90 days of the date on the remittance advice.” The non-network participating provider may appeal; a network provider needs a written appointment from the family.^{[23][24][25][19]}

Does TriWest require the referring provider on ABA claims?

Not as a claim field. TriWest’s ACD provider guide lists what every ABA claim must carry: the HIPAA taxonomy for each provider type (103K00000X, 106E00000X, 106S00000X), “the provider’s full name and National Provider Identifier (NPI) … for all providers authorized under the ACD,” a TIN that matches the authorization, the rendering provider (“the ABA supervisor, assistant behavior analyst, or BT”), session start and end times in military format on every line, one line per session, GT or 95 for remote parent sessions and 99 on outcome-measure units, and the place of service. A referring provider is not on that list. The referral does its work before the claim: the diagnosing provider’s referral is what TriWest verifies before it authorizes the assessment, and it lasts two years.^[2]

Can an ABA provider end services or discharge a child under TRICARE?

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.^[19]

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.^[19]

Which provider level may deliver and bill each ABA code under TRICARE?

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.^[19]

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.”^[19]

Has TRICARE announced the 2027 ABA CPT code changes?

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.^[29][30][31]

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.^[29][30][31]

What happens in a TRICARE ABA audit, and when are claims recouped?

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.^[31]

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."^[31]

How TRICARE West (TriWest) works state by state

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:

Intake gates

The questions that decide whether a family can start with TRICARE West (TriWest), and what they have to bring. Each maps onto something intake should ask on the first call.

Delivery & billing rules

Coverage decides whether TRICARE West (TriWest) 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.

Common questions

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Every ID, document, and detail this payer requires — gathered conversationally the moment a family reaches out, with insurance verified before your team touches the file.