---
title: TRICARE West ABA coverage under TriWest.
url: "https://carelu.com/payers/tricare-west-triwest"
markdown_url: "https://carelu.com/payers/tricare-west-triwest.md"
state: US (national)
payer: TRICARE West (TriWest)
kind: Commercial insurance
description: "How TRICARE West covers ABA under the Autism Care Demonstration: the TriWest referral and clinical-necessity path, required outcome measures, the published place-of-service rules for school and community, daily unit ceilings and the 97155 penalty."
last_reviewed: October 2026
---

# TRICARE West ABA coverage under TriWest.

_Payer Guide · TRICARE West (TriWest) · Last updated October 2026 · 28 primary sources_

> TriWest took the West Region on Jan. 1, 2025 — ACD rules, a published place-of-service map, and the 97155 monthly penalty.

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.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — TriWest issues an authorization for the initial ABA assessment once the beneficiary is enrolled in the ACD [5][3]
- **Prior auth for treatment**: Required — a separate treatment authorization after clinical necessity review; reauthorization is requested 60 to 30 days before expiry [5][2][3]
- **Autism diagnosis required?**: Yes — definitive ASD diagnosis by a TRICARE-authorized ASD diagnosing provider, plus a completed DSM-5-TR ASD criteria checklist and a validated assessment tool [2][3]

## At a glance

- **Covers ABA?:** Yes — under the Autism Care Demonstration, separate from the TRICARE basic benefit
- **Contractor:** TriWest Healthcare Alliance, West Region, since Jan. 1, 2025
- **Demonstration authority:** Authorized through Dec. 31, 2028
- **Prior auth:** Assessment and treatment authorized separately; treatment follows a clinical necessity review
- **Auth increments:** 6 months; reauthorization requested 60–30 days before expiry
- **Referral cycle:** Referrals last 2 years; a new DSM-5-TR checklist is required at each renewal
- **Assessment clock:** Assessment must start within 28 days of approval and 97151 completed within 14 days of the first service date
- **Parent training:** Six parent/caregiver sessions every six months; first within 30 days of each treatment authorization
- **Fee schedule:** Published by DHA per locality (eff. 5/1/2026), e.g. Nebraska 97153 by a technician $23.55/15 min

## 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

- **Home (POS 12) and clinic/center (POS 11):** Open to all ABA provider types authorized in the treatment plan. Travel to and from a clinic or center is not reimbursable. [2][4]
- **School (POS 03):** Preschool, public, private or homeschool. Only the ABA supervisor may deliver, under CPT 97153. A current IEP must accompany the treatment plan for public or private school, services must be specific and short-term with a planned fade, school hours must be separated from technician hours in the plan, and providers may not duplicate what the IEP already covers. For homeschooled children, ABA must fall outside homeschooling hours. [2][4]
- **Daycare, non-preschool (POS 99):** Daycare centers, child development centers, after-school and adult care settings are payable only where therapy actively addresses core ASD symptoms. The provider may not act as a support aide or observer during routine activities, and the plan must explain why home or center will not work and how caregivers are involved. [2][4]
- **Community (POS 99):** Grocery stores, parks, restaurants and community events, with preauthorization, using 97153 (or 97155 for protocol modification). Medical offices and appointments, sporting events, participation in sports, camps, daily-living and job-skills settings, and travel in a vehicle are excluded. [2][4]
- **Telehealth (POS 02):** Only 97156, and only after the first six-month treatment period, with GT or 95 modifier. Audio-only is not allowed under the ACD. 97151, 97153, 97155, 97157 and 97158 may not be delivered remotely. [2][4]
- **Goals excluded everywhere:** Educational, academic and vocational goals are excluded in every setting, school included. ABA supervisors may not replace academic support or act as a 1:1 aide. [2][4]

## 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]

- **Step 1 — the diagnosing provider sends the referral:** A TRICARE-authorized PCM or specialized ASD diagnosing provider submits the diagnostic evaluation, the date of the initial ASD diagnosis (month, day and year), TriWest’s DSM-5-TR ASD criteria checklist and the results of an approved validated assessment tool: STAT, ADOS-2, ADI-R, CARS-2, or GARS-3 with additional documentation. ABA providers may not complete the checklist. For active duty families, EFMP enrollment and ECHO registration complete the enrollment criteria. [2][5][16]
- **Step 2 — TriWest places a provider:** Within 15 business days of verifying the referral, TriWest identifies an ABA provider who can meet TRICARE access-to-care standards. It contacts providers to see whether they can assess and treat in time, asks the family’s preferences, and ranks candidates with its ACD Provider Steerage Model. A family may name a provider, but if it does, access-to-care cannot be guaranteed. [2][5][16]
- **Step 3 — TriWest issues the 97151 authorization:** “Once the beneficiary meets ACD enrollment criteria, TriWest will issue an authorization for an initial ABA assessment,” and the assessment is authorized to an ABA provider group. Initial assessments are approved for 32 units of 97151 (eight hours), which include the PDDBI. 97151 cannot be done by telehealth. [2][5][16]
- **Step 4 — start within 28 days, finish within 14:** The assessment must start within 28 days of the referral verification date, and the authorization’s start date is set to match that date. Every 97151 unit must fall within 14 days of the first date of service. An authorized ABA supervisor conducts the assessment, or an assistant behavior analyst if delegated. [2][5][16]
- **Step 5 — submit the treatment plan and outcome measures:** After the assessment, the provider requests treatment by submitting the treatment plan and outcome measures through the online referral management system on Availity, with the dedicated ACD fax (877-875-9037) as the fallback. TriWest completes reviews within five business days of receipt and tells the family and the provider in writing when services are approved. [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]

## 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).

- **Georgia** (mandate: Ava’s Law (O.C.G.A. § 33-24-59.10)): fully-insured TRICARE West (TriWest) plans issued in Georgia sit under the state mandate. State Medicaid baseline: [Georgia Medicaid guide](https://carelu.com/payers/georgia-medicaid).
- **North Carolina** (mandate: N.C.G.S. § 58-3-192 (autism coverage)): fully-insured TRICARE West (TriWest) plans issued in North Carolina sit under the state mandate. State Medicaid baseline: [North Carolina Medicaid guide](https://carelu.com/payers/north-carolina-medicaid).
- **Indiana** (mandate: Indiana autism insurance mandate (IC 27-8-14.2)): fully-insured TRICARE West (TriWest) plans issued in Indiana sit under the state mandate. State Medicaid baseline: [Indiana Medicaid (IHCP) guide](https://carelu.com/payers/indiana-medicaid).
- **Virginia** (mandate: Virginia autism insurance mandate (§ 38.2-3418.17)): fully-insured TRICARE West (TriWest) plans issued in Virginia sit under the state mandate. State Medicaid baseline: [Virginia Medicaid (DMAS) guide](https://carelu.com/payers/virginia-medicaid).
- **Tennessee** (mandate: Tenn. Code Ann. § 56-7-2367 (neurological parity)): fully-insured TRICARE West (TriWest) plans issued in Tennessee sit under the state mandate. State Medicaid baseline: [TennCare (Tennessee Medicaid) guide](https://carelu.com/payers/tenncare-tennessee-medicaid).
- **Ohio** (mandate: Ohio autism insurance mandate (R.C. 3923.84)): fully-insured TRICARE West (TriWest) plans issued in Ohio sit under the state mandate. State Medicaid baseline: [Ohio Medicaid guide](https://carelu.com/payers/ohio-medicaid).
- **New Jersey** (mandate: P.L. 2009, c.115 (N.J.S.A. 17:48-6ii et al.)): fully-insured TRICARE West (TriWest) plans issued in New Jersey sit under the state mandate. State Medicaid baseline: [NJ FamilyCare (New Jersey Medicaid) guide](https://carelu.com/payers/new-jersey-medicaid).
- **Maryland** (mandate: Habilitative services mandate (Md. Ins. § 15-835 + COMAR 31.10.39.03)): fully-insured TRICARE West (TriWest) plans issued in Maryland sit under the state mandate. State Medicaid baseline: [Maryland Medicaid (Medical Assistance) guide](https://carelu.com/payers/maryland-medicaid).
- **Colorado** (mandate: Colorado autism insurance mandate (C.R.S. § 10-16-104(1.4))): fully-insured TRICARE West (TriWest) plans issued in Colorado sit under the state mandate. State Medicaid baseline: [Health First Colorado (Colorado Medicaid) guide](https://carelu.com/payers/colorado-medicaid).
- **Utah** (mandate: Utah autism insurance mandate (Utah Code § 31A-22-642; caps removed 2020)): fully-insured TRICARE West (TriWest) plans issued in Utah sit under the state mandate. State Medicaid baseline: [Utah Medicaid guide](https://carelu.com/payers/utah-medicaid).
- **Arizona** (mandate: Steven’s Law (A.R.S. § 20-826.04; dollar caps repealed by SB 1590, 2025)): fully-insured TRICARE West (TriWest) plans issued in Arizona sit under the state mandate. State Medicaid baseline: [AHCCCS (Arizona Medicaid) guide](https://carelu.com/payers/arizona-ahcccs).
- **New York** (mandate: NY autism mandate (Ins. Law §§ 3216(i)(25), 3221(l)(17), 4303(ee))): fully-insured TRICARE West (TriWest) plans issued in New York sit under the state mandate. State Medicaid baseline: [New York Medicaid (NYS DOH / eMedNY) guide](https://carelu.com/payers/new-york-medicaid).
- **New Mexico** (mandate: New Mexico autism insurance mandate (NMSA 1978 § 59A-22-49)): fully-insured TRICARE West (TriWest) plans issued in New Mexico sit under the state mandate. State Medicaid baseline: [New Mexico Medicaid (Turquoise Care) guide](https://carelu.com/payers/new-mexico-medicaid).
- **Missouri** (mandate: Missouri autism insurance mandate (RSMo § 376.1224)): fully-insured TRICARE West (TriWest) plans issued in Missouri sit under the state mandate. State Medicaid baseline: [MO HealthNet (Missouri Medicaid) guide](https://carelu.com/payers/missouri-medicaid).
- **Texas** (mandate: Texas autism mandate (Tex. Ins. Code § 1355.015)): fully-insured TRICARE West (TriWest) plans issued in Texas sit under the state mandate. State Medicaid baseline: [Texas Medicaid (THSteps-CCP) guide](https://carelu.com/payers/texas-medicaid).
- **Massachusetts** (mandate: ARICA — Ch. 207, Acts of 2010 (M.G.L. c. 175 § 47AA et al.)): fully-insured TRICARE West (TriWest) plans issued in Massachusetts sit under the state mandate. State Medicaid baseline: [MassHealth (Massachusetts Medicaid) guide](https://carelu.com/payers/masshealth-massachusetts-medicaid).
- **Florida** (mandate: Steven A. Geller Autism Coverage Act (§ 627.6686, Fla. Stat.)): fully-insured TRICARE West (TriWest) plans issued in Florida sit under the state mandate. State Medicaid baseline: [Florida Medicaid — Behavior Analysis Services (AHCA) guide](https://carelu.com/payers/florida-medicaid).
- **Kansas** (mandate: Kansas autism insurance mandate (K.S.A. 40-2,194)): fully-insured TRICARE West (TriWest) plans issued in Kansas sit under the state mandate. State Medicaid baseline: [KanCare (Kansas Medicaid) guide](https://carelu.com/payers/kansas-medicaid).
- **Nebraska** (mandate: Neb. Rev. Stat. § 44-7,106 (autism coverage, 25 hr/wk cap)): fully-insured TRICARE West (TriWest) plans issued in Nebraska sit under the state mandate. State Medicaid baseline: [Nebraska Medicaid (Heritage Health) guide](https://carelu.com/payers/nebraska-medicaid).
- **Idaho** (mandate: No autism statute — DOI Bulletin 18-02 (habilitative-parity floor, plan years from 2019)): fully-insured TRICARE West (TriWest) plans issued in Idaho sit under the state mandate. State Medicaid baseline: [Idaho Medicaid guide](https://carelu.com/payers/idaho-medicaid).
- **Iowa** (mandate: Iowa autism mandates (Iowa Code §§ 514C.31, 514C.28; caps and age limits removed by H.F. 330 from 1/1/2026)): fully-insured TRICARE West (TriWest) plans issued in Iowa sit under the state mandate. State Medicaid baseline: [Iowa Medicaid (IA Health Link) guide](https://carelu.com/payers/iowa-medicaid).
- **Oklahoma** (mandate: Nick’s Law (36 O.S. § 6060.21; age and hour caps removed 2022)): fully-insured TRICARE West (TriWest) plans issued in Oklahoma sit under the state mandate. State Medicaid baseline: [Oklahoma Medicaid (SoonerCare / SoonerSelect) - Oklahoma Health Care Authority guide](https://carelu.com/payers/oklahoma-medicaid).
- **Michigan** (mandate: Michigan autism mandate (MCL 500.3406s, 550.1416e; through age 18, $50K/$40K/$30K caps allowed)): fully-insured TRICARE West (TriWest) plans issued in Michigan sit under the state mandate. State Medicaid baseline: [Michigan Medicaid guide](https://carelu.com/payers/michigan-medicaid).
- **Hawaii** (mandate: Luke’s Law (HRS § 431:10A-133; under 14, $25,000/yr ABA cap)): fully-insured TRICARE West (TriWest) plans issued in Hawaii sit under the state mandate. State Medicaid baseline: [Hawaii Medicaid (Med-QUEST / QUEST Integration) guide](https://carelu.com/payers/hawaii-medicaid).
- **California** (mandate: SB 946 autism mandate (H&S § 1374.73, Ins. Code § 10144.51; no age or dollar caps)): fully-insured TRICARE West (TriWest) plans issued in California sit under the state mandate. State Medicaid baseline: [Medi-Cal (California Medicaid) guide](https://carelu.com/payers/medi-cal-california-medicaid).
- **Pennsylvania** (mandate: Act 62 of 2008 (40 P.S. § 764h; under 21, CPI-adjusted cap $51,908 for 2026)): fully-insured TRICARE West (TriWest) plans issued in Pennsylvania sit under the state mandate. State Medicaid baseline: [Pennsylvania Medicaid (Medical Assistance) guide](https://carelu.com/payers/pennsylvania-medicaid).
- **New Hampshire** (mandate: RSA 417-E:2 autism coverage (HB 569, 2010; no age or dollar caps in current text)): fully-insured TRICARE West (TriWest) plans issued in New Hampshire sit under the state mandate. State Medicaid baseline: [New Hampshire Medicaid guide](https://carelu.com/payers/new-hampshire-medicaid).
- **Wisconsin** (mandate: Wis. Stat. § 632.895(12m) + Ins 3.36 (intensive start ages 2–9; 2026 floors $74,240 / $37,119)): fully-insured TRICARE West (TriWest) plans issued in Wisconsin sit under the state mandate. State Medicaid baseline: [Wisconsin Medicaid (ForwardHealth) guide](https://carelu.com/payers/wisconsin-medicaid).
- **South Carolina** (mandate: Ryan’s Law (S.C. Code § 38-71-280; group plans, dx by age 8, under 16, $73,400 behavioral-therapy cap for 2026)): fully-insured TRICARE West (TriWest) plans issued in South Carolina sit under the state mandate. State Medicaid baseline: [South Carolina Healthy Connections Medicaid guide](https://carelu.com/payers/south-carolina-medicaid).
- **Kentucky** (mandate: KRS 304.17A-142 autism coverage (no age, annual-benefit or visit caps since 2019)): fully-insured TRICARE West (TriWest) plans issued in Kentucky sit under the state mandate. State Medicaid baseline: [Kentucky Medicaid guide](https://carelu.com/payers/kentucky-medicaid).
- **Washington** (mandate: Mental health parity (RCW 48.44.341 et al.; RCW 48.43.766 from 2027); no stand-alone autism statute): fully-insured TRICARE West (TriWest) plans issued in Washington sit under the state mandate. State Medicaid baseline: [Washington Apple Health (Medicaid) guide](https://carelu.com/payers/washington-medicaid).
- **Connecticut** (mandate: Conn. Gen. Stat. §§ 38a-514b / 38a-488b (behavioral therapy under 21, under 26 from 1/1/2027; no dollar cap)): fully-insured TRICARE West (TriWest) plans issued in Connecticut sit under the state mandate. State Medicaid baseline: [Connecticut Medicaid (HUSKY Health) guide](https://carelu.com/payers/connecticut-medicaid).
- **Illinois** (mandate: Illinois autism mandate (215 ILCS 5/356z.14; under 21, $36,000/yr CPI-adjusted)): fully-insured TRICARE West (TriWest) plans issued in Illinois sit under the state mandate. State Medicaid baseline: [Illinois Medicaid (HFS) guide](https://carelu.com/payers/illinois-medicaid).
- **Louisiana** (mandate: La. R.S. 22:1050 (under 21, $36,000/yr cap)): fully-insured TRICARE West (TriWest) plans issued in Louisiana sit under the state mandate. State Medicaid baseline: [Louisiana Medicaid (Healthy Louisiana) guide](https://carelu.com/payers/louisiana-medicaid).
- **Oregon** (mandate: Oregon Laws 2013, ch. 771, § 2 (ABA up to 25 hr/wk, first requested under 9) + ORS 743A.168 parity): fully-insured TRICARE West (TriWest) plans issued in Oregon sit under the state mandate. State Medicaid baseline: [Oregon Health Plan (Medicaid) guide](https://carelu.com/payers/oregon-medicaid).
- **Minnesota** (mandate: Minn. Stat. § 62A.3094 (large-employer plans, children under 18)): fully-insured TRICARE West (TriWest) plans issued in Minnesota sit under the state mandate. State Medicaid baseline: [Minnesota Medical Assistance (EIDBI) guide](https://carelu.com/payers/minnesota-medicaid).
- **Maine** (mandate: Maine autism mandate (24-A M.R.S. §§ 2768, 2847-T, 4259; age 10 and under, $36,000/yr ABA cap allowed)): fully-insured TRICARE West (TriWest) plans issued in Maine sit under the state mandate. State Medicaid baseline: [MaineCare (Maine Medicaid) guide](https://carelu.com/payers/maine-medicaid).
- **Vermont** (mandate: 8 V.S.A. § 4082 (formerly § 4088i; birth to 21, no dollar or hour cap)): fully-insured TRICARE West (TriWest) plans issued in Vermont sit under the state mandate. State Medicaid baseline: [Vermont Medicaid (Green Mountain Care / DVHA) guide](https://carelu.com/payers/vermont-medicaid).
- **Alabama** (mandate: Riley Ward Act (Ala. Code § 27-54A-2; large group, 18 and under, ABA caps $40K/$30K/$20K by age)): fully-insured TRICARE West (TriWest) plans issued in Alabama sit under the state mandate. State Medicaid baseline: [Alabama Medicaid guide](https://carelu.com/payers/alabama-medicaid).
- **South Dakota** (mandate: SDCL 58-17-154 to -162 (ABA; annual floors $36,000/$25,000/$12,500 through age 18; ACA individual/small-group exempt)): fully-insured TRICARE West (TriWest) plans issued in South Dakota sit under the state mandate. State Medicaid baseline: [South Dakota Medicaid guide](https://carelu.com/payers/south-dakota-medicaid).
- **Nevada** (mandate: NRS 689B.0335 autism mandate (under 18, or 22 in high school; $72,000/yr ABA cap)): fully-insured TRICARE West (TriWest) plans issued in Nevada sit under the state mandate. State Medicaid baseline: [Nevada Medicaid guide](https://carelu.com/payers/nevada-medicaid).
- **Montana** (mandate: Montana autism mandate (MCA 33-22-515; group plans, through age 18, caps of $50,000/yr to age 8 and $20,000/yr ages 9–18 allowed)): fully-insured TRICARE West (TriWest) plans issued in Montana sit under the state mandate. State Medicaid baseline: [Montana Medicaid guide](https://carelu.com/payers/montana-medicaid).
- **Alaska** (mandate: AS 21.42.397 autism coverage (under 21; no visit or dollar caps; small groups of 20 or fewer exempt)): fully-insured TRICARE West (TriWest) plans issued in Alaska sit under the state mandate. State Medicaid baseline: [Alaska Medicaid guide](https://carelu.com/payers/alaska-medicaid).
- **North Dakota** (mandate: No autism statute — Insurance Dept. Bulletin 2018-1 (insured plans may not exclude ABA as experimental; federal parity limits)): fully-insured TRICARE West (TriWest) plans issued in North Dakota sit under the state mandate. State Medicaid baseline: [North Dakota Medicaid guide](https://carelu.com/payers/north-dakota-medicaid).
- **Arkansas** (mandate: Ark. Code § 23-99-418 (Act 196 of 2011; ABA under 18 and $50,000/yr as enacted)): fully-insured TRICARE West (TriWest) plans issued in Arkansas sit under the state mandate. State Medicaid baseline: [Arkansas Medicaid guide](https://carelu.com/payers/arkansas-medicaid).
- **Rhode Island** (mandate: R.I. Gen. Laws ch. 27-20.11 (group plans; until age 15; no dollar cap in current text)): fully-insured TRICARE West (TriWest) plans issued in Rhode Island sit under the state mandate. State Medicaid baseline: [Rhode Island Medicaid guide](https://carelu.com/payers/rhode-island-medicaid).
- **Wyoming** (mandate: No autism statute — DOI Bulletin 01-2019 (mental-health parity, W.S. 26-20-701; no ABA exclusions from 7/1/2019)): fully-insured TRICARE West (TriWest) plans issued in Wyoming sit under the state mandate. State Medicaid baseline: [Wyoming Medicaid guide](https://carelu.com/payers/wyoming-medicaid).
- **West Virginia** (mandate: W. Va. Code § 33-24-7k et al. (group plans; ages 18 months–18, dx by 8, $30,000/yr ABA cap for 3 years then $2,000/month)): fully-insured TRICARE West (TriWest) plans issued in West Virginia sit under the state mandate. State Medicaid baseline: [West Virginia Medicaid (BMS) guide](https://carelu.com/payers/west-virginia-medicaid).
- **District of Columbia** (mandate: D.C. Code §§ 31-3271–31-3272 (habilitative services incl. autism, under 21; ABA named in DC EHB benchmark)): fully-insured TRICARE West (TriWest) plans issued in District of Columbia sit under the state mandate. State Medicaid baseline: [District of Columbia Medicaid guide](https://carelu.com/payers/district-of-columbia-medicaid).
- **Mississippi** (mandate: Miss. Code Ann. § 83-9-26 (HB 885, 2015; ABA may stop at age 8 and 25 hr/wk unless medically necessary)): fully-insured TRICARE West (TriWest) plans issued in Mississippi sit under the state mandate. State Medicaid baseline: [Mississippi Medicaid guide](https://carelu.com/payers/mississippi-medicaid).
- **Delaware** (mandate: Delaware autism mandate (18 Del. C. §§ 3366, 3570A; under 21, CPI-adjusted ABA cap $38,601.65 for 2026)): fully-insured TRICARE West (TriWest) plans issued in Delaware sit under the state mandate. State Medicaid baseline: [Delaware Medicaid (DMAP / Diamond State Health Plan) guide](https://carelu.com/payers/delaware-medicaid).

## Intake gates

The questions that decide whether a family can start with TRICARE West (TriWest), and what they have to bring.

- **Age limit**: No age limit and no annual cap on ABA under the demonstration. Age instead decides which instrument and which diagnosing provider apply. If the first ASD diagnosis comes at age 8 or older, the beneficiary must first be evaluated by a specialized ASD diagnosing provider; an adult beneficiary who ages out of a diagnosing provider’s pediatric scope may only be diagnosed and referred by a clinical psychologist. On outcome measures the split is the PSI-4 short form for birth through 12 years 11 months and the SIPA for 11 through 19 years 11 months, with either acceptable in the 11 to 12 years 11 months overlap and only the SIPA above it. [2][3]
- **Diagnosis recency**: Two clocks. If the beneficiary has never had ABA and the initial ASD diagnosis is more than two years old, an updated evaluation is required. And 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. Usefully, the diagnostic evaluation and the validated assessment tool are one-time requirements and are not repeated at the two-year renewal. For a beneficiary new to the ACD, TRICARE West will accept outcome measures administered up to one year before ABA starts. [2][3]
- **Who may diagnose**: The ACD’s closed list, plus two West-specific rules. Approved primary care providers are 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 qualifying Doctors of Nursing Practice. A first diagnosis at age 8 or older requires the specialist half of the list. An adult beneficiary past a diagnosing provider’s pediatric scope may only be diagnosed and referred by a clinical psychologist. The DSM-5-TR checklist is theirs to complete, never the ABA provider’s. 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. [19][2][3][4]
- **Diagnostic tools required**: A validated tool at the door and four standardized measures for the life of the case. 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 SRS-2 are due before treatment 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. Only the scores go in — the full publisher report or a clearly written hand-scored protocol with summary score sheets, labelled parent or teacher, with the respondent’s name and relationship. 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 — requests made outside that update are cancelled, and measures are not split between providers. [2][9]
- **Referral required?**: Four conditions 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 — capture where the family sits on that clock. Referrals last two years. Treatment then follows a clinical necessity review of goals, requested hours, location of services and outcome-measure scores; if changes are required the provider has 10 calendar days to submit a modified plan for a second review, and reauthorization may be filed up to 60 days ahead but no later than 30 days before expiry. [2][7][3]
- **Telehealth**: The narrowest telehealth rule in this directory, and TriWest publishes it explicitly. Telehealth is POS 02, one code only — 97156 — and only after the first six-month treatment period, with a GT or 95 modifier. Audio-only is not allowed under the ACD at all. 97151, 97153, 97155, 97157 and 97158 may not be delivered remotely. Plan the first six months as fully in-person and treat remote parent training as an earned option rather than a starting assumption. [2]
- **Prior-auth decision time**: “TriWest will complete reviews within five business days of receipt.” If TriWest asks for more documents and they are “not received within 10 calendar days, the request will be canceled until the information is received.” There is no fast lane: “There is no expedited review process, therefore, late submissions will not be reviewed and may cause a gap in authorization,” and “authorizations cannot be backdated.” Reauthorization for each six-month period is submitted through Availity as early as 60 calendar days and no later than 30 calendar days before the current authorization ends (the DHA rule: “as early as 60 calendar days in advance and no later than 30 calendar days in advance”). [2][16][19]
- **Other insurance (who pays first)**: “For other beneficiary categories, TRICARE pays secondary to Medicare and other primary coverage. If TRICARE is the secondary payer, the provider is required to submit claims to the primary payer before billing TRICARE” (TRICARE is always primary for active-duty service members, and it pays before Medicaid, TRICARE supplements, IHS and state victims-of-crime programs). “If TRICARE receives claim before OHI processes it, the claim will be denied,” as will one without the other payer’s EOB or COB payment data; file with TRICARE within 90 calendar days of the OHI adjudication date. ABA is on TriWest’s list of services that “require a TRICARE pre-authorization regardless of OHI” — “Prior approval is needed for ABA services for all beneficiaries, even if they have other health insurance.” TRICARE will not pay what the other plan denied for failure to meet its requirements. [23][26][2][27]

## Delivery and billing rules

Coverage decides whether TRICARE West (TriWest) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: Authorized ABA supervisors are BCBAs, BCBA-Ds, licensed behavior analysts or clinical psychologists. In the tiered model they are assisted by BCaBAs, QASP-S, licensed assistant behavior analysts and behavior technicians (RBT, ABAT, BCAT or state-certified). All must hold the licences or certifications their state requires. The hard floor: the ABA supervisor must personally perform at least one 97155 session per month per beneficiary and may not delegate it, on pain of a 10% penalty on every ABA claim for that beneficiary for the whole six-month authorization. BACB-required supervision of technicians is not billable under the ACD; claims for supervision are denied or recouped. [2]
- **Concurrent billing (97153 + 97155)**: 97153 with 97155 concurrently: the higher rate is paid and the other denied. 97153 with 97156 is allowed when one provider works directly with the beneficiary while a different supervisor or assistant runs parent training without the beneficiary present. 97155 with 97156 is allowed on the same pattern. 97151 with 97153 or 97156 is allowed when a supervisor or assistant performs an assessment task while another provider delivers treatment — the beneficiary may be present for only one. 97157 with 97158 is allowed when an assistant leads the parent group while the supervisor runs the beneficiary group. [2]
- **Daily limits / MUEs**: 97153: no more than 32 units (8 hours) per day or 160 units (40 hours) per week. 97155: no more than 8 units per day. 97156: no more than 8 units per day. 97157 and 97158: no more than 6 units per day, maximum 8 participants per group. 97151: 32 units for the initial assessment and 24 units per reassessment period, plus one unit per outcome measure under a separate authorization with modifier 99. 99366/99368: one unit per six-month treatment authorization. [2]
- **Session-note signature**: Progress notes must carry the complete name and licence or certification of the rendering ABA supervisor, assistant behavior analyst or behavior technician, with a dated signature — and, where the supervisor is not the rendering provider, the supervisor’s full name as well. The note must name the place of service in words (GPS coordinates or an address do not satisfy it) and, where several services happen at one location, describe where each took place and who was present. Missing signatures, missing credentials, missing location and missing clinical status are TriWest’s named audit failures. [2]
- **Place of service**: Home POS 12 and clinic/office POS 11 for all authorized provider types (clinic travel is not reimbursable). School POS 03: supervisor-only, CPT 97153, IEP required, short-term, no duplication of IEP services, homeschool ABA outside homeschooling hours. Daycare (non-preschool) POS 99: only where therapy actively addresses core ASD symptoms and the plan justifies why home or center will not work; the provider may not act as an aide or observer. Community POS 99: preauthorization required; medical appointments, sports participation, camps, daily-living and job-skills settings and vehicle travel are excluded. Telehealth POS 02: 97156 only, after the first six-month period, GT or 95 modifier, no audio-only. Parent training is limited by code, whatever the setting: 97156 “may only be used in a home or clinic-based setting,” so it cannot be billed at a daycare, school or community site; DHA limits 97157 to a clinic/office. Educational, academic and vocational goals are excluded in every setting. [2][19]
- **Bill as provider**: The rendering provider on each line is the ABA supervisor, assistant behavior analyst or behavior technician who actually delivered the service. Assistant behavior analysts and behavior technicians are not independent providers under TRICARE policy: they cannot be listed as the billing provider and cannot bill for any ABA service, and are compensated by their authorized ABA supervisors. The DHA rule behind it: paid claims must “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 every provider on the claim carries its HIPAA taxonomy (103K00000X behavior analyst, 106E00000X assistant behavior analyst, 106S00000X behavior technician). [2][19]

## What intake should collect for TRICARE West (TriWest)

- **ZIP code, then region:** The East/West line is drawn by ZIP and six states moved on Jan. 1, 2025. Confirm West before you route anything to TriWest or Availity.
- **Plan type and sponsor category:** Prime, Select, USFHP or TRICARE Young Adult, and active duty vs. retiree — it sets the copay and, for active duty families, the EFMP/ECHO requirement.
- **EFMP and ECHO registration dates:** Provisional ECHO runs 90 days; if EFMP proof is not in by then the family is disenrolled and loses ABA eligibility. Capture where they are in the clock.
- **Referral date and expiry:** Referrals run two years. Capture the issue date, the diagnosing provider, and whether the DSM-5-TR checklist is on file — only an approved diagnosing provider can complete it.
- **Outcome measures on hand:** Which measures exist and when. TRICARE West accepts measures administered up to a year before ABA starts for a beneficiary new to the ACD.
- **Requested settings, with justification:** School requires an IEP and supervisor-only delivery; community requires preauthorization; daycare requires a written reason home or clinic will not work. Ask on the first call, not at plan-writing.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Common questions

### Can an RBT or BCaBA bill ABA codes under TRICARE?

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.

### How much notice must an ABA provider give before stopping TRICARE ABA services?

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.

### Can an LCSW diagnose autism for TRICARE ABA?

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.

### Does TRICARE require EVV for ABA sessions?

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.

### Does TRICARE require graphs for ABA reassessments?

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. TriWest’s provider guide asks the supervisor to “show progress in graphs or summaries for goals.”

### Does TRICARE West (TriWest) require the referring provider on ABA claims?

TriWest’s ACD provider guide does not list one among the claim requirements. It requires each provider’s taxonomy, name and NPI, a TIN matching the authorization, the rendering provider, session times on every line, one line per session, the right modifiers and the place of service. The referral is checked when TriWest authorizes care, not on the claim.

### Who administers TRICARE West now?

TriWest Healthcare Alliance, under contracts that began Jan. 1, 2025. Six states — Arkansas, Illinois, Louisiana, Oklahoma, Texas and Wisconsin — moved from the East Region to the West on that date. TRICARE resolves the boundary by ZIP code lookup.

### Can ABA be delivered in a school in the West Region?

Yes, but narrowly. Only the authorized ABA supervisor may deliver, under CPT 97153, with a current IEP submitted alongside the treatment plan, specific school-setting goals targeting core ASD symptoms, a short expected duration and a planned fade. Providers may not duplicate IEP services or target academic goals.

### What is the 97155 monthly rule?

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 that is not met, TriWest applies a 10% penalty to all ABA claims for that beneficiary for the entire six-month authorization period.

### How far ahead can a reauthorization be filed?

Up to 60 calendar days before the current authorization ends, and no later than 30 days before it expires. Submissions inside 30 days risk a gap in care.

### How long is an ACD referral good for?

Two years, regardless of a move. TriWest accepts a new referral within six months of expiry, and a new DSM-5-TR ASD criteria checklist is required at each renewal — completed by an approved TRICARE diagnosing provider, not by the ABA provider.

### Do West Region families get an Autism Services Navigator?

Yes — every ACD participant in the West is assigned one. Navigators coordinate care, build the comprehensive care plan and carry documents through a PCS move, but they do not review treatment plans for clinical necessity or decide coverage. USFHP members and overseas beneficiaries do not get one.

### How many 97151 units does TriWest authorize for an ABA assessment?

Initial assessments are approved for 32 units (eight hours) per authorization period and reassessments for 24 units (six hours), including the PDDBI. The units must be completed within 14 days of the first service date, and 97151 cannot be done by telehealth. Each outcome measure gets one separately authorized 97151 unit billed with modifier 99.

### Can TriWest back-date an ABA authorization?

No. TriWest states that authorizations cannot be backdated and there is no expedited review, so a late reauthorization can leave a gap in coverage. File each reauthorization 30 to 60 days before the current one ends.

### Can a second ABA provider assess a child while the first keeps treating under TRICARE West?

Yes for the assessment: a second-opinion assessment is allowed within the two-year referral window with no new referral. But only one provider can give treatment at a time, and only one treatment authorization can be active. If the family switches, the first provider’s authorization ends just before the second provider’s starts, and the first provider submits a discharge report.

### What is the process to get a TRICARE West authorization for an ABA assessment?

The diagnosing provider sends TriWest a complete referral: the diagnosis and its date, the DSM-5-TR checklist and a validated assessment tool, plus EFMP/ECHO for active duty families. Once the child is enrolled in the ACD, TriWest places a provider within 15 business days and issues the initial assessment authorization itself, 32 units of 97151. The assessment must start within 28 days of referral verification and be finished within 14 days of the first session. The treatment plan and outcome measures then go in through Availity.

### Can an out-of-state BCBA provide ABA by telehealth to a TRICARE West family?

Only parent training (97156), only after the first six-month authorization, and only where the child’s state allows it. TriWest says cross-state telehealth requirements differ by state and providers must follow state-specific credentialing rules. The DHA manual requires compliance with licensing rules both where the provider practises and where the patient receives care. Assessment and direct ABA cannot be delivered by telehealth under the ACD.

### What does TRICARE pay for ABA in the West Region?

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 Nebraska: 97151 $43.99, 97153 by a behavior technician $23.55, 97155 by a BCBA $31.25. Look up the locality where care is delivered on health.mil.

### Can we bill 97156 in a daycare for a TRICARE West child?

No. TriWest’s ACD guide says 97156 “may only be used in a home or clinic-based setting.” A non-preschool daycare (POS 99) can be approved for direct ABA that targets core ASD symptoms, but parent training has to happen at home, in the clinic, or by telehealth after the first six-month treatment period.

### How long does it take to credential with TriWest for TRICARE West ABA?

TriWest publishes only the certification clock: within 10 business days of a complete application on its ACD page, and “typically” 10–15 days in its provider guide. Credentialing of ABA supervisors follows, with no published timeframe. Claims may not pay until the supervisor is fully credentialed, and a group contract is executed once every supervisor on the initial roster is credentialed.

### What is TriWest’s timely filing limit for TRICARE West ABA claims?

One year (365 days) from the date of service, and TriWest recommends filing within 30 days. When other insurance pays first, file within 90 calendar days of the other plan’s adjudication.

### How long do we have to appeal a TRICARE West ABA claim?

90 days from the remittance for both a claim reconsideration and an appeal. Appeals are limited to policy-limitation and medical-necessity denials and must be in writing.

## Primary sources

1. [TriWest — Autism Care Demonstration (TRICARE West provider)](https://tricare.triwest.com/en/provider/autism-care-demonstration/)
2. [TriWest — Autism Care Demonstration Provider Guide (PDF)](https://tricare.triwest.com/globalassets/tricare/provider/autism-care-demostration-provider-guide.pdf)
3. [TRICARE — Autism Care Demonstration](https://tricare.mil/Plans/SpecialPrograms/ACD)
4. [TRICARE — Autism Care Demonstration Q&A](https://tricare.mil/Plans/SpecialPrograms/ACD/QandA)
5. [TRICARE West — Steps to Obtain ABA Services](https://tricare.mil/About/Regions/West-Region/Find-Care/Autism-Care-Demonstration/How-to-Obtain-ABA-Services)
6. [TRICARE West — Ongoing ABA Services](https://tricare.mil/About/Regions/West-Region/Find-Care/Autism-Care-Demonstration/Ongoing-ABA-Services)
7. [TRICARE West — Clinical Necessity Reviews](https://tricare.mil/About/Regions/West-Region/Find-Care/Autism-Care-Demonstration/Clinical-Necessity-Reviews)
8. [TRICARE West — Autism Services Navigator](https://tricare.mil/About/Regions/West-Region/Find-Care/Autism-Care-Demonstration/Autism-Services-Navigator)
9. [TRICARE — Understanding Outcome Measures for ABA Services](https://tricare.mil/About/Regions/West-Region/Find-Care/Autism-Care-Demonstration/Outcome-Measures)
10. [TRICARE — Regions](https://tricare.mil/About/Regions)
11. [TRICARE — Compare Health Plan Costs](https://tricare.mil/Costs/Compare)
12. [Humana Military — Beneficiaries in the new TRICARE contract](https://www.humanamilitary.com/beneupdates)
13. [Federal Register — Extension of the Comprehensive Autism Care Demonstration (Aug. 4, 2022)](https://www.govinfo.gov/content/pkg/FR-2022-08-04/html/2022-16742.htm)
14. [DHA — ABA Maximum Allowed Rates, effective May 1, 2026 (Autism Care Demonstration, by locality)](https://health.mil/Reference-Center/Publications/2026/04/01/ABA-Rates-2026)
15. [DHA — Applied Behavior Analysis Maximum Allowed Amounts (all years)](https://health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Rates-and-Reimbursement/ABA-Max-Allowed-Amounts)
16. [TriWest — TRICARE West Region ACD Quick Reference Guide (rev. April 6, 2026)](https://tricare.triwest.com/globalassets/tricare/provider/tricare-west-region-autism-care-demonstration-qrg.pdf)
17. [TriWest — TRICARE Provider Telehealth/Telemedicine FAQs, West Region (June 26, 2025)](https://tricare.triwest.com/globalassets/tricare/provider/tricare-provider-telehealth-telemedicine-faqs.pdf)
18. [TRICARE Policy Manual 6010.63-M (2021 ed.), Ch. 7 Sec. 22.1 — Telehealth (Revision C-54, Jun 24, 2026)](https://manuals.dha.mil/View-Publication/TPT5/FileName/C7S22_1)
19. [TRICARE Operations Manual 6010.62-M (2021 ed.), Ch. 18 Sec. 3 — Autism Care Demonstration (Revision C-57, Jun 24, 2026)](https://manuals.dha.mil/View-Publication/TOT5/Revision/66/FileName/C18S3)
20. [TriWest — Provider Certification and Credentialing (TRICARE West)](https://tricare.triwest.com/en/provider/intro-to-tricare/certification-and-credentialing/)
21. [TriWest — Join Our Network (TRICARE West)](https://tricare.triwest.com/en/provider/join-our-network/)
22. [TRICARE Operations Manual 6010.62-M (2021 ed.), Ch. 4 Sec. 1 — Provider Certification and Credentialing (Revision C-57, Jun 24, 2026)](https://manuals.dha.mil/View-Publication/TOT5/FileName/C4S1)
23. [TriWest — Timeliness and EFT/ERA (TRICARE West claims guidelines)](https://tricare.triwest.com/en/provider/claims-guidelines/timeliness-and-eft-era/)
24. [TriWest — Reconsiderations and Appeals (TRICARE West claims guidelines)](https://tricare.triwest.com/en/provider/claims-guidelines/reconsiderations-and-appeals/)
25. [TRICARE Operations Manual 6010.62-M (2021 ed.), Ch. 1 Sec. 3 — TRICARE Processing Standards (Revision C-43, Jun 24, 2025)](https://manuals.dha.mil/View-Publication/TOT5/FileName/C1S3)
26. [TriWest — TRICARE Provider Handbook: Claims Processing and Billing Information](https://tricare.triwest.com/en/provider/tricare-provider-handbook/claims-processing-and-billing-information/)
27. [eCFR — 32 CFR 199.8, Double coverage](https://www.ecfr.gov/current/title-32/subtitle-A/chapter-VII/subchapter-M/part-199/section-199.8)
28. [TriWest — Provider Pulse newsletter archive (TRICARE West, monthly issues)](https://tricare.triwest.com/en/provider/provider-pulse/provider-pulse-archive/)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.