Fillable Initial and Re-Assessment Treatment Plan Content

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Initial and Re-Assessment Treatment Plan Content

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1
Applied Behavior Analysis (ABA)
Initial and Re-Assessment
Treatment Plan Content
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.
Overview
TRICARE requires specific information be included in all initial treatment plans and reassessments submitted to Health Net
Federal Services, LLC (HNFS) as part of its Comprehensive Autism Care Demonstration (Autism Care Demo). Please reference
TRICARE Operations Manual at http://manuals.tricare.osd.mil for complete details.
Denition and Rules
• A treatment plan is a written document outlining the provider’s plan of care for TRICARE patients receiving applied
behavior analysis (ABA) services.
• Submit all ABA treatment plans to HNFS, along with an Outpatient TRICARE Ongoing/Notification Request Form. Use
our online authorization and referral submission tool at www.tricare-west.com > I’m a Provider > Secure Tools/Submit
Authorization Requests.
• Submit all reassessments/updated treatment plans to HNFS between 30–60 days prior to the end of a patient’s authorization
period. Please follow this guideline to avoid delays or terminations of authorized care, or denials for pended claims. Health
Net Federal Services will not issue retrospective authorizations if supporting clinical documentation is submitted less than
30 days prior to the end of the authorization period.
Required Content
IDENTIFYING INFORMATION
• name of beneficiary
• date of birth
• date of initial assessment
• DoD Benefit Number (DBN) or Social Security number (SSN)
• referring provider /physician-primary care manager (P-PCM)
• Autism Corporate Service Provider/company
• date and time of reassessment
• Board Certified Behavior Analysts® (BCBAs) /Board Certified Assistant Behavior Analysts® (BCaBAs) conducting
assessment and/or treatment plan re-assessments
BACKGROUND AND HISTORY
• School
• Is the child of school age?
• Is the child enrolled in school?
• What are his/her specific hours in school?
• IEP (only required if services are requested in a public or private school setting)
• Include the current and signed Individualized Education Plan (IEP).
• Indicate the IEP was submitted to HNFS or document the reason for an attestation.
• Other Services
• Specify the hours for other services indicated (occupational/speech therapy).
• Include a statement specifying if no other services were received.
A Wholly-Owned Subsidiary of Centene Corporation
2
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.
• Diagnosis
• Please code to the most specific level possible.
• Severity of Symptoms (determined by the specialized diagnosing provider):
• Include statement of the level of severity (mild – level 1, moderate – level 2, severe – level 3).
• Example: Patient A was given a diagnosis of Autism Spectrum Disorder (F84.0), severity level 1 (mild) by Dr. Smith,
Developmental Pediatrician
• Prescribed medications (if applicable)
• Medical Co-Morbidities (if applicable)
• Include a statement if the beneficiary does not have any other medical co-morbidities.
• Family History
• Include any family history and related family training in support of performing ABA therapy.
• Specify where the beneficiary lives and with whom (siblings, parents).
• Include any other relevant information about family stressors, such as medical history, active medical problems, current
medications, dose and purpose, allergies, and/or special diet.
• Medications
• Length of Care
• Specify the amount of time the patient has been receiving ABA services (start date of entrance into the Autism Care
Demo to current).
• Location of Services
• Parent/Guardian Signature
• ABA Supervisor Name
• Use of PDD-BI for beneciaries under the age of 18.5. For benecaries over the age of 18.5 the ABA supervisor should
continue using the assessment already in process.
• Location of services (for example, school, at home, centerbase/clinic)
INITIAL ASSESSMENT: REQUIRED COMPONENTS
• Behavior Deficits: Behavior deficits are those that impede the beneficiary’s safe, healthy independent functioning in all
domains (socialization, communication, adaptive).
• Behavior deficits must be objectively measured and identified.
• Include assessment notes (baseline/skill level at time of assessment) regarding the beneficiary’s performance when the initial
assessment was completed and baseline measures of the assessment tool utilized (for example, VB-MAPP) and specified
treatment interventions for identified target in each domain.
• Goals/Objectives: Goals and objectives must be specific, measurable (6 out of 10 opportunities, 8 out of 10 trials, etc.) and
the assessment tool domain must be identified (for example, VB-MAPP, Carolina, ABLLS).
• Goals are the broad spectrum, complex short-term and long-term desired outcomes of ABA.
• Objectives are the short, simple, measurable steps that must be accomplished in order to reach the short-term and long-term
goals of ABA.
• Include clearly defined objectives and goals individualized to the strengths, needs and preferences of the beneficiary and his/
her family members.
• Identify long term goals (for example, six months in duration) and short-term objectives, such as the intermediary steps to
meet long term goal.
• Update goals with each reassessment and clearly note if met, not met or modified with an explanation.
3
• ABA Intervention Procedure
• List the ABA intervention procedure for goal management (for example, task analysis [TA], discrete trial training [DTT]).
• Generalization Goals/Family Goals:
• Family goals and objectives are selected jointly by the authorized ABA supervisor and the parents(s)/caregiver(s).
• Family goals should include mastered goals that will be targeted for generalization.
• Generalization goals should be specific and measurable.
• Example: Mr. and Mrs. Smith will instruct Child A to brush teeth and utilize the task analysis data sheet and backward
chaining as instructed by the BCBA one time per day across five consecutive days.
• Example: Mr. and Mrs. Smith will instruct Child A to complete his independent work station once per day on
non-school days across a four-week period and use prompting strategies to assist in independence while taking
data on bene’s performance.
• Behavior Intervention Plan (BIP) for Target Behavior Excesses
• The BIP should be developed by the BCBA or assistant behavior analyst to address, as applicable, a behavior that interferes with
the patient’s ability to learn new skills or display mastered skills, disrupts the learning environment, prevents integration
with peers and in the community (dangerous to self/other), and appropriate behaviors in excess.
• The BIP should include the following:
• dates (date created and revision dates)
• operational definition(s)
• episodic severity
• baseline data
• hypothesized function(s) of behavior(s)
• functional alternative response
• setting events
• precursor behaviors
• antecedents for target behavior(s) (environmental, behavioral)
• data collection methods
• antecedent/prevention strategies for target behavior(s)
• consequence strategies
• direct treatment (intermittent schedules of reinforcement, differential schedules of reinforcement)
• goal for reduction (include in the treatment plan)
• goal for replacement (include in the treatment plan)
• crisis plan (if needed)
• generalization and maintenance of replacement behavior(s) (include in the treatment plan)
• Beneficiary Participation Statement
• Include a statement attesting the beneficiary can actively participate in ABA services.
• CPT® Code Recommendations
• List each CPT code based on the hours to be provided to the beneficiary.
Example
Authorization
Period
97151 97153 97156 97155
1/1/19–6/29/19 16 units/authorization period 50 units/week 8 units/month 16 units/month
7/1/19–12/31/19 16 units/authorization period 50 units/week 8 units/month 16 units/month
1/1/20–6/29/20 16 units/authorization period 40 units/week 6 units/month 12 units/month
4
TREATMENT PLAN RE-ASSESSMENT REQUIRED COMPONENTS
• Date and Time of Reassessment
• Indicate the date and time the BCBA or assistant behavior analyst conducted the re-assessment for a new authorization.
• Authorized ABA Supervisor
• If the assistant behavior analyst has written the treatment plan, please note the name of the BCBA and the name of the
assistant behavior analyst.
• Beneficiary Participation Statement
• See description in “Initial Assessment” section.
• Goals/Objectives
• See description in “Initial Assessment” section.
• ABA Intervention Procedure
• See description in “Initial Assessment” section.
• Graphic Representation of Progress to Goals
• ABA TP update assessment notes address 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. Documentation should note interventions that were ineffective and required modification
of the TP. TP updates shall document TP modifications that were the result of the outcome evaluations.
• Tips for graph presentation:
• Include original baseline measurement and all treatment data.
• Use symbols or styles that are easily identified in black and white (such as fax copies).
• Limit number of targets represented on a single graph.
• Include axis labels.
• Include linear trend lines.
• Identify reasons for outliers or a lack of progress.
• Change lines for introduction of new variables/contingencies/targets.
• Include figure caption at the bottom of graph.
• Evaluation of progress on each treatment target (i.e., Met, Not Met, Discontinued).
• Prescribed Medications
• Include a statement if the beneficiary does not have any prescribed medications.
• Generalization Goals/Family Goals
• See description in “Initial Assessment” section.
• Behavior Intervention Plan (BIP) for Target Behavior Excesses
• See description in “Initial Assessment” section.
• Parent/Family Participation Statement
• Include a statement attesting the parent/family is or is not actively participating in ABA program.
• CPT Codes Recommendation
• Update based on data analysis and beneficiary progress/lack of progress (clinical judgment should be used when
determining number of units requested).
• See sample in the “Initial Assessment” section.
• Signatures
• The parent(s)/cargiver and the ABA supervisor are required to provide signatures at the end of the treatment plan.
For more information on TRICARE’s ABA benefit, please visit www.tricare-west.com > Benefits & Copays > Benefits A-Z >
Applied Behavior Analysis.
5
Comprehensive Autism Care Demonstration
Treatment Plan Checklist
All Treatment Plans
name of beneciary
date of birth
date of initial assessment
DoD Benets Number (DBN) or Social Security number (SSN)
referring provider/physician-primary care manager (P-PCM)
Autism Corporate Service Provider/company
date and time of reassessment
BCBA/BCaBA conducting reassessment and treatment plan update
background information (must contain the following):
Is child enrolled in school?/school age/specic hours in school
presence of Individualized Education Plan (IEP) if services occur in school
hours for other services indicated (occupational/speech therapy)
diagnosis
severity of symptoms (determined by specialized diagnosing provider)
medical co-morbidities, if applicable
prescribed medications
family history
length of time receiving applied behavior analysis (ABA) services (start date of entrance into the Autism
Care Demonstration to current)
location of services
medications
signatures of ABA provider and parent(s)/caregiver
Initial Assessment
objectively measured behavior decits identied in appropriate domains
goals/objectives (specic, measurable, assessment tool domain identied)
ABA intervention procedure listed for goal measurement (i.e., TA, DTT)
generalization goals/family goals (specic and measurable)
behavior intervention plan for target behavior excesses
statement that beneciary can actively participate in ABA
CPT
®
code recommendations
Treatment Plan Reassessments
date and time of reassessment
authorized ABA supervisor conducting assessment
statement indicating beneciary is actively participating in ABA
goals/objectives (specic, measurable, assessment tool domain identied)
ABA intervention procedure listed for goal measurement (for example, TA, DTT)
graphic representation of progress goals to baseline
behavior intervention plan for target behavior excesses
generalization goals/family goals (specic and measurable)
statement parent/family is actively participating in ABA program
CPT
®
code recommendations
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.
CPT is a registered trademark of the American Medical Association. All rights reserved. HF0917x091 (10/19)
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Initial and Re-Assessment Treatment Plan Content

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Completed 16 August 2020

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