A TRICARE card is not a commercial card, and an intake team that treats it like one will get the case wrong. ABA is not part of the TRICARE basic medical benefit at all. It is covered under the Comprehensive Autism Care Demonstration — a separate demonstration program, currently authorized to run through Dec. 31, 2028, with its own eligibility chain, its own mandatory outcome-measure regime, and its own rules about where a session may happen.
In the TRICARE East Region the demonstration is administered by Humana Military. The practical consequence for intake: nothing starts until an approved ASD diagnosing provider issues a referral with a DHA-approved DSM-5 checklist, and nothing continues unless four standardized instruments keep arriving on schedule. Missing paperwork here does not slow the case down — it stops it.
DHA is explicit that ABA sits outside the medical benefit: occupational therapy, physical therapy, speech therapy, psychological services, psychological testing and prescription drugs are covered by the TRICARE medical benefit, while ABA "is a benefit covered under the ACD," which is "separate from the TRICARE medical benefit." The demonstration is run under 10 U.S.C. § 1092 demonstration authority, not as a standard covered service, and it has been extended more than once — the Aug. 4, 2022 Federal Register notice carried it from its Dec. 31, 2023 sunset to Dec. 31, 2028. That end date is the current one; there is no later extension notice on the Federal Register docket as of this review.[1][6][12]
Because it is a demonstration, the rules are unusually prescriptive and unusually enforced. Humana Military states plainly that "claims for services rendered without prior authorization will be denied," and that every participating ABA provider must attend annual training — a 10% penalty is applied to all claims billed under the provider Tax ID for providers who do not. Annual record audits (35 records) are conducted for Autism Corporate Service Providers and sole ABA providers. None of this has a commercial-plan analogue.[1][6][12]
Two conditions gate the door: the child must be enrolled in a TRICARE health plan, and must be diagnosed with ASD by an approved diagnosing provider. Humana Military names the covered diagnosis as Autism Spectrum Disorder (F84.0) under DSM-5. Eligible categories include dependents of active duty members, retirees and TRICARE-eligible Reserve Components, member-plus-family coverage under TRICARE Reserve Select and TRICARE Retired Reserve, TAMP and TRICARE For Life, TRICARE Young Adult, NATO dependents, and CHCBP participants.[1][2][12]
Who may diagnose is a closed list, and it is the single most common intake failure. Approved primary care providers are limited to family practice physicians, pediatricians, and pediatric or family nurse practitioners. Approved specialists are board-certified or board-eligible physicians in developmental-behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology, or adult or child psychiatry, plus doctoral-level licensed clinical psychologists and Doctors of Nursing Practice meeting specific criteria. Two age rules ride on top: if the first ASD diagnosis comes at age 8 or later, it must come from a specialized ASD diagnosing provider; and a child diagnosed more than two years before ABA is requested must get an updated diagnostic assessment.[1][2][12]
For active duty families there is a second, non-clinical gate that intake should ask about on the first call: the service member must enroll the child in their branch’s Exceptional Family Member Program, and the child must register for the Extended Care Health Option. If the ECHO path is not completed, ABA cannot be authorized regardless of the clinical picture.[1][2][12]
The referral itself is a defined document, not a note. Per Humana Military it "must include a definitive diagnosis of ASD using the DSM-5 (or current edition) criteria by a PCM or specialized ASD diagnosing provider," the DSM-5 criteria "must be documented in a DHA-approved checklist in the referral," and a validated assessment tool must accompany the referral and confirm the diagnosis.[8][12][1]
On receipt of a complete referral, Humana Military authorizes an initial assessment, treatment-plan development and the outcome measures, provided a TRICARE-authorized ABA supervisor has an opening to accept the beneficiary.[8][12][1]
The ABA supervisor completes the initial assessment and treatment plan and submits them with the baseline outcome measures. A treatment authorization is then issued for six months.[8][12][1]
The supervisor submits an updated treatment plan plus the PDDBI parent and teacher forms and the PSI-4 short form or SIPA, and requests reauthorization before the current period expires.[8][12][1]
This is the ACD’s signature requirement and it has no commercial equivalent. Four instruments are required and the required ones "must be received prior to issuing a treatment authorization." The cadence: the PDDBI at baseline and every six months (the ABA supervisor completes the teacher form); the Vineland-3 at baseline and annually; the SRS-2 parent form at baseline and annually; and the PSI-4 short form (ages birth through 12) or the SIPA (ages 11 to 19) at baseline and every six months. DHA states families "must complete the four outcome measures every six months or every 12 months" depending on the measure.[9][3][1]
The submission mechanics get authorizations bounced as often as the scores do. Humana Military requires outcome measures to be completed no earlier than 90 days before their due date; requires the full publisher print report or hand-scored protocols; and states that "the scores cannot be imbedded within the TP or any other clinical documents." The name of the person completing the form and their relationship to the beneficiary must match and appear on all forms. For the Vineland-3, all composite scores must be submitted — communication, daily living, socialization, motor skills, adaptive behavior composite, and both maladaptive behavior composites.[9][3][1]
What happens if they are not submitted is unambiguous. Humana Military will assist a family who cannot complete a measure through an ACD team associate, "however, if the barriers cannot be resolved, ABA services will not be able to be authorized." Outcome measures can be performed by TRICARE-authorized ASD diagnosing providers or, when Humana Military authorizes it, by the ABA provider without an additional PCM referral — and when the ABA provider administers one, bill it under CPT 97151 with a 99 modifier to distinguish it from an assessment.[9][3][1]
School is the setting that surprises people. DHA states that "ABA services rendered by a behavior technician in the school setting aren’t covered." A Board Certified Behavior Analyst may be authorized where there is a clinically necessary and appropriate goal, subject to clinical necessity review, with pre-authorization required and the contractor approving the goals, which "must be focused and time-limited." Community settings are similar but narrower: parents are generally expected to generalize mastered skills on their own, and a BCBA "may be authorized for certain community settings" only after checking with the contractor. Humana Military lists "community locations not being authorized prior to rendering services" as a common documentation failure.[2][10][11]
The goal-level exclusions bind in every setting. Humana Military excludes goals targeting activities of daily living, vocational and/or educational goals, ABA involving aversive techniques or restraints, ABA for diagnoses other than ASD, and ABA for symptoms and behaviors that are not part of the core symptoms of ASD. Training and supervising a behavior technician, report writing outside CPT 97151, emails and phone calls, and office and therapeutic supplies are not payable either.[2][10][11]
The ACD adopted only the Category I codes that transferred from Category III: 97151, 97153, 97155, 97156, 97157 and 97158, plus 99366 and 99368 for medical team conferences. Other codes are not covered. Authorized ABA supervisors and ACSPs bill as outpatient specialty providers; claims must be submitted electronically, EFT enrollment is required, and timely filing is one year from the date of service. Start and stop times belong on the individual claim lines, even when the same code is billed twice in a day by the same rendering provider.[7][12][4]
Three traps recur. Concurrent billing is excluded for all ACD Category I codes except where the family and the beneficiary receive separate services and the beneficiary is not present in the family session — documentation must show two separate rendering providers and two separate locations (which may be two rooms in the same building). If 97153 and 97155 are billed concurrently, the higher rate is paid and the other is denied. And all 97151 units must be used within 14 calendar days of the first date of service for 97151, or the claim is denied; delays outside the provider’s control go through the appeals process.[7][12][4]
On what the family pays: ABA is treated as outpatient specialty care and a single copayment covers all ABA services received on one day. Under TRICARE Prime, active duty family members pay $0 for network specialty care in both Group A and Group B; retirees and all others pay $39. Under TRICARE Select, active duty family members pay $39 network (Group A) or $33 (Group B), and retirees and all others pay $52 network or 25% non-network. There are no yearly or lifetime caps on ABA, and the amounts count toward the family catastrophic cap. Verify current-year figures on the TRICARE cost page before quoting them.[7][12][4]
The clinical policy above is national, but three state-level layers change what a family's card actually buys: the state autism mandate (what fully-insured plans must cover), the carrier's state Medicaid plans (which follow the state Medicaid rules, not this commercial policy), and plan funding type (self-funded ERISA plans can carve benefits differently). Here's the picture in the states we cover:
Fully-insured TRICARE East (Humana Military) plans issued in Georgia sit under the state mandate above. State Medicaid baseline: Georgia Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in North Carolina sit under the state mandate above. State Medicaid baseline: North Carolina Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Indiana sit under the state mandate above. State Medicaid baseline: Indiana Medicaid (IHCP) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Virginia sit under the state mandate above. State Medicaid baseline: Virginia Medicaid (DMAS) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Tennessee sit under the state mandate above. State Medicaid baseline: TennCare (Tennessee Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Ohio sit under the state mandate above. State Medicaid baseline: Ohio Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in New Jersey sit under the state mandate above. State Medicaid baseline: NJ FamilyCare (New Jersey Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Maryland sit under the state mandate above. State Medicaid baseline: Maryland Medicaid (Medical Assistance) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Colorado sit under the state mandate above. State Medicaid baseline: Health First Colorado (Colorado Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Utah sit under the state mandate above. State Medicaid baseline: Utah Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Arizona sit under the state mandate above. State Medicaid baseline: AHCCCS (Arizona Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in New York sit under the state mandate above. State Medicaid baseline: New York Medicaid (NYS DOH / eMedNY) guide →
Fully-insured TRICARE East (Humana Military) plans issued in New Mexico sit under the state mandate above. State Medicaid baseline: New Mexico Medicaid (Turquoise Care) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Missouri sit under the state mandate above. State Medicaid baseline: MO HealthNet (Missouri Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Texas sit under the state mandate above. State Medicaid baseline: Texas Medicaid (THSteps-CCP) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Massachusetts sit under the state mandate above. State Medicaid baseline: MassHealth (Massachusetts Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Florida sit under the state mandate above. State Medicaid baseline: Florida Medicaid — Behavior Analysis Services (AHCA) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Kansas sit under the state mandate above. State Medicaid baseline: KanCare (Kansas Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Nebraska sit under the state mandate above. State Medicaid baseline: Nebraska Medicaid (Heritage Health) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Idaho sit under the state mandate above. State Medicaid baseline: Idaho Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Iowa sit under the state mandate above. State Medicaid baseline: Iowa Medicaid (IA Health Link) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Oklahoma sit under the state mandate above. State Medicaid baseline: Oklahoma Medicaid (SoonerCare / SoonerSelect) - Oklahoma Health Care Authority guide →
Fully-insured TRICARE East (Humana Military) plans issued in Michigan sit under the state mandate above. State Medicaid baseline: Michigan Medicaid guide →
Fully-insured TRICARE East (Humana Military) plans issued in Hawaii sit under the state mandate above. State Medicaid baseline: Hawaii Medicaid (Med-QUEST / QUEST Integration) guide →
Fully-insured TRICARE East (Humana Military) plans issued in California sit under the state mandate above. State Medicaid baseline: Medi-Cal (California Medicaid) guide →
Fully-insured TRICARE East (Humana Military) plans issued in Pennsylvania sit under the state mandate above. State Medicaid baseline: Pennsylvania Medicaid (Medical Assistance) guide →
The questions that decide whether a family can start with TRICARE East (Humana Military), and what they have to bring. Each maps onto something intake should ask on the first call.
None. DHA states plainly that the Autism Care Demonstration carries no age limit, no time limit and no yearly or lifetime dollar cap on ABA. What ages out is the diagnosing pathway, not the benefit: if the first ASD diagnosis comes at age 8 or later it must come from a specialized ASD diagnosing provider rather than a primary care provider. Separately, whether the child is still a TRICARE-eligible dependent is its own eligibility question — the ACD gates on plan enrollment, not on age.[1][12]
Two clocks, and both belong on the intake form. First, the diagnosis: a child diagnosed more than two years before ABA is requested must get an updated diagnostic assessment — so ask for the date of the initial ASD diagnosis, not just the diagnosis. Second, the referral: it runs two years, and every two years an approved ASD diagnosing provider must issue a new referral with an updated DHA-approved DSM-5 checklist. Neither is the ABA provider’s to sign, which is why the two-year renewal is a diary item to set on day one rather than a task to discover at reauthorization. Outcome measures carry their own window: they must be completed no earlier than 90 days before their due date.[1][12][9]
A closed list, and the single most common intake failure on a TRICARE case. Approved primary care providers are limited to family practice physicians, pediatricians, and pediatric or family nurse practitioners. Approved specialists are board-certified or board-eligible physicians in developmental-behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology, or adult or child psychiatry, plus doctoral-level licensed clinical psychologists and Doctors of Nursing Practice meeting specific criteria. A physician assistant or an unlisted specialty cannot diagnose or refer for the ACD, whatever their scope elsewhere. And a first diagnosis at age 8 or later must come from the specialist half of the list.[1][2][12]
Two instruments-and-forms requirements, on different clocks. At the door, the referral must carry “a definitive diagnosis of ASD using the DSM-5 (or current edition) criteria,” those criteria “must be documented in a DHA-approved checklist in the referral,” and a validated assessment tool must accompany the referral and confirm the diagnosis. Then, for the life of the case, four standardized outcome measures are mandatory and “must be received prior to issuing a treatment authorization”: the PDDBI at baseline and every six months (the ABA supervisor completes the teacher form), the Vineland-3 at baseline and annually, the SRS-2 parent form at baseline and annually, and the PSI-4 short form (birth through 12) or the SIPA (ages 11 to 19) at baseline and every six months. Submission mechanics bounce as many authorizations as scores do: measures completed no earlier than 90 days before their due date, the full publisher print report or hand-scored protocols, scores that “cannot be imbedded within the TP or any other clinical documents,” a respondent name and relationship that match across all forms, and — for the Vineland-3 — all composite scores including both maladaptive behavior composites. Where the ABA provider administers a measure, bill CPT 97151 with a 99 modifier.[12][9][3][1]
Required, defined, and renewable on a two-year clock. The referral is a document rather than a note: it must include a definitive DSM-5 ASD diagnosis by a PCM or specialized ASD diagnosing provider, the DSM-5 criteria documented in a DHA-approved checklist, and a validated assessment tool confirming the diagnosis. On a complete referral Humana Military authorizes the initial assessment, treatment-plan development and the outcome measures, provided an authorized ABA supervisor has an opening; a six-month treatment authorization follows the completed assessment and baseline measures. For active duty families a second, non-clinical gate applies and intake should ask about it on the first call: the sponsor must enrol the child in their branch’s Exceptional Family Member Program, and the child must register for the Extended Care Health Option. Without the ECHO path, ABA cannot be authorized regardless of the clinical picture. “Claims for services rendered without prior authorization will be denied.”[8][12][1]
Every ABA service is pre-authorized, and there is no published expedited track. The DHA rule the contractor works under: it “shall complete 100% clinical necessity reviews for ABA services for all compliant TPs within five business days for authorization processing standards.” Humana Military authorizes the initial assessment “upon receipt of all necessary documents,” and missing clinical information “may result in delays, terminations of authorized care and denials.” The clock that matters is reauthorization: “Humana Military does not accept retrospective referrals and will not backdate late submissions. Providers can submit requests for ongoing treatment up to 60 days in advance. However, submitting requests less than 30 days before the current authorization expires may result in non-reimbursement.” Diary every six-month auth for day 60 before expiry, and never later than day 30.[14][8][15]
“TRICARE is the secondary payer to all health benefits and insurance plans, except for Medicaid, TRICARE supplements, the Indian Health Service and other programs or plans as identified by Defense Health Agency (DHA).” With Medicaid, TRICARE pays first (“In any double coverage situation involving Medicaid, CHAMPUS is always the primary payer”). Otherwise “the provider must bill the OHI first,” then file with TRICARE showing the other plan’s payment. OHI normally waives TRICARE referrals and authorizations, but ABA is on Humana’s list of services that “require prior authorization even when OHI coverage exists” — get the ACD authorization too. TRICARE will not pay amounts the other plan denied “because the beneficiary failed to meet some other requirement of coverage,” so follow the primary plan’s PA rules as well.[15][16][14]
Humana Military does not publish an ABA telehealth code list on its public ACD pages. What it does publish is the documentation consequence: the progress note must record the place of service as home, clinic/center, daycare (non-preschool), school, community or telemedicine, and GPS coordinates do not satisfy that. The West Region contractor publishes the DHA-level rule in full — telehealth limited to 97156, only after the first six-month treatment period, with a GT or 95 modifier and no audio-only — but that is TriWest’s published restatement, not an East Region document, so confirm before scheduling remote hours in the East.[10][1]
Blocked on: Humana Military’s ABA dedicated line at (866) 323-7155, or the authorization letter itself in provider self-service. TRICARE Operations Manual Ch. 18, Sec. 3 is the governing document, but manuals.health.mil blocks automated retrieval.
Coverage decides whether TRICARE East (Humana Military) pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Assistant behavior analysts and behavior technicians must receive supervision in accordance with their certifying and licensing bodies. Behavior technicians may not conduct the ABA assessment or establish the treatment plan. Only one authorized ABA supervisor is approved to provide ABA for a beneficiary at a time; a consulting supervisor does not take over the plan or the billing. Supervision itself is not a payable service — training and supervising a behavior technician is an express exclusion.[12][11]
Excluded for all ACD Category I codes except where the family and the beneficiary receive separate services and the beneficiary is not present in the family session — documentation must show two separate rendering providers and two separate locations (two rooms in the same building qualify). If 97153 and 97155 are billed concurrently, the higher rate is paid and the other is denied. Where 97151 and 97156 fall on the same date and time with different rendering providers, modifier HS (beneficiary not present) or HR (beneficiary present) must be applied or the claim denies for concurrent billing.[12][7]
Progress notes must carry the name and credentials of the rendering ABA supervisor, assistant behavior analyst or behavior technician, with a dated signature. Notes are not submitted with claims but are pulled in ABA quality audits and compared against the claims. Required elements include beneficiary name, date and start/end times with session length, place of service, participants and their relationship to the beneficiary, clinical status as DHA defines it, a narrative session summary, techniques used, response to treatment and progress toward goals. A treatment plan alone does not satisfy the 97151 note requirement.[10]
The note must record the place of service as home, clinic/center, daycare (non-preschool), school, community or telemedicine — GPS coordinates do not satisfy this. ABA rendered by a behavior technician in a school is not covered; a BCBA may be authorized for focused, time-limited, contractor-approved goals after clinical necessity review. Community locations must be authorized before services are rendered. Educational, vocational and activities-of-daily-living goals are excluded in every setting.[2][10][11]
Only authorized ABA supervisors or Autism Care Corporate Services Providers may bill. Claims must be submitted by the rendering practitioner and the rendering and billing providers must match — a mismatch is one of the documentation failures Humana Military calls out. HIPAA taxonomies: behavior analyst 103K00000X, assistant behavior analyst 106E00000X, behavior technician 106S00000X.[12][10]
Humana Military does not publish per-day unit ceilings on its public ACD pages; the ceilings live in TRICARE Operations Manual Ch. 18, Sec. 3 and in the authorization itself. One hard clock is public: all authorized 97151 units must be used within 14 calendar days of the first 97151 date of service or the claim is denied.[12]
Blocked on: Humana Military provider self-service authorization letter, the ABA dedicated line at (866) 323-7155, or TRICARE Operations Manual Ch. 18, Sec. 3 at manuals.health.mil
Yes, but not through the regular medical benefit. ABA is covered under the Comprehensive Autism Care Demonstration, a separate program currently authorized through Dec. 31, 2028 and administered in the East Region by Humana Military. Every ABA service requires prior authorization.
Four: the PDDBI (baseline and every six months, with the ABA supervisor completing the teacher form), the Vineland-3 (baseline and annually), the SRS-2 (baseline and annually), and the PSI-4 short form for ages birth through 12 or the SIPA for ages 11 to 19 (baseline and every six months). They must be received before a treatment authorization will issue.
The authorization does not issue. Humana Military will put an ACD team associate on resolving the barrier, but states that if the barriers cannot be resolved, ABA services will not be able to be authorized.
No. DHA states that ABA rendered by a behavior technician in the school setting is not covered. A BCBA may be authorized where there is a clinically necessary, focused and time-limited goal, but only with pre-authorization and contractor approval of the goals.
Every two years. An approved ASD diagnosing provider must issue a new referral and an updated DHA-approved DSM-5 checklist; the ABA provider cannot supply either. Treatment authorizations themselves run in six-month increments.
The copayment or cost-share for their plan, with one copayment covering all ABA services on the same day. Active duty family members in TRICARE Prime pay $0 for network specialty care; retirees and others pay $39. Select amounts run $33 to $52 network depending on category and group. There is no yearly or lifetime cap on ABA.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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