---
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: September 2026
---

# TRICARE West ABA coverage under TriWest.

_Payer Guide · TRICARE West (TriWest) · Last updated September 2026 · 13 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

## 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]

## 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]

## 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).

## 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. [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][14][15]
- **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. [16][2][17]

## 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. Educational, academic and vocational goals are excluded in every setting. [2]
- **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. [2]

## 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

### 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.

## 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. [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)
15. [TRICARE Operations Manual 6010.62-M (2021 ed.), Ch. 18 Sec. 3 — Autism Care Demonstration (Change 11, Jul 24, 2024)](https://manuals.health.mil/pages/DisplayManualHtmlFile/2024-08-06/AsOf/tot5/c18s3.html)
16. [TriWest — TRICARE Provider Handbook: Claims Processing and Billing Information](https://tricare.triwest.com/en/provider/tricare-provider-handbook/claims-processing-and-billing-information/)
17. [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)

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.

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