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TRICARE East Initial ABA Request (Autism Care Demo)

Under TRICARE's Autism Care Demonstration (ACD), the ABA supervisor's initial assessment and treatment plan must reach Humana Military before ABA services start in the East Region. This eight-page courtesy form organizes that submission: diagnosis and severity, medications, school hours, outcome measures, treatment targets with measurable goals, parent goals, a weekly schedule and the CPT units requested.

Who completes it

The authorized ABA supervisor (BCBA, BCBA-D or other) completes the assessment and treatment plan and signs it with the parent or caregiver; behavior technicians may not conduct assessments or write treatment plans. The referring provider's ASD diagnosis and severity level are carried over from the referral.

Submitting and payment

How to submit it
Upload it with the referral or authorization request in Humana Military's provider self-service portal at HumanaMilitary.com; fax it only if online submission is not possible.
Who pays
Units are requested by CPT code: 97151 for the assessment, 97153 to 97158 for treatment and family guidance, and 99366 or 99368 for team conferences, subject to TRICARE Operations Manual limits.

Good to know

  • Outcome measures listed are the Vineland-3, SRS-2, PDDBI and PSI/SIPA; attach the full publisher print report or the hand-scored protocol with summary score sheets.
  • Only one ABA supervisor may design, monitor and supervise a beneficiary's ABA at a time. Attach the Individual Education Plan if the child is in special education or services are requested at school.
  • Each treatment target needs a baseline, measurement method, short and long-term goals, measurable objectives and the ABA services addressing it; attach functional assessments for problem behaviors.
  • Humana says the form is optional, but missing clinical information can delay or terminate authorized care and lead to denied claims. Policy is in TRICARE Operations Manual Chapter 18, Section 3.

Get the official form

Download the current version from the source each time; forms change without notice.

Initial request for Applied Behavior Analysis (ABA)

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who can complete the TRICARE initial ABA assessment and treatment plan?

The authorized ABA supervisor, such as a BCBA or BCBA-D, who designs, monitors and supervises the beneficiary's ABA. Behavior technicians may not conduct ABA assessments or establish treatment plans. The parent or caregiver also signs the plan alongside the ABA supervisor.

When must the initial ABA treatment plan be submitted?

Before ABA services begin. Humana Military requires the initial assessment and treatment plan to be submitted prior to the start of ABA under the Autism Care Demonstration, and the referral with a definitive ASD diagnosis must already have been approved.

Which outcome measures go with the TRICARE initial ABA request?

The form lists the Vineland-3, SRS-2, PDDBI and PSI/SIPA, with the date each was completed. Attach the full publisher print report or the hand-scored protocol and summary score sheets, and summarize findings across language, development, social communication and adaptive behavior.