Penguin Health
TRICARE · Autism Care Demonstration · Applied behavior analysis
TRICARE audits every ABA provider's notes against a fourteen-element list
The Autism Care Demonstration is the most audited ABA benefit in the country. TOM 6010.62-M Chapter 18, Section 3 lists fourteen session note elements for every CPT code session, the regional contractors compare a minimum of 30 records per provider group to claims every year, and DHA told Congress that about 63 percent of session notes failed the FY 2022 reviews. The matching rule set lives in the rules library in the Penguin Health app.
FY 2022 contractor reviews, per the DHA report to Congress of January 2024.
The minimum per provider group, with recoupment of insufficient claims.
DoD IG, North Region, of $120.1M paid for 2015 to 2016 ABA claims.
Across 17,603 participants, per the DHA annual report of April 2026.
The manual
What TOM Chapter 18, Section 3 requires
TRICARE covers ABA through the Comprehensive Autism Care Demonstration, and since the T-5 contracts took effect on January 1, 2025 the governing text is TOM 6010.62-M, Chapter 18, Section 3, read here at Revision C-22 of November 8, 2024. Paragraph 8.7.2 enumerates what every session note contains, paragraph 8.11.6.1 restricts each CPT code's setting and delivery, and paragraph 8.9 requires the contractors, Humana Military in the East and TriWest in the West, to audit session notes against claims and recoup every claim found insufficient.
- Beneficiary's full name, not initials
- The date and time of session, including start and end time
- Location of rendered services
- Length of session
- A legible name of the rendering provider, with provider type or level
- A signature of the rendering provider with the date signed
- Name of the authorized ABA supervisor
- Name of all session participants, and never other beneficiaries in group notes
- Current clinical status, evidenced by signs and symptoms
- Narrative content of the session and the techniques attempted
- Response to treatment, its outcome, and the response to significant others
- Degree of progress toward the treatment goals
- Every section individualized to the beneficiary and the session
- The final product of 97151 is the treatment plan, but every encounter still documents a session note
- Times, length, renderer with type or level, and signature
- The activities, measures, and observations administered
- Only 97156 may be delivered via telehealth, and only after the first six-month authorization, with the GT or 95 modifier
- School is 97153 by the authorized supervisor only, with an IEP on file
- 97156 is home or clinic only; 97157 is clinic only
- Groups must not exceed eight participants; larger groups are recouped in full
- 97155 direction at least monthly, and at least four times per six-month authorization
- A missed month costs 10 percent of all of that beneficiary's ABA claims for the entire authorization
- Six parent or caregiver sessions every six months, the first within 30 days of authorization
The checklist
The TRICARE session note checklist
Every row is a requirement of TOM 6010.62-M Chapter 18, Section 3, Revision C-22, with the rule in the Penguin set that checks it. TRICARE publishes no calendar-day signing deadline; the TPM requires contemporaneous, dated, authenticated entries, so the set checks the dated signature rather than inventing a deadline the manual does not contain.
| The note shows | What that means in practice | Source | Rule |
|---|---|---|---|
| Full name, start and end time, location, length | The frame of every note. Initials fail. | para. 8.7.2.1 to .4 | TRI-1 |
| Renderer named with type/level, signed with the date signed | A legible name with the BCBA, BCaBA, or RBT level, and a dated signature. | para. 8.7.2.5 to .6 | TRI-2 |
| Authorized ABA supervisor named | The supervisor on the case, on every note. | para. 8.7.2.7 | TRI-3 |
| All session participants named | Everyone in the room; group notes never name other clients. | para. 8.7.2.8 | TRI-4 |
| Current clinical status by signs and symptoms | How the client presented, not a checkbox. | para. 8.7.2.9 | TRI-5 |
| Narrative content and techniques attempted | A narrative and the techniques tried. Data alone fails. | para. 8.7.2.10 to .11 | TRI-6 |
| Response to treatment and progress toward goals | What happened, the outcome, and the degree of progress. | para. 8.7.2.12 to .13 | TRI-7 |
| Individualized to the beneficiary and session | Template text that fits any client fails. | para. 8.7.2.14 | TRI-8 |
| 97151 carries its own session note | The treatment plan alone is insufficient. | para. 8.7.2.15 | TRI-9 |
| No telehealth on in-person codes | POS 02 or 10 on 97151, 97153, 97155, 97157, or 97158 flags. | para. 8.11.6.1 | TRI-10 |
| Parent training and groups never at school | 97156 is home or clinic only; 97157 is clinic only. | para. 8.11.6.1.4.6, .5.4 | TRI-11 |
| Groups of eight or fewer | TRICARE recoups all claims for larger groups. | para. 8.11.6.1.5.2 | TRI-12 |
| Units within the daily cap | 32 for 97153; 8 for 97155 and 97156; 6 for 97157 and 97158. | para. 8.11.6.1 | TRI-13 |
In the rules library
Thirteen TRICARE rules, ready to turn on
Open the rules library in the Penguin Health app, choose TRICARE Autism Care Demonstration ABA, and click Add to organization. Rules your organization already has are left alone, so adding the set twice only fills gaps. After adding, edit any rule or add your own alongside them.
Each rule runs only on notes billed to TRICARE, through Humana Military in the East Region and TriWest in the West. Penguin checks the CentralReach payer name, so a TRICARE rule never fires on a commercial note in the same organization, and an organization whose payer names differ edits that match after adding the set.
Penguin reads signed session notes from CentralReach, read-only, after signature and before the claim, and runs the set on every note. Deterministic rules compare record fields. AI rules are read by the AI, which returns a pass or fail with a one-sentence reason.
Thirteen rules for the TRICARE Comprehensive Autism Care Demonstration under TOM 6010.62-M Chapter 18, Section 3: the fourteen-element session note of paragraph 8.7.2, the 97151 assessment session note, per-code telehealth and school setting bans, the eight-participant group limit, and the per-code daily unit caps the contractors audit against.
- reviewed
- Nov 4, 2026
- runs on
- Notes billed to TRICARE, through Humana Military in the East Region and TriWest in the West
- sources
- TOM 6010.62-M Ch. 18 Sec. 3 (Rev. C-22, Nov 8, 2024), TPM Ch. 1 Sec. 5.1, the DHA ACD annual reports, and both contractors' audit guides
- watching
- The TOM section, the DHA annual report, and both regional contractors' provider notices, weekly
Every failure ships with QA guidance for that program code: an educational email, numbered action steps, and a QA email pre-filled with the date of service and a link to the note. Each reviewer action is written to a write-once audit log with seven-year retention. Billing state Medicaid alongside TRICARE? The rules library covers twenty-nine, including Texas and Virginia.
Maintained by Penguin
A demonstration with a termination date
The ACD has been revised continuously since 2014 and is set to terminate on December 31, 2028, with a congressionally mandated review already recommending ABA move into the basic TRICARE benefit. However that lands, the documentation rules will move, and the set moves with them.
manuals.health.mil publishes each TOM change as a new rendering and blocks automated fetching, so the section is fingerprinted weekly and each flagged change is verified by hand in a browser, alongside the DHA annual report and both contractors' provider notices.
We rewrite the affected rule, cite the document that changed it, and date the review. The set shows its sources and review date in the library.
An updated rule runs in the next scheduled validation and on demand against notes you have already reviewed, so a changed requirement shows you exactly which past notes it touches.
- The ACD takes effect
TRICARE consolidates ABA coverage for autism into the Comprehensive Autism Care Demonstration.
- DoD IG projects $81.2M improperly paid
DODIG-2018-084 projects $81.2M of $120.1M paid for ABA in the North Region for 2015 and 2016 was improper, after the 2017 South Region audit projected $1.9M of $3.1M. The IG's findings put the session-note-to-claim comparison into the contractor audits.
- The big revamp
Revision C-85 rebuilds the demonstration: outcome measures, parent participation minimums, and the fourteen-element progress note list.
- Revision C-22, the current text
The ACD section as it reads today.
LibraryTRI-1 through TRI-13 are built against this revision.
- T-5 contracts take over
Humana Military takes the East Region, TriWest the West, and the ACD section renumbers from TOM 6010.59-M Chapter 18, Section 4 to TOM 6010.62-M Chapter 18, Section 3.
- NASEM recommends a permanent benefit
The congressionally mandated NASEM review recommends ending the demonstration and covering ABA as a TRICARE basic benefit. DHA says it is reviewing.
- TRICARE set reviewed
Checked against Revision C-22, the manual's change history (C-22 still the section's latest revision), and both contractors' audit guides. Current.
- The ACD terminates
TOM Chapter 18, Section 3, paragraph 10.0 ends the demonstration on December 31, 2028. Whatever replaces it rewrites the rules, and the set is updated with them.
State alerts
Get an email when TRICARE changes its documentation rules
We fingerprint 56 official payer documents every week, TRICARE's among them. When one changes, a person verifies what changed and writes a short plain-language summary before anything is sent. A few emails a year, not a newsletter. Unsubscribe anytime.
Check your inbox: confirm your email and you are on the list.
You will get a confirmation email first. Watching more than one state? Pick your states here.
Next step
Run a month of TRICARE notes through Penguin
Bring one month of session notes. We add the TRICARE set from the rules library, run it, show every finding beside the source it maps to, and hand your QA lead the fix for each one. Or get a demo account and click through Penguin on your own time first.