TriCare: Getting Your 97151 Assessment Authorization

CPT 97151 covers the initial ABA assessment conducted by a BCBA. Under TRICARE West, families usually must initiate or support the authorization process. The steps below are the most reliable paths to getting approved quickly.

A Note on Alpaca Support

Alpaca will also attempt to reach out to TRICARE on your behalf to help move the authorization process forward. That said, parent or caregiver initiated requests are usually the fastest and most reliable pathway, especially for initial 97151 authorizations. TRICARE often requires confirmation or action directly from the family, which is why we strongly encourage parents to make the initial call whenever possible.

Before You Start: Information You Will Need

Have this ready before making any calls or submitting requests.

Rendering / Group Information

• Group Name: Alpaca Health

• Group NPI: 1386460848

• EIN: 99-1064613

• Fax: (302) 274-0656

Corporate Headquarters

• 5049 Edwards Ranch Rd, STE 400

• Fort Worth, TX 76109-4139

Clinical Requirements

• Autism diagnosis from an approved provider

• Referring provider information (usually the child’s PCM)

• Parent or caregiver available to engage with TRICARE

Path 1: Call the Autism Care Navigator (Recommended First Step)

This is usually the fastest and cleanest route.

Who calls

• The parent or caregiver

What to do

1. Call the TRICARE West Autism Care Navigator.

2. State that the child has an autism diagnosis and needs an initial ABA assessment.

3. Request authorization for CPT 97151.

4. Provide your practice’s group NPI and contact information if asked.

Why this works

• Autism Care Navigators specialize in ABA and understand the 97151 process.

• They coordinate between TRICARE, the PCM, and the provider.

Tip

• Encourage families to take notes and ask where the request is being routed.

Path 2: Call TRICARE West Directly

Use this if the family cannot reach their Autism Care Navigator or needs follow-up.

Who calls

• Parent or caregiver

• Practice admin can be on the line for support if the family allows

What to say

“My child has an autism diagnosis and we are requesting authorization for an initial ABA assessment under CPT 97151 with a TRICARE-authorized provider.”

Be ready to provide

• Child’s sponsor information

• Diagnosis confirmation

• Your group NPI and fax number

What to ask

• Has a referral been received

• Does the PCM referral need to be submitted or resent

• Expected turnaround time

Path 3: Ask the Primary Care Manager (PCM) for a Referral

This is required in many cases and often the missing step.

Who contacts the PCM

• Parent or caregiver

What to ask the PCM

• Submit a referral for Applied Behavior Analysis

• Specifically note initial ABA assessment (CPT 97151)

Key reminder for families

• The PCM referral is not the authorization itself, but TRICARE usually will not approve 97151 without it.

After the Request Is Submitted

What to expect

• Authorizations are typically issued as a one-time cap of 16 units (4 hours)

• These units must be used within a 14-day window starting from the first 97151 date of service

• Unused units expire at the end of the 14-day window and do not roll over

Follow-up best practice

• If no update in 7 to 10 business days, the family should call TRICARE or the Autism Care Navigator again

• Reference that this is an initial ABA assessment pending review

Common Reasons for Delays

• PCM referral missing or incomplete

• Diagnosis documentation not attached

• Mismatch between provider name, NPI, or address

• TRICARE waiting on parent confirmation

Pro Tip for Practice Owners

Proactively coach families on these calls. Many delays happen because families do not know the right language to use. A short prep email or call script can reduce authorization time by weeks.

If you need help verifying referral status or troubleshooting a stuck authorization, you can coordinate internally using the Harvi group information listed above.