TRICARE Recoups 10% of a Child's Six Months of ABA Claims If 97155 Skips a Month

TRICARE's Autism Care Demonstration requires the authorized ABA supervisor to bill 97155 at least once in every month a child receives direct treatment. Miss a month and the contractor recoups 10% of all ABA claims for that child across the whole six-month authorization. A separate 10% penalty applies to any provider who hasn't completed the annual ACD provider education, and TriWest, the West region contractor, puts that deadline at December 31.

Why one missed month costs six

The rule sits in the TRICARE Operations Manual, Chapter 18, Section 3, paragraph 8.11.6.1.3.4: "CPT code 97155 must be completed at least one time per month by the authorized ABA supervisor." The next line sets the penalty: after a post-payment review, "the contractor shall recoup a 10% penalty on all ABA claims for that beneficiary for the entire six-month authorization."

That's a recoupment, so it arrives months after the gap. A supervisor out on leave for four weeks, or a family that cancels every supervision visit in a month, can cost 10% of six months of that child's ABA claims. TriWest's August Provider Pulse told providers to update "scheduling, clinical recommendations, and billing workflows immediately."

What the manual says

• When it applies: TriWest says 97155 must be billed by the ABA supervisor in any calendar month when direct treatment is billed under 97153, 97156, 97157 or 97158.
• Audit floor: at least four 97155 sessions in each six-month authorization.
• Short authorizations: where an authorization runs less than six months, for example after a PCS move, at least 50% of the authorized months must meet the monthly rule.
• Annual education: every ACD provider must complete contractor-hosted provider education "no less than annually." The contractor "shall impose a 10% claims penalty for all ABA rendered services during the non-compliant period." TriWest's July Pulse says the course must be done "by the final day of the calendar year" and that providers must keep evidence of completion. In the West region it's on Availity, under the TriWest Learning Center tile, as "Annual Provider Training."

The limits

TriWest's August bulletin describes the 97155 penalty as applying to "all ABA claims across the entire six-month authorization period" and leaves out "for that beneficiary." The manual is narrower, and the manual governs. We read TriWest's notices; we didn't find an equivalent 2026 notice from Humana Military for the East region, although the manual binds both contractors. The manual doesn't yet say how the monthly rule maps onto the 2027 code set, which splits 97155's current work across two codes from January 1. Watch for a manual change before then. The demonstration itself runs until December 31, 2028.

What you must know or do

• Clinical directors: list every TRICARE client and, for each month of the current authorization, whether the authorized supervisor billed 97155. Any month with 97153, 97156, 97157 or 97158 and no 97155 is a 10% exposure on that child's whole authorization.
• Schedulers: book one 97155 visit per TRICARE client per month now, with a backup supervisor named for leave and turnover. Count four per authorization as the floor.
• Owners: confirm every provider billing under your TRICARE agreement has finished this year's ACD provider education before December 31, and file the completion certificates where an auditor can find them.