Applied Behavior Analysis (ABA) Services
Customize your policy alerts
Sign up for Aloha Care Policy MP-37 alerts
Get alerted when Policy MP-37 changes without checking for updates manually.
Monitor payer policy activity
Defines medical necessity, authorization, provider qualifications, supervision, documentation, billing, and step-down requirements for ABA services under Aloha Care QUEST Integration (Medicaid) for members under age 21 with Autism Spectrum Disorder.
No material clinical or coverage changes in this revision.
Coverage Criteria for ABA Services
Initial Therapy
Covered when ALL of the following are met:
Diagnosis must be rendered by an approved clinician (developmental behavioral pediatrician, developmental pediatrician, pediatrician, neurologist, psychologist, or psychiatrist).
Treatment Plan and Provider Qualifications
Covered when ALL of the following treatment plan and provider qualifications are met:
Treatment plan must be updated at least every 26 weeks with progress reports and an updated treatment plan for re-authorization.
Records must include signatures of the rendering provider and supervising LBA and documentation of supervision activities.
Authorized Services
Authorized services include:
Intensity must be individualized and medically necessary; requests for high intensity (e.g., up to 40 hrs/week) require clinical justification and are not automatically approved.
Concurrent Billing Rules
Concurrent billing of 97153 and 97155 is permitted only when ALL of the following are met:
Concurrent billing is not permitted if the LBA is solely observing, if documentation does not differentiate the concurrent services with separate notes and start/stop times, or if LBA involvement does not meet the definition of medically necessary protocol modification.
Coverage excludes services that are duplicative of supports already provided by DOE, HCBS, or custodial programs. Services provided by family or household members are not covered. Experimental or non‑evidence‑based treatments are excluded. Services that are primarily custodial in nature are not covered. Telehealth use that is inappropriate for safety (for example, when a caregiver is required but not present) may be excluded. Services provided outside Hawaii without prior authorization, or services that do not comply with Hawaii licensure, Med‑QUEST, or Medicaid coverage rules, may also be denied or require additional review.
Requests that lack clinical justification may be denied or require additional review. Examples include requests for >30–40 hours per week without documentation of severe behavioral needs or profound skill deficits. A lack of documented response to treatment and failure to modify the treatment plan when progress is inadequate is a basis for reduction or denial of continued hours. Providers must demonstrate clinical need and ongoing response to therapy; failure to do so (including not implementing a step‑down or modification plan when progress is not shown) places the request at risk for non‑coverage.
Coding and Billing Examples
| 97151 | Behavior identification assessment (LBA) |
| 97155 | Adaptive behavior treatment with protocol modification (LBA/BCaBA) |
| 97153 | Adaptive behavior treatment by protocol (RBT/BCaBA supervised) |
| 97156 | Family adaptive behavior treatment guidance |
| 0362T | ABA requiring multiple staff for severe behaviors |
| 0373T | ABA requiring multiple staff for severe behaviors |
| 97157 | Multiple-family adaptive behavior treatment |
| 97158 | Group adaptive behavior treatment |
Prior Authorization, Documentation, and Provider Responsibilities
Prior authorization and reauthorization required
Prior authorization is required for all ABA treatment services. Initial authorization requests must include the diagnostic evaluation, baseline assessments, and a treatment plan signed by a Licensed Behavior Analyst (LBA). Re-authorization is required every 26 weeks and must include progress reports and an updated treatment plan.
Titration / step-down plan required in treatment plan
Include a data-driven titration/step-down plan in the LBA-developed treatment plan describing how service intensity will decrease as skills improve, caregiver training, objective milestones, generalization strategies, and revision of goals/hours based on progress data. For high-intensity care (>30–40 hrs/week) the plan must also document severe needs, an anticipated step-down timeline, a clear clinical rationale, and evidence of functional progress.
- Describe how service intensity will decrease over time as skills improve
- Describe caregiver training to support maintenance
- Identify objective milestones that support titration
- Describe generalization strategies across home/school/community
- Revise goals and hours based on progress data
- For >30–40 hrs/week: include documented severe needs, anticipated step-down timeline, clear clinical rationale, and evidence of functional progress
Maintain session-level and progress documentation; make available on request
Maintain and make available upon request session-level records including date, time, duration, and location of each service; start/stop times for time-based codes; data collection demonstrating progress; targeted goals/skills and the member’s response; FBA and baseline data for each target behavior; supervision documentation per BACB and MQD; and signatures of the rendering provider and supervising LBA. Also document changes to interventions when adequate progress is not demonstrated.
- Date, time, duration, and location of each service
- Start/stop times for time-based codes
- Data collection demonstrating progress and member response to targeted goals/skills
- FBA and baseline data for each target behavior
- Supervision documentation compliant with BACB and MQD standards
- Signatures of rendering provider (RBT/BCaBA) and supervising LBA
- Documentation of changes to interventions when progress is inadequate
Triggers for denial or additional review
Requests may be denied or subjected to additional review when hours requested exceed customary limits (>30–40 hrs/week) without strong clinical justification, when services are provided by family/household members, when there is no documented response to treatment or failure to modify the treatment plan, when services are delivered without appropriate supervision, or when services are experimental, primarily custodial, use telehealth inappropriately, or are provided outside Hawaii without required authorization/licensure.
- Requested hours >30–40 hrs/week without documented severe needs and justification
- Services provided by family/household members
- No documented response to treatment or failure to modify the treatment plan
- Services delivered without appropriate supervision
- Experimental or non–evidence-based treatments or primarily custodial care
- Inappropriate telehealth (e.g., no caregiver present when required)
- Services provided outside Hawaii without prior authorization or not compliant with Hawaii licensure/Med-QUEST rules
Background and Rationale
Applied Behavior Analysis (ABA) is an evidence‑based therapy that applies behavioral principles to improve socially significant skills, adaptive functioning, and to reduce maladaptive behaviors. Under Medicaid/EPSDT, medically necessary ABA for members under age 21 with Autism Spectrum Disorder is covered when the policy criteria are met. This policy aligns ABA coverage with Med‑QUEST guidance and BACB supervision standards, emphasizing individualized, data‑driven treatment plans, objective baseline measurement, and demonstrable functional progress.
Key Definitions
Level of Care — Outpatient ABA Settings
Outpatient ABA (community/school/home)
Initial authorization requires submission of diagnostic evaluation, baseline assessments, and an LBA-signed treatment plan.
Failure to modify the treatment plan when progress is not demonstrated may result in reduction or denial of hours.
ABA Coverage Eligibility
ABA coverage eligibility
ABA coverage is limited to members under 21 with ASD and requires the following:
Diagnosis must be rendered by an approved provider type (developmental behavioral pediatrician, developmental pediatrician, pediatrician, neurologist, psychologist, or psychiatrist).
Diagnostic evaluation as a standalone service does not require prior authorization, but treatment services do.
ABA Treatment Modalities and Service Types
ABA treatment modalities
Diagnostic evaluation does not require prior authorization. Supervision and documentation must follow BACB and MQD requirements.
High-Intensity Services and Visit Limits
Policy Revision History
Policy MP-37 originally effective 2026-01-22.
Policy MP-37 effective date set to 2026-03-22.
Policy MP-37 last revised on 2026-05-08 (updates reflected in procedural, documentation, supervision, and titration requirements).
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.