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ModifiedAmbetter NevadaPolicy CP.BH.104

Applied Behavior Analysis (ABA) for Autism Spectrum Disorder

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Defines medical necessity, documentation, assessment, and treatment planning requirements for ABA services for members with autism spectrum disorder when ABA is a covered benefit under Ambetter Nevada plans.

Policy Summary

PayerAmbetter Nevada

PolicyApplied Behavior Analysis (ABA) for Autism Spectrum Disorder

Policy CodePolicy CP.BH.104

Change TypeMaterial updates to assessment tools, diagnostic/CDE requirements, and treatment hours guidance

Effective Date

Next Review Date

Key ActionSubmit a Comprehensive Diagnostic Evaluation (CDE) and recent behavior assessment (BCBA-completed) with an individualized treatment plan and clinical justification for any requested hours above 6 hours/day or 30 hours/week.

SourceLink

POLICY UPDATE CHANGES

Added new recommended screening tools (EarliPoint, SWYC POSI, RITA-T, CSBS-ITC) and removed KADI.

Clarified diagnosis and assessment requirements including requirement for at least one primary clinician tool and one parent/caregiver tool (CDE-based) and updated list of accepted instruments (e.g., CARS-2, ADOS-2, ASRS, SRS-2).

Revised treatment hours guidance to not exceed six hours per day up to 30 hours per week with pathways to justify additional hours via clinical documentation.

Removed specific examples of coordination of care responsibilities and reorganized criteria for clarity; added transition planning and discharge considerations with care-team input.

Added HCPCS codes (H0031, H0032, H0046, H2012, H2014, H2019, S5110, S511) to the policy.

30 hrsdefault maximum/week

6 hrsdefault maximum/day

within 5 yrsCDE recency (continuation)

every 6 monthsbehavior assessment update

≥80%attendance threshold

30–40 hrscomprehensive ABA range

Coverage Criteria for ABA Services

inv-01: Initial and continuation ABA medical necessity criteria

Covered when ALL of the following are met:

Eligibility and diagnosis: Member has a confirmed ASD diagnosis per current DSM (or state-defined equivalent) established by a licensed clinician or provider authorized under state law; documentation includes DSM-based severity level and presence/absence of intellectual or language impairment

See I.A.1-4

Comprehensive diagnostic evaluation (CDE): CDE documents functional impact across settings and must include direct observation, caregiver interview, developmental history, test scores, evaluator credentials/signature, and at least one primary clinician tool and one parent/caregiver tool; for treatment initiation a CDE within 3 years is preferred or a diagnostic interview within 12 months if the CDE is 3–5 years old; for continuation a CDE within 5 years is requiredCDE within 5 years for continuation

See I.B and I.C

Policy Summary

PayerAmbetter Nevada

PolicyApplied Behavior Analysis (ABA) for Autism Spectrum Disorder

Policy CodePolicy CP.BH.104

Change TypeMaterial updates to assessment tools, diagnostic/CDE requirements, and treatment hours guidance

Effective Date

Next Review Date

SourceLink

On This Page

Behavioral assessment for initiation:

Behavioral assessment completed by a BCBA (or state-equivalent) within 2 months prior to treatment start, including record review, interviews, rating scales, direct observation using continuous or discontinuous procedures, and results from at least one maladaptive behavior assessment or one skills acquisition assessment as appropriate (with visual representations/graphs)

Behavioral assessment within 2 months for initiation

Individualized treatment plan: Treatment plan aligns with assessment results and includes background/concerns, individualized measurable goals with baselines and mastery criteria, crisis plan, setting rationale, justified number of treatment hours, specified supervision and Adaptive Behavior Treatment with Protocol Modification, parent/caregiver training plan (2–4 goals), coordination of care, and transition/discharge/titration plan

See I.E.2.c and subsections

Treatment intensity limits and justification: Routine direct ABA services do not exceed six hours per day and 30 hours per week; requests exceeding these limits require clinical documentation demonstrating why lower intensity would be insufficient, how additional hours will be used to target specific goals, and, as applicable, multidisciplinary corroboration>6 hours/day or >30 hours/week require clinical justification

See I.E.2.c.vii and I.E.2.c.vii.d.i-ii

Continuation criteria: Continuation of services requires documented clinical benefit or reasonable expectation of benefit, updated behavior assessment at least every 6 months (or as clinically appropriate), documentation of percentage of scheduled sessions completed and caregiver participation, and ongoing parent/caregiver training and coordination of careUpdated behavior assessment every 6 months; attendance ideally >=80%

See I.E.3 and I.E.3.d-e

inv-02: Discontinuation / Transfer criteria

Appropriate discontinuation/transfer when ANY of the following occur:

Discontinue or transfer triggers: Member has achieved desired socially significant outcomes and services are no longer required to maintain functioning; services are replacing school/respite/community care (i.e., in lieu of those settings); there has been no clinically significant progress for at least six months with no reasonable expectation a revised plan would produce progress (e.g., consistent lack of change in data, increase in targeted behaviors, failure to meet mastery criteria, lack of generalization); treatment or intensity provided for convenience; family or analyst elects to end or temporarily suspend services; member transitioned to another provider or community resources6 months of no significant progress

See II.A-F and II.C.1-4

inv-03: General coverage and clinical practice expectations

Covered when ALL of the following are met and documented:

Individualization of services: Service intensity, number of goals, and modalities must be individualized based on the person's needs, family priorities, and qualified behavior analyst judgment rather than a uniform mandated intensity

Supported by NAS and CASP guidance

Qualified diagnostician and recommendation: ABA must be recommended by a qualified licensed health care provider authorized to diagnose ASD and recommend ABA (per state law as applicable); diagnostic evaluation should reference DSM-5-TR criteria and include evaluator credentials

See I.C and I.A

Comprehensive assessment and treatment planning: Comprehensive diagnostic and behavior assessments performed by BCBA or state-equivalent with objective measurement, direct observation, and functional analysis inform a detailed behavior-analytic treatment plan listing service hours, goals, caregiver training, crisis plan, and coordination of care; plan should consider age, school attendance, and daily activities

See I.B and I.E

Data-driven practice: Ongoing objective data collection and analysis must inform treatment adjustments; caregiver training and generalization across environments are expected; progress must be documented graphically and numerically

Reflects CASP essential practice elements

inv-04: Initial and Continuation Coverage Criteria

Covered when ALL of the following are met (policy sections I.A–I.E as applicable to state law and the member's health plan):

Diagnosis and assessment: ASD diagnosis supported by a Comprehensive Diagnostic Evaluation (CDE) that includes at least one primary clinician assessment tool (e.g., ADOS-2, CARS-2, ASRS) and one parent/caregiver tool (e.g., SRS-2); identify ASD severity level, intellectual and language impairment, and relevant medical/genetic/environmental factors; tool versions current at time of testingCDE with clinician + caregiver tool

CDE recency rules and state-specific exceptions apply

Referral and recommendation: ABA must be recommended by a qualified licensed health care provider within scope of practice who can diagnose ASD and recommend ABA (or equivalent titles per state law); recommendations should be documented in the CDE/treatment planqualified licensed provider per state

Allows state-defined provider titles where applicable

Behavior assessment & treatment plan: Behavior assessment must include distinct maladaptive behavior and skills acquisition assessments with direct observation and measurement (continuous or discontinuous); individualized treatment plan must include visual goal representation, crisis plan, 2–4 parent/caregiver training goals, coordination of care, transition/discharge planning, and documentation of percentage of scheduled sessions successfully completedbehavior assessment by BCBA or state-equivalent

If Vineland is used, an additional direct skills assessment is required

Treatment intensity and supervision: Standard treatment does not exceed six hours per day and up to 30 hours per week; Adaptive Behavior Treatment with Protocol Modification must occur at least 2 hours/week or 10% of direct service (whichever is greater) and generally not exceed 20% of direct service unless justified; requests above standard limits require clinical justification<=6 hrs/day and <=30 hrs/week; ABT with protocol mod >=2 hrs/week or >=10%

Clinical documentation required to justify higher intensity/frequency/duration

Progress and continuation: Continuation requires documented clinical benefit or reasonable expectation of benefit, updated behavior assessment when indicated, documentation of goal progress or lack of progress, continued caregiver training, coordination of care, and recording of session attendance/success (note if <80%)documented progress or clear rationale

See I.E.3 and NMN criteria for lack of clinically significant progress

Services that are otherwise covered under the Individuals with Disabilities Education Act (IDEA) are excluded from medical necessity under this policy when they duplicate school-provided services. Note: unless restricted by a state Medicaid benefit, ABA may occur in coordination with school services and transition plans.

Goals or interventions that are more appropriately provided by other disciplines are not considered medically necessary under this ABA policy. Examples identified in the policy include goals better served through behavioral health outpatient services, speech therapy, occupational therapy, vocational rehabilitation, supportive respite care, recreational therapy, or physical therapy.

The current policy removed prior standalone exclusions that categorically excluded members who require 24‑hour medical or nursing monitoring or have certain dangerous behaviors; appropriateness is now guided by state‑defined criteria and clinician judgment rather than an absolute, blanket exclusion.

Earlier versions of the policy included explicit lists of coordination‑of‑care examples and prescriptive statements about medical stability. Those example lists were removed; the revised policy instead requires documentation of coordination of care, transition planning, and discharge considerations developed with the care team and emphasizes clinician judgment and plan‑specific requirements rather than enumerated examples.

When ABA services would duplicate supports or goals already provided under IDEA, or when specific goals are more appropriately addressed by other qualified disciplines, those ABA services are considered not medically necessary and may be denied.

While some prior blanket exclusion statements were removed in this revision, the policy retains exclusionary intent in situations where services duplicate other covered benefits or where state‑specific rules apply. Operational changes reorganized and clarified exclusions and transitioned several prior categorical statements into guidance informed by state criteria and clinical assessment.

Per the revised policy, ABA services are considered not medically necessary when there is a documented lack of clinically significant progress as defined in the criteria (for example, consistent absence of behavior reduction or skill acquisition over time, increasing targeted behaviors, or failure to meet mastery criteria). The policy frames these situations as not medically necessary rather than simply not covered.

Coding and Billing Codes

Coding implications section present but codes not listed in provided excerptmixed

No codes listed

Referenced CPT / Temporary ABA procedure codesCPT

97151	Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non- face-to-face analyzing past data, scoring/ interpreting the assessment, and preparing the report/treatment plan.
97152	Behavior identification-supporting assessment, administered by one technician
97153	Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes.
97154	Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes.
97155	Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes.
97156	Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes.
97157	Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes.
97158	Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes.
0362T	Behavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior.
0373T	Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior.

Referenced HCPCS / Behavioral health codesHCPCS

H0031	Mental health assessment, by nonphysician.
H0032	Mental health service plan development by nonphysician.
H0046	Mental health services, not otherwise specified.
H2012	Behavioral health day treatment, per hour.
H2014	Skills training and development, per 15 minutes.
H2019	Therapeutic behavioral services, per 15 minutes.
S5110	Home care training, family; per 15 minutes.
S5111	Home care training, family; per session.

HCPCS / Procedure Codes referencedHCPCS

H0031
H0032
H0046
H2012
H2014
H2019
S5110
S511

inv-16: Maximum routine direct ABA service — Do not exceed 6 hours/day or 30 hours/week unless clinically justified

Maximum routine direct ABA serviceDo not exceed 6 hours per day or 30 hours per week unless clinical documentation justifies additional hours

Clinical justification for excess hoursRequests >6 hours/day or >30 hours/week require documentation of severity, frequency, complexity of impairments, how additional hours will be used, and multidisciplinary coordination as applicable

Documentation elements for justificationInclude clinical observations/assessment findings, explicit rationale for increased instructional trials or behavior reduction interventions, and supporting multidisciplinary input where applicable

inv-17: Standard ABA treatment intensity — Does not exceed six hours per day up to 30 hours per week

Standard ABA treatment intensityDoes not exceed six hours per day up to a total of 30 hours per week

ExceptionsAdditional hours may be authorized when clinical documentation demonstrates needs (e.g., persistent/severe challenging behaviors, limited functional communication) that cannot be addressed at lower intensity

Supervision guidanceAdaptive Behavior Treatment with Protocol Modification expected at least 2 hours/week or 10% of direct service (per policy) when applicable

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Submit recent behavioral assessment and individualized treatment plan for PA

Prior authorization requires submission of a recent behavioral assessment (completed no more than 2 months prior to the start of the initial treatment authorization), an individualized treatment plan aligned to assessment results, and justification for requested hours (including rationale if >6 hours/day or >30 hours/week).

Behavioral assessment must be completed by a BCBA or state-equivalent and include record review, interviews, rating scales, direct observation, and results from at least one maladaptive or skills acquisition assessment.
Treatment plan must specify number of treatment hours and include signatures from parent/legal guardian and direct-care BCBA when revised.

Prior Authorization

Include comprehensive diagnostic evaluation and required elements with PA

Prior authorization must include a comprehensive diagnostic evaluation (CDE) documenting DSM diagnosis, direct observation, caregiver interview, test scores, evaluator name/signature/credentials, and at least one primary clinician tool plus one parent/caregiver tool per the CDE requirements.

If CDE is >3 years and <5 years old, submit a diagnostic interview/evaluation within 12 months that meets the listed elements for initiation.
For continuation, a CDE conducted within the past five years is required unless re-evaluation is indicated sooner.

Prior Authorization

PA must include BCBA-conducted behavior assessment and individualized plan

For PA, submit a diagnostic evaluation and a behavior assessment completed by a Board-Certified Behavior Analyst (BCBA/BCBA‑D) or state-equivalent, plus an individualized treatment plan that specifies service hours and supervision; clinical justification is required if requested hours exceed standard limits.

Behavior assessment must include direct observation and measurement (continuous or discontinuous procedures) and appropriate maladaptive or skills acquisition assessments with visual representations.
Requested hours and supervision must be justified in the treatment plan, and behavior assessments must be current per state/professional standards.

Step Therapy

Authorization may be reduced or adjusted based on clinical justification

If clinical documentation shows that lower intensity/frequency/duration is sufficient to achieve goals, the plan may authorize services at a lower level than requested; conversely, additional hours beyond six hours/day or 30 hours/week require clinical justification per policy criteria.

Documentation should explain how reduced intensity will meet goals or, if requesting higher intensity, must include clinical observations, assessment findings, rationale for increased instructional trials, and multidisciplinary coordination as applicable.

Prior Authorization

Provide clinical justification and multidisciplinary support for non-standard hours

Providers must include clinical justification and supporting documentation when requesting hours outside the standard limits; PA submissions should reference the CDE, BCBA assessment, treatment plan, and signatures to support medical necessity.

If requesting >6 hours/day or >30 hours/week, include data demonstrating that needs cannot be addressed at lower intensity and a plan for how additional hours will be used.
Include coordination-of-care documentation and multidisciplinary input when applicable.

Billing Rule

Include CDE/assessment/plan mapped to billed CPT/HCPCS codes

When submitting authorization requests tied to procedure/HCPCS codes, include the diagnostic evaluation, BCBA-completed behavior assessment, individualized treatment plan specifying number of hours and supervision, and clinical justification if hours exceed standard limits.

Referenced CPT/temporary codes (e.g., 97151–97158, 0362T, 0373T) and HCPCS codes (e.g., H0031, H0032, H0046, H2012, H2014, H2019, S5110/S511) should align with the services documented in the PA request.
Ensure treatment plan lists direct service, group, and supervision hours corresponding to billed codes.

Documentation Required

Submit a CDE documenting DSM diagnosis, severity, comorbidities, and evaluator credentials

Submit a Comprehensive Diagnostic Evaluation (CDE) that documents DSM diagnosis, ASD severity level, presence/absence of intellectual or language impairment, evaluator name/signature/credentials, developmental history, direct observation, caregiver interview, and test scores.

Diagnosis must be supported by at least one primary clinician tool and one parent/caregiver tool as identified in the CDE requirements.
For continuation, a CDE within the past five years is required unless re-evaluation is indicated sooner.

Documentation Required

Ensure treatment plan includes BCBA signature, credentials, guardian signature, and required plan elements

Treatment plans must include a BCBA/BCBA‑D HIPAA‑compliant signature with credentials and role, and the parent/legal guardian's signature; plans must list individualized measurable goals with baselines and mastery criteria, a dedicated crisis plan, coordination of care, and caregiver training components.

Revised treatment plans (e.g., when increasing hours) require signatures from the parent/legal guardian and direct-care BCBA.
Parent/caregiver training must include two to four training goals and a documented plan (ideally a minimum of two hours/month unless clinically justified).

Documentation Required

Document behavior identification assessments, supporting assessments, and direct measurement

Provide documentation of behavior identification assessments, supporting assessments, treatment plans, and direct observation/measurement (continuous or discontinuous); assessments must be current per professional/licensure/state standards and include visual representations as appropriate.

Behavior assessments must include maladaptive and skills acquisition components, with graphs/tables/grids as appropriate.
If indirect-only measures (e.g., Vineland) are used, an additional direct skills assessment may be required.

Documentation Required

Include at least one primary clinician tool and one parent/caregiver tool in the CDE

CDE documentation must include at least one primary clinician assessment tool and one parent/caregiver tool; tool versions must be current at time of testing and reported in the evaluation.

Primary clinician tools include instruments like ADOS-2, CARS-2, ASRS; parent/caregiver tools include SRS-2 and others listed in the CDE guidance.
Report must include test names, scores, dates, and the evaluator's summary.

Documentation Required

Include maladaptive and skills acquisition assessments plus visual data and crisis/transition planning in plan

Behavior assessments and individualized treatment plans must include distinct maladaptive behavior and skills acquisition assessments, visual representations of goals and data, a dedicated crisis plan, coordination of care, parent/caregiver training goals (2–4), transition/discharge planning, and documentation of percent of scheduled sessions successfully completed.

Visual representations (graphs, tables, grids) should accompany assessment data and behavior reduction graphs for school settings when applicable.
Treatment plans must specify how goals will be titrated and include mastery criteria and baselines.

Denial Risk

Avoid duplicative services covered by IDEA—may be denied

Services that are otherwise covered under the Individuals with Disabilities Education Act (IDEA) are not medically necessary under this policy when duplicative of school-provided services and may be denied if duplicative.

Unless restricted by state Medicaid benefit, ABA may occur in coordination with school services, but duplication with IDEA-covered services can be denied as not medically necessary.

Documentation Required

Provide documentation when attendance is <80% to justify continuation

If attendance falls below 80% of the authorized hours within an authorization period, provide supporting documentation to justify continuation at the previously approved level; absence documentation should show actions to address barriers when absences are due to medical, educational, or family reasons.

Document percentage of scheduled sessions successfully completed for both member and caregiver.
If attendance <80%, include justification and evidence of attempts to address barriers.

Denial Risk

Missing required assessments or plan elements may trigger denial

Failure to meet initiation or continuation criteria (including missing required assessments, treatment plan elements, updated behavior assessments, or documentation of progress) may result in denial or non‑coverage of services.

Ensure submission of all required CDE elements, BCBA-conducted behavior assessments, and updated assessments at required intervals to avoid denial triggers.
Document clinical progress or reasonable expectation of benefit for continuation.

Denial Risk

Do not request >6 hrs/day or >30 hrs/week without clinical justification

Requests for treatment that exceed six hours per day or 30 hours per week without clinical documentation justifying the increased intensity may be denied; submit data demonstrating need, a clinical rationale, and multidisciplinary support when applicable.

Provide assessment findings showing persistent/severe behaviors, limited functional communication, or escalating problems that cannot be addressed at lower intensity.
Include a plan explaining how additional hours will be used (increased trials, sustained practice, enhanced behavior reduction) and coordination-of-care evidence.

Denial Risk

Attendance <80% without documentation may affect continuation

Attendance below 80% of authorized sessions without supporting documentation may impact continuation of services; providers should document session completion percentages and attempts to engage caregivers.

Document caregiver participation and any documented attempts to engage caregivers if monthly caregiver training minimums are not met.
Absences attributed to medical, educational, or family barriers require documentation of actions taken to address those barriers.

Definitions and Background

Autism spectrum disorder (ASD) is a lifelong neurodevelopmental condition with variable presentation. Applied Behavior Analysis (ABA) is an evidence‑based approach that uses behavioral principles, direct observation, measurement, and functional analysis to increase adaptive skills (for example, language and self‑help) and decrease targeted maladaptive behaviors across settings and modalities.

inv-35: ABA definition — application of behavioral principles to increase skills and decrease behaviors

DefinitionApplication of behavioral principles to everyday situations to increase skills (e.g., language, self-help, play) and decrease targeted behaviors (e.g., aggression, self-injury) using direct observation and functional analysis

ScopeMay be provided across settings (home, clinic, school, community) and modalities (in-person, telehealth) and integrated with other therapies

Core methodsUses direct observation, measurement, functional analysis, and environmental modification to produce meaningful behavior change

inv-36: Comprehensive Diagnostic Evaluation (CDE) definition

DefinitionComprehensive Diagnostic Evaluation (CDE): a multidisciplinary evaluation documenting the effect of symptoms on functioning across settings, including clinician and caregiver assessment tools, direct observation, developmental history, test scores, and evaluator signature/credentials

Tool requirementsCDE must include at least one primary clinician assessment tool and at least one parent/caregiver tool

Recency for initiation/continuationCDE within 3 years for initiation (with provisions for diagnostic interview if 3-5 years old); CDE within 5 years required for continuation

inv-37: Applied Behavior Analysis (ABA) definition (alternate entry)

DefinitionApplied Behavior Analysis (ABA): a behavioral treatment approach that analyzes, designs, implements, and evaluates environmental modifications using direct observation and measurement to produce meaningful behavior change and skill acquisition

Evidence baseRecognized as an evidence-based, validated treatment for ASD emphasizing objective assessment and data-driven practice

IndividualizationIntensity and goals individualized based on needs, family priorities, and qualified behavior analyst judgment (no uniform hour mandate)

inv-38: ASD severity levels per DSM-5-TR

DSM-5-TR severity levelsLevel 1: Requiring support; Level 2: Requiring substantial support; Level 3: Requiring very substantial support

Domains describedSeverity levels describe impairment in social communication and restricted/repetitive behaviors and the level of support required

Clinical useSeverity level should be documented in diagnostic evaluation (CDE) to inform treatment planning and intensity decisions

inv-39: CDE — requirement for at least one primary clinician tool and one parent/caregiver tool

CDE tool requirementCDE must include at least one primary clinician assessment tool and one parent/caregiver tool to support diagnosis and treatment planning

Examples of clinician toolsPrimary clinician tools include instruments such as ADOS-2, CARS-2, ADI-R, STAT (documented in policy tool lists)

Examples of caregiver toolsParent/caregiver tools include instruments such as M-CHAT, SRS-2, SCQ (as applicable and current at time of testing)

inv-40: Behavior assessment definition — maladaptive and skills acquisition assessments; Vineland caveat

Behavior assessment definitionBehavior assessment requires distinct maladaptive behavior and skills acquisition assessments using direct observation and measurement (continuous and/or discontinuous procedures)

Vineland caveatIf the Vineland is used as a primary skills assessment, an additional direct skills assessment is required to meet policy standards

Provider qualificationsBehavior assessments must be completed by a BCBA or other duly certified/licensed/registered state-equivalent as defined by state law

ABA Clinical and Measurement Criteria

inv-41: Outpatient / community-based ABA criteria (level-of-care group)

Level-of-care: Outpatient / community-based ABA: Admission requires member to be medically appropriate for outpatient/community-based services (not requiring 24-hour medical/nursing care per plan/state), recent behavior assessment by BCBA or state-equivalent, individualized treatment plan with specified hours and caregiver training; continued stay requires documented progress or reasonable expectation of benefit and updated behavior assessment at least every six monthsBehavioral assessment within 2 months for initiation; updated assessment every 6 months for continuation

See level-of-care criteria and I.E

inv-42: Outpatient ABA / Home-based ABA criteria

Outpatient ABA / Home-based ABA admission: Member has ASD diagnosis per CDE, BCBA-completed behavioral assessment, individualized treatment plan with caregiver training and crisis plan; requested treatment intensity does not exceed standard limits unless clinically justified; treatment setting rationale must explain how setting maximizes outcomes

See I.E.2.b-vi and I.E.2.c.vii

inv-43: ABA clinical and documentation requirements for authorization and continued services

Assessment and documentation required for authorization: Submit CDE and BCBA-completed behavior assessment, treatment plan with goals/baselines/mastery criteria, crisis plan, caregiver training plan (2–4 goals), documentation of scheduled session completion rate, visual representations of progress (graphs), and signatures (BCBA and parent/legal guardian)CDE within 3 years for initiation or diagnostic interview per rules; behavior assessment within 2 months for initiation

See documentation and prior authorization requirements

Ongoing documentation for continued services: Provide updated behavior assessments at least every 6 months (or as clinically appropriate), data demonstrating progress toward goals, documentation of caregiver participation and training hours, coordination of care records, and justification for any requested increases in hours above standard limitsUpdated behavior assessment every 6 months; attendance ideally >=80%

See I.E.3 and prior auth guidance

inv-44: ABA clinical criteria — clinical and practice expectations for covered ABA services

Clinical practice expectations: ABA services must follow evidence-based, behavior-analytic principles including objective assessment of environmental effects on behavior, functional analysis where appropriate, consistent data collection, individualized goal selection, emphasis on generalization and maintenance, and ongoing treatment adjustments based on data

Reflects CASP core characteristics and NAS guidance

Provider qualifications for assessment: Behavioral assessments and treatment planning must be completed or overseen by a Board Certified Behavior Analyst (BCBA/BCBA-D) or equivalent as defined by state law; documentation must include credentials and HIPAA-compliant signature

See I.E.2.b.i and I.D

Caregiver engagement and training: Caregiver training must be performance-based, caregiver-driven, include 2–4 training goals with baseline and mastery criteria, and an assessment/plan to address barriers to engagement; training ideally at least two hours per month unless clinical documentation justifies fewer hours~2 hours/month recommended

inv-45: ABA assessment and measurement criteria — summarized from policy sections I.B–I.E

Screening and assessment tool expectations: Acceptable screening tools updated (e.g., EarliPoint, SWYC POSI, RITA-T, CSBS-ITC); diagnosis via CDE requires at least one primary clinician tool and one caregiver tool; clinician tools include CARS-2, ADOS-2, ASRS and caregiver tools include SRS-2, with versions current at time of testingminimum clinician + caregiver tool

See I.B.2.c.vi and related updates

Behavioral measurement and assessments: Behavior assessments must include direct, observable measurement (continuous or discontinuous), distinct maladaptive and skills acquisition assessments, and visual data displays; if Vineland is used, an additional direct skills assessment is requiredBCBA or state-equivalent completion

See I.E.2.b.vi and I.B.2 notes

Assessment frequency for continuation: Updated behavior assessment required at least every 6 months for continuation or sooner if indicated; CDE recency rules also apply per initiation/continuation guidance

Settings, Modalities, and Caregiver Training

inv-46: Settings and modalities — outpatient, home, community settings (1 top-level node)

Settings and modalities: ABA services may be delivered in home, clinic, school, or community settings and in-person or via telehealth as appropriate; setting selection must be justified in the treatment plan by how it will maximize outcomes given the member's assessed needs and available resources

Refer to setting rationale in treatment plan (I.E.2.c.vi)

inv-47: Telehealth — modality considerations and criteria

Telehealth is an acceptable supplemental modality to in-person ABA based on individual clinical needs, caregiver availability, environmental supports, and state allowances; telehealth should not be used as a complete replacement of in-person services and providers should follow CASP Telehealth Practice Parameters

Clinical decisions guided by individual needs and state regulations

inv-48: Parent/Caregiver Training — required training content and expectations

Parent/Caregiver Training required elements: Treatment plan must include 2–4 parent/caregiver training goals with baseline data, expected behaviors, and mastery criteria; documented plan for training frequency and content, assessment of barriers to engagement, and documentation of caregiver participation (ideally two hours/month unless clinically justified for fewer)2–4 training goals; ~2 hours/month recommended

See I.E.2.c.xi and I.E.3.e

Role of caregiver training in authorization and continuation: Caregiver training is required for initiation and continuation; documentation of family participation and attempts to engage caregivers (if participation limited) must be provided and considered in continuation decisionsDocumented family participation or documented attempts

If caregivers unwilling/unable, consider alternative modalities

Visit Limits and Intensity

inv-49: Direct ABA therapy — routine limits 6 hours/day; 30 hours/week

Routine direct ABA therapy limitRoutine direct ABA therapy does not exceed 6 hours per day or 30 hours per week

Authorization of additional hoursAdditional hours beyond routine limits require clinical documentation justifying the need and explanation of how extra hours will be used

Documentation to includeClinical observations, assessment findings, trend data for behaviors, and multidisciplinary coordination as applicable

inv-50: Comprehensive ABA intensity range — 30-40 hours/week

Comprehensive ABA intensity rangeComprehensive ABA intensity range cited in policy: 30-40 hours per week (updated from prior 25-40)

Individualized determinationEven within comprehensive ranges, the number of weekly hours must be individualized by a qualified behavior analyst considering goals, other services, and learning rate

Policy contextThe policy references NAS guidance that does not endorse a uniform intensity for all individuals and emphasizes individualized planning

inv-51: ABA direct treatment — up to 6 hours/day and 30 hours/week as standard; more may be authorized with clinical justification

Standard direct treatment limitsStandard authorization: up to 6 hours per day and up to 30 hours per week; this is the expected routine intensity

Authorization beyond standardRequests for more than standard limits may be authorized when clinical documentation demonstrates that needs cannot be met at lower intensity and includes a rationale and treatment utilization plan

Supervision and proportion guidanceAdaptive Behavior Treatment with Protocol Modification should be provided at least 2 hours/week or 10% of direct service hours where applicable

See I.E.2.c.xi and I.E.3.e

Updated assessment every 6 months; CDE within 5 years for continuation

See I.E.3.c and I.B.1.a.ii