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    v1.0.28
    OpenPayerPolicy UpdatesPsychiatry/Behavioral HealthAmbetter Nevada ABA Documentation Update | OpenPay…
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    ModifiedAmbetter NevadaPolicy CP.BH.105

    Applied Behavioral Analysis Documentation Requirements

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    This policy governs clinical documentation, service-note, treatment-activity, protocol-modification, telehealth, discharge, and related record requirements for covered Applied Behavioral Analysis (ABA) services. It applies to providers, rendering clinicians and technicians, supervising practitioners, members/enrollees, and caregivers involved in ABA services.

    Policy Summary
    PayerAmbetter Nevada
    PolicyApplied Behavioral Analysis Documentation Requirements
    Policy CodePolicy CP.BH.105
    Change TypeModified
    Effective DateOct 1, 2026
    Last ReviewFeb 1, 2026
    Next Review DateNot specified
    Key ActionObtain prior authorization approval for ABA services when required before services are rendered or billed.
    SourceLink
    POLICY UPDATE CHANGES

    The policy added prior authorization, documentation-update, active-treatment, and payment-denial or recoupment requirements for ABA services.

    The policy expanded service-activity-note requirements to include treatment summaries, protocol modifications, caregiver participation, telehealth safeguards, progress, treatment response, participant identification, and care coordination.

    The policy added discharge-summary requirements for members/enrollees who no longer meet medical necessity criteria for ABA services.

    The policy established protocol-modification documentation expectations, including a minimum of two hours per week or 10% of direct service hours, whichever is greater, and a maximum of 20% unless clinically justified.

    The policy purpose was revised from providing medical necessity guidance to providing documentation guidance because the policy is not a medical necessity policy.

    Former medical necessity criteria in sections I.A–I.D were removed.

    Requirements were added for prior authorization approval, updated clinical documentation, and documentation and data collection.

    Documentation requirements were expanded for service notes, detailed treatment-activity summaries, telehealth, progress, member/enrollee response, addenda, discharge planning, and provider and caregiver signatures.

    Protocol-modification documentation requirements were added and the related code H0032 was added in multiple provisions.

    Unsupported 97153 and 97154 units billed during the entire six-month authorization period may be denied or recouped.

    HIPAA compliance language and additional HCPCS codes were added to the policy.

    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.

    10%Minimum protocol-modification proportion
    20%Maximum protocol-modification proportion unless justified
    6 monthsAuthorization period
    100%Active treatment expected during billed session
    MonthlyMinimum one-on-one protocol review frequency
    8Additional HCPCS codes added

    ABA Documentation Coverage Criteria

    General ABA documentation requirements

    When ABA is a covered benefit, clinical documentation must contain all applicable requirements.

    General ABA documentation

    • Active treatment: Use session time continuously and efficiently in a clinically justified manner consistent with treatment-plan goals, with the full session consisting of active treatment components and minimal nonprogrammed or idle time.

      Unstructured or non-therapeutic periods, administrative or documentation tasks completed outside direct intervention, and periods without documented data collection or therapeutic interaction addressing specific treatment goals do not constitute active session engagement.

    • Service note content: Include identification information, the exact session date and start and end times, note-creation date and rationale when different from the service date, pauses and resumptions, location, service type and applicable code, qualified-rendering-provider signature, treatment summary, progress, response, participants, and coordination of care.

      If the legal name differs from the preferred name, include the legal name at the top of the note, with the preferred name in parentheses and used throughout the remaining documentation.

    • Treatment summary: Document current clinical status and presenting symptoms, primary target areas, techniques used, direct treatment, and applicable barriers to treatment-plan implementation and how they were addressed.

      Include cumulative graphs of goals and objectives and baseline data as applicable.

    Protocol modification documentation

    For services associated with 0373T, 97155, H0032, and/or 97158, document all applicable protocol-modification requirements.

    Protocol modification services

    • Protocol modification amount: Protocol modification occurs for at least two hours per week or 10% of the direct service hours provided, whichever is greater, and no more than 20% of direct service hours provided unless clinical documentation justifies exceeding that amount.Minimum: 2 hours per week or 10% of direct service hours, whichever is greater; maximum: 20% unless clinically justified

      This requirement supports associated 97153 and 97154 units during the authorization period.

    • Monthly supervisor service: Provide at least monthly one-on-one service delivery with the member/enrollee for development of a new or modified protocol or clinical review when no modification is needed.At least monthly

      Technician supervision alone or team meetings do not constitute protocol modification.

    Caregiver training documentation

    When caregiver training occurs, document caregiver involvement and related barriers.

    Caregiver training: For 97156 or 97157, document caregiver participation and/or identify barriers to caregiver engagement and the plan to address those barriers.

    A caregiver signature is recommended on clinical notes documenting caregiver participation.

    Telehealth requirements

    When services are delivered via telehealth, document compliance with the stated technology and privacy requirements.

    Telehealth delivery: Use a platform that complies with HIPAA privacy and security standards, and ensure the rendering provider or technician has a functioning camera turned on and functioning audio input and output.

    Telehealth delivery of monthly one-on-one protocol development or clinical review is subject to state-guideline allowances.

    Discharge documentation

    When the member/enrollee no longer meets medical necessity criteria for ABA, complete a discharge summary with all applicable elements.

    Discharge summary: Document referrals provided, the rationale or reason for discharge supported by a progress summary, the qualified rendering provider's signature, the caregiver's signature, and the date of discharge.

    Discharge planning is required in all treatment plans and upon termination of services.

    Unstructured or non-therapeutic periods are not considered active session engagement. Examples include meals or free play when they are not embedded with documented teaching.

    Administrative tasks and documentation completed outside of direct intervention are not active session engagement and should not be counted as active treatment time.

    Periods without documented data collection or documented therapeutic interaction addressing specific treatment goals are not active session engagement.

    Technician supervision alone and team meetings do not constitute protocol modification. Protocol-modification documentation must support the applicable clinical activity, including protocol development or modification and the required direction or observation when applicable.

    Do not include protected health information (PHI) or personally identifiable information (PII) for individuals who are not members or enrollees in the clinical documentation.

    Applicable Codes and Service Parameters

    CPT CodesCPT
    97151Behavior 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.
    97152Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes.
    97153Adaptive 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.
    97154Group 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.
    97155Adaptive 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.
    97156Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face.
    97157Multiple-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.
    97158Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes.
    0362TBehavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with a patient, requiring administration by the physician or other qualified health care professional who is on site, assistance of two or more technicians, a patient who exhibits destructive behavior, and completion in an environment customized to the patient's behavior.
    0373TAdaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring administration by the physician or other qualified health care professional who is on site, assistance of two or more technicians, a patient who exhibits destructive behavior, and completion in an environment customized to the patient's behavior.
    HCPCS CodesHCPCS
    H0031Mental health assessment, by nonphysician.
    H0032Mental health service plan development by nonphysician.
    H0046Mental health services, not otherwise specified.
    H2012Behavioral health day treatment, per hour.
    H2014Skills training and development, per 15 minutes.
    H2019Therapeutic behavioral services, per 15 minutes.
    S5110Home care training, family; per 15 minutes.
    S5111Home care training, family; per session.
    CPT codes referenced in documentation guidanceCPT
    0373T
    97155
    97158
    97156
    97157
    97153
    97154
    HCPCS codes referenced in documentation guidanceHCPCS
    H0032
    H0031
    H0046
    H2012
    H2014
    H2019
    S5110
    S511
    Protocol Modification Minimum
    Minimum protocol modificationAt least two hours per week or 10% of direct service hours provided, whichever is greater.
    Applicable servicesApplies when services associated with 0373T, 97155, H0032, and/or 97158 are rendered.
    Measurement basisThe percentage is calculated from direct service hours provided.
    Protocol Modification Maximum
    Maximum protocol modificationNo more than 20% of direct service hours provided.
    Exception

    Documentation and Billing Actions

    Prior Authorization

    Prior Authorization Required

    Obtain prior authorization approval for ABA services when required before services are rendered or billed. Claims may be affected when required approval is not in place.

    Prior Authorization

    Prior Authorization and Added Documentation

    Prior authorization approval is required when applicable, and the policy adds documentation requirements for supported ABA services. Ensure records demonstrate compliance with the applicable authorization and documentation requirements before billing.

    Documentation Required

    Clear and Legible Records

    All documentation submitted for ABA services must be clear and legible so it can support treatment planning, utilization review, communication, and reimbursement compliance.

    Policy Context

    ABA documentation should demonstrate medical necessity, delivery of active treatment, and progress toward individualized treatment goals. Records should reflect objective assessment and direct observational data, ongoing data collection and analysis, individualized behavior-analytic treatment planning, caregiver collaboration and training, and treatment-plan adjustment when progress is lacking. The documentation should also show that treatment promotes dignity, independence, autonomy, health, safety, skill acquisition, and quality of life.

    ABA Clinical Practice Elements

    ABA clinical practice elements

    ABA treatment documentation should demonstrate the following clinical practice elements.

    ABA clinical practice elements: Use objective assessment and analysis; understand the context and value of behavior; promote dignity; apply behavior-analytic principles to improve health, skills, independence, quality of life, and autonomy; collect, quantify, and analyze objective direct-observational data; establish individualized meaningful goals informed by baseline assessment; design supportive social and learning environments; link challenging behavior to its function; use individualized, detailed behavior-analytic treatment plans; implement protocols repeatedly, frequently, and consistently across environments; adjust treatment based on ongoing analysis and progress; train caregivers and other involved persons; and maintain comprehensive behavior-analyst supervision.

    These elements should be apparent throughout assessment and treatment and support progress toward health, safety, skill acquisition, independence, autonomy, and quality-of-life goals.

    Active treatment and progress

    ABA service documentation must support active treatment and individualized treatment-goal monitoring.

    Active treatment and progress monitoring:

    Telehealth Services

    Telehealth

    When ABA services are delivered by telehealth, all of the following requirements apply.

    Telehealth ABA delivery: Use a HIPAA-compliant privacy and security platform with the rendering provider's or technician's camera turned on and functioning audio input and output.

    State guidelines govern whether certain monthly one-on-one protocol-development or clinical-review services may be delivered via telemedicine or telehealth.

    Policy Summary
    PayerAmbetter Nevada
    PolicyApplied Behavioral Analysis Documentation Requirements
    Policy CodePolicy CP.BH.105
    Change TypeModified
    Effective DateOct 1, 2026
    Last ReviewFeb 1, 2026
    Next Review DateNot specified
    Key ActionObtain prior authorization approval for ABA services when required before services are rendered or billed.
    SourceLink
    On This Page
    ABA Documentation Coverage CriteriaApplicable Codes and Service ParametersDocumentation and Billing ActionsPolicy ContextABA Clinical Practice ElementsTelehealth Services
    The 20% maximum may be exceeded when clinical documentation justifies the additional amount.
    Applicable servicesApplies to protocol-modification services associated with 0373T, 97155, H0032, and/or 97158.
    One-on-One Protocol Development or Clinical Review
    Minimum frequencyAt least monthly.
    PurposeOne-on-one service delivery is used to develop a new or modified protocol or conduct a clinically justified clinical review when no modification is needed.
    Delivery requirementsThe service must be rendered by the ABA supervisor and may not be delivered via telemedicine or telehealth unless allowed by state guidelines.
    Authorization Period
    Authorization periodSix months.
    Units reviewedThe policy specifically addresses 97153 and 97154 units billed during the entire authorization period.
    Payment consequenceUnits not supported by the protocol-modification requirements may be subject to denial of payment or recoupment.
    Former Protocol-Modification Daily Limit
    Former daily limitThe former limit was 8 units, or 2 hours, per day.
    Current statusThe 8-unit/2-hour daily limit was removed from the policy.
    Related requirementProtocol-modification services are instead subject to the policy's minimum and maximum protocol-modification documentation requirements.
    Documentation Required

    Regular Review and Signatures

    Review and update clinical documentation at regular intervals. Include the signatures and printed names of the member/enrollee, legal guardian, rendering clinician or technician, and supervising practitioner or Qualified Healthcare Provider, as applicable.

    Documentation Required

    Active Treatment Throughout the Session

    Documentation and data collection must show that active treatment was delivered throughout the full duration of billed services, with continuous, clinically justified use of session time and minimal nonprogrammed or idle time.

    Denial Risk

    Non-Active Time Examples

    Do not count non-active engagement as support for billed active-treatment time.

    • Unstructured or non-therapeutic periods, such as meals or free play, unless embedded with documented teaching.
    • Administrative tasks or documentation completed outside direct intervention.
    • Periods without documented data collection or therapeutic interaction addressing specific treatment goals.
    Documentation Required

    Required Service Activity Note

    Complete a service activity note for every service rendered before submitting the claim. The note must identify the provider and member, document the session details and service type, include the qualified rendering provider or technician’s signature, and summarize the treatment activity and clinical response.

    • Provider organization and rendering provider or technician clearly identified.
    • Member name on each page, with legal and preferred names handled as required; include DOB or unique identifier.
    • Exact service date and start/end times, note-creation date and rationale when different, pauses and resumptions, and service location.
    • Type of service and applicable code, qualified rendering provider or technician signature, treatment activity, progress, response, participants, and coordination of care.
    • Include protocol modifications or a clinically justified rationale for no modifications when applicable; document caregiver participation or barriers when caregiver training occurs and telehealth requirements when applicable.
    Documentation Required

    Addenda Requirements

    Addenda created after the original clinical note must clarify or correct existing documentation without substantively changing the nature, duration, or content of services rendered.

    • Clearly reference the original clinical note being supplemented.
    • Include the date the addendum was completed.
    • Include the rendering clinician or technician’s legible name, signature, and credentials.
    Documentation Required

    Discharge Documentation

    Document discharge planning in every treatment plan and upon termination of services. When the member/enrollee no longer meets medical-necessity criteria, the discharge summary must include applicable referrals, discharge rationale supported by the progress summary, required signatures, and the discharge date.

    • Signature of the qualified rendering provider.
    • Signature of the caregiver.
    • Date of discharge.
    Documentation Required

    Clear, Legible, and Complete Documentation

    Submit documentation that is clear, legible, and complete. Records must contain the required service, treatment, progress, participation, signature, and plan-adjustment information needed to support the billed services and applicable policy requirements.

    • Document progress or lack of progress toward identified goals, including cumulative graphs and baseline data as applicable.
    • When progress is lacking, include clinical rationale and evidence of treatment-plan adjustment under 97155 or H0032.
    • Identify all active participants and their relationship to the member/enrollee, and exclude PHI or PII for non-members/enrollees.
    Billing Rule

    Document Protocol Modification Services

    When services associated with 0373T, 97155, 97158, H0032, 97156, or 97157 are rendered, document the applicable protocol-modification, supervision, observation, caregiver-training, and treatment requirements in the service activity note.

    • For 0373T, 97155, 97158, and H0032, list protocol modifications or provide a clear, clinically justified rationale for no modifications, identifying the protocol components reviewed.
    • Protocol modification must occur at least two hours per week or 10% of direct service hours, whichever is greater, and no more than 20% unless clinically justified.
    • Provide at least monthly one-on-one service with the member/enrollee for development of a new or modified protocol, or document the clinical review and justification when no modification is needed.
    • Document technician direction when applicable and direct observation of the rendering provider for 0373T, 97155, and H0032.
    • For 97156 or 97157, document caregiver participation or barriers to engagement and the plan to address those barriers.
    Denial Risk

    Unsupported Billed Units

    Billed units that are not fully supported by clinical documentation may be denied or recouped. Ensure each billed unit is supported by records demonstrating the service delivered, active treatment, and applicable authorization and protocol requirements.

    Denial Risk

    Insufficient Protocol Modification

    Across the six-month authorization period, 97153 and 97154 units must be supported by the required protocol-modification documentation. Units billed without sufficient protocol modification support are subject to denial or recoupment.

    • Protocol modification expectations include at least 10% of direct service hours, subject to the policy’s minimum and maximum requirements.
    • Example: if 100 hours of 97153/97154 are billed and only 7% protocol modification is documented, the unsupported units may be denied or recouped for the authorization period.
    Denial Risk

    Incomplete Service Documentation

    Missing treatment documentation, progress information, or required treatment-plan adjustments can result in adverse payment action. Document progress or lack of progress toward treatment goals and support any lack of progress with clinical rationale and plan adjustments.

    • Include cumulative graphs of goals and objectives and baseline data when applicable.
    • For lack of documented progress, include evidence of treatment-plan adjustment under 97155 or H0032.
    Denial Risk

    Unsupported 97153/97154 Units

    All 97153 and 97154 units billed for the member/enrollee during the entire six-month authorization period that are not supported by the protocol-modification requirements may be denied or recouped.

    • Maintain documentation supporting the required protocol-modification frequency and percentage throughout the authorization period.
    • Apply the requirement across the full six-month authorization period, not only to an individual session or claim.
    Document clinically justified active treatment, target areas, techniques, direct treatment, data collection, progress or lack of progress, treatment response and outcomes, and treatment-plan adjustment when progress is lacking.

    Lack of documented progress must be accompanied by clinical rationale and evidence of treatment-plan adjustment under 97155 or H0032. Progress documentation includes cumulative graphs of goals and objectives and baseline data as applicable.