Prior authorization required for all ABA services

Prior authorization is required for all Applied Behavior Analysis (ABA) services. Authorization must be obtained per plan policy, state Medicaid requirements, and provider contract terms; services rendered without required prior authorization, or services that exceed the scope, duration, or units authorized, may be denied or reimbursed at a reduced rate. Prior authorization does not guarantee coverage or reimbursement.

Maintain documentation supporting medical necessity and provider qualifications

Medical record documentation must support the medical necessity of ABA services and the services billed. Documentation must include the service rendered, the CPT code and units reported, the qualifications of the rendering provider, and supervision/oversight when applicable; retain records per applicable record-retention requirements. Failure to provide adequate documentation may result in claim denial or recoupment.

Use required modifiers to identify rendering provider role and supervision

Modifiers are required to identify the role of the rendering provider and supervision; use appropriate modifiers consistent with the reported service and provider type. Claims submitted without required or appropriate modifiers, or with modifiers inconsistent with the reported service, provider type, or scope of practice, may be denied regardless of prior authorization.

• HO = master’s-level clinician (BCBA or licensed mental health provider)
• HP = doctorate-level clinician (BCBA‑D or licensed mental health provider)
• HN = bachelor-level (BCaBA)
• No modifier = less than bachelor’s (Registered Behavior Technician, RBT) when applicable