CurrentAnthemPolicy N/A

Applied Behavior Analysis (97155) — Continued Stay Service Authorization (HealthKeepers Plus Medicaid)

Form and requirements for requesting continued authorization of Applied Behavior Analysis (ABA) services for Anthem HealthKeepers Plus Medicaid members in Virginia; describes documentation, care coordination, progress reporting, and provider attestation requirements.

Policy Summary

PayerAnthem

PolicyApplied Behavior Analysis (97155) — Continued Stay Service Authorization (HealthKeepers Plus Medicaid)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionInclude original CNA and CNA addendum, updated ISP, graphical progress on each ISP goal, and LMHP attestation when submitting continued stay authorization requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20 hrs/wkhigh-dosage threshold

CNA, ISP, progressrequired attachments

LMHP signatureattestation required

Coverage and Continued Stay Criteria

Continued Stay Authorization Criteria

Covered when documentation supports ongoing need and medical necessity as attested by an LMHP-level clinician.

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Continued Stay Documentation: All of the following must be provided: original Comprehensive Needs Assessment (CNA) and CNA addendum; updated Individual Service Plan (ISP) reflecting current goals and interventions; summary of treatment progress including graphical progress for each ISP goal; overview of family involvement; documentation of generalization of adaptive functioning across multiple settings; progress toward discharge and a plan to gradually reduce services or identify lower levels of care; objective measures for each treatment goal with measurement methods and responsible party; description of dosage (days/hours) and service delivery specifics.

Supports justification for continued ABA services

High-Dosage Requests: If requested services exceed 20 hours (80 units) per week, include the schedule of activities used to structure sessions and a description of how those activities facilitate implementation of the behavioral modification plan.>20 hours/week

Required for high-intensity service requests

Provider Attestation: An LMHP, LMHP-R, LMHP-S or LMHP-RP must review psychiatric history and complete the assessment or addendum, and attest (signature and date) that the individual meets medical necessity criteria for the service.

Signature attestation required on form

Authorization Requests, Documentation, and Submission Instructions

Prior Authorization

Continued stay prior authorization requirements

Requests for continued stay prior authorization must include proposed start and end dates and the total units requested. The request must state the planned hours of service per week. For any request exceeding 20 hours per week (80 units), include the schedule of activities used to structure service sessions and describe how those activities facilitate implementation of the behavioral modification plan.

Provide proposed From/To dates and total units.
State planned hours per week.
If >20 hours/week (80 units), attach schedule of activities and description of how activities support the behavioral plan.

Denial Risk

Provider action gap — Not addressed

Item flagged as "Not addressed" in source: provider action gap. If any required element below is not addressed in the submission, the provider should note this explicitly and include a plan/timeline to supply the missing information to avoid delay or potential exclusion of the request.

If unable to provide an original CNA or CNA addendum, indicate why and supply a timeline for submission.
If graphical progress per goal is not available, state alternate measures and plan to deliver graphical data.

Documentation Required

Required documentation for continued authorization

Include the following documentation with continued authorization requests: the original Comprehensive Needs Assessment (CNA) and any CNA addendum (an addendum may be in a progress note) describing new information impacting care and rationale for continued services; an updated Individual Service Plan (ISP) reflecting current goals and interventions; a summary of treatment progress including graphical presentation of progress on each ISP goal/objective; overview of family involvement and training needs; summary of generalization of adaptive functioning across settings; progress toward anticipated discharge including plans to taper services and identify lower levels of care; objective measures and how they are tracked; descriptions of interventions and dosage (days/hours); and standardized assessments where applicable.

Original CNA and CNA addendum (addendum may be in a progress note).
Updated ISP with current goals, objective measures, interventions, and dosage (days/hours).
Graphical presentation of progress on each ISP goal/objective.
Overview of family involvement, progress made, and ongoing training needs.
Summary of generalization/maintenance of skills in multiple settings and ISP updates to test generalization.
Progress toward discharge with plan to reduce services and identify lower levels of care.
Documentation of objective measurement methods (frequency, rater, logging), standardized assessments when used.

Note

Retro review indication

If this is a retroactive request, mark the form "Retro Review Request" and provide the service start date. Retro review requests should clearly indicate the member's current participation status and include all documentation covering the retroactive period to support medical necessity.

Select Retro Review Request = Yes when applicable.
Provide start date of service for retro requests.
Attach complete documentation covering the retroactive service period.

Policy Background and Purpose

The purpose of this continued-stay authorization form is to support ongoing authorization of ABA services by documenting the member’s ongoing needs, measurable progress toward individualized goals, and planning for reduction or discharge of services. Providers must supply the original CNA (with any addendum), an updated ISP reflecting current goals and interventions, objective measures and graphical presentations of progress for each ISP goal, a summary of family involvement and generalization across settings, and a plan addressing anticipated discharge and how services will be reduced while maintaining gains. For high-intensity requests exceeding 20 hours (80 units) per week, include the schedule of activities used to structure sessions and describe how those activities implement the behavioral modification plan.

Service Level and Setting Criteria

Outpatient/ABA Services Criteria

Outpatient Applied Behavior Analysis (ABA) continued stay requests are evaluated using the following service-level documentation and authorization requirements.

Required Attachments: Include original CNA and CNA addendum, updated ISP, and a summary of treatment progress with graphical presentations for each ISP goal.

Attachments listed on form

Proposed Service Information: Requests must state proposed service dates and total units; for requests exceeding 20 hours (80 units) per week submit the schedule of activities and rationale.>20 hours/week

Schedule required for high-dosage requests

Retro Review: If requesting retroactive authorization, indicate 'Retro Review Request' and provide the start date of service if the member is currently participating.

Operational instruction for retro review

Applied Behavior Analysis Continued Stay Clinical Criteria

ABA Continued Stay Clinical Criteria

Documentation and clinical elements that must support continued ABA services; all elements below should be addressed in progress reports and ISP updates.

Goals and Measures: Person-centered, recovery-oriented, trauma-informed treatment goals written collaboratively with the individual; objective measures for each goal (use frequency counts and anchored severity ratings where applicable); specify how often measures are taken and who is responsible; include standardized assessments when appropriate.

Goals must be measurable and meaningful

Interventions and Dosage: Describe interventions including activities involved, targeted skills, necessary adaptations, responsibilities by provider type, and dosage (days/hours). Describe efforts and plans to generalize skills to least restrictive environments.

Required to justify continued intensity

Progress and Treatment Evolution: Describe progress in terms of identified goals and objectives; document any changes to goals or measurements and rationale; include resources, strengths, and barriers; explain how the plan is evolving to support recovery.

Continued stay requires explanation of plan evolution

Family Involvement and Generalization: Provide an overview of family/caregiver involvement, progress made, ongoing family training needs, and documentation of generalization/maintenance of skills across multiple settings.

Supports sustainable outcomes and discharge planning

Discharge Planning: Include progress toward anticipated discharge, plan to gradually reduce services, identification of lower levels of care and natural supports, care coordination needs, and estimated discharge date.

Discharge planning should begin at first contact and be updated