Anthem EPSDT Behavioral Therapy Prior Auth

Coverage and Medical Necessity Criteria

Medical Necessity and Eligibility Criteria

Covered when ALL of the following are met:

Ordering and purpose: Ordered by the child's PCP, other licensed physician, licensed physician assistant, or licensed nurse practitioner who has knowledge of the child's developmental history and current status and is medically necessary to correct or ameliorate significant impairments in major life activities resulting from developmental, behavioral, or mental disabilities.

General medical necessity criteria (1-8): 1) Individual medically stable to benefit; 2) Current or provisional DSM psychiatric diagnosis relevant to need for behavioral therapy; 3) Individual meets at least two of: (a) non-verbal or limited functional communication/pragmatic language/intelligible speech or receptive/expressive language impairment; (b) severe impairment in social interaction/social reasoning/social reciprocity/interpersonal relatedness; (c) frequent intense self-injurious or aggressive behavioral outbursts; (d) disruptive obsessive, repetitive, or ritualized behaviors; (e) difficulty with sensory integration; 4) Level of impairment requires treatment not provided by another DMAS program or lower level of care and requires behavioral interventions and expertise of an LMHP, LBA, or LABA; provider must document that less intensive modalities have been ruled out or tried and were not successful; 5) Expected to increase adaptive/social-communicative functioning and produce generalized behavioral change; 6) Individual willing to participate; 7) Family/caregivers lack skills to manage behaviors in home and at least one family member/caregiver must participate, agree to training, and implement behavioral strategies; 8) Not appropriate for children who have attained behavioral control and only require social skills enhancement; children eligible for CMHRS are not eligible for EPSDT Behavioral Therapy.

Assessment, Preliminary Treatment Plan and ISP Criteria

Assessment and service planning requirements (must be met to support medical necessity):

Assessment content and conduct: Comprehensive assessment completed by an LMHP, LBA, or LABA under LBA supervision; conducted face-to-face with the child and parents/caregivers; includes a diagnosis relevant to need for behavioral therapy; comprehensive health and developmental history; reasons the individual needs behavioral therapy and why traditional outpatient treatments are insufficient; information about targeted behaviors including frequency, duration, and intensity; clear indication of status relative to Medical Necessity and Eligibility Criteria; and treatment history within the last year across relevant disciplines (pediatrics, medication management, neurology, psychiatry, speech-language, OT/PT, outpatient counseling/family therapy, behavioral therapy, family training, residential/inpatient care).

ISP requirements and timing: A preliminary treatment plan is used for authorization; an Individual Service Plan (ISP) must be developed within 30 days of service initiation by an LMHP, LBA, or LABA under LBA supervision; the ISP must demonstrate need for EPSDT Behavioral Therapy, define each target behavior, specify the behavioral modification strategy for each target behavior, and describe measurement and data collection methods for each target behavior; ISP must be signed by the individual and/or parent/guardian, reviewed at least every three months and updated at least annually; ISP must include child-focused goals, parent/caregiver education goals, service coordination goals, and for requests exceeding 20 hours/week include a schedule of activities showing therapeutic function and number of hours requested.

Continuation Criteria

Continuation of service authorization requires ALL of the following:

Documentation for continuation: An updated order or letter of recommendation from the child's PCP, physician, nurse practitioner, or physician assistant familiar with the child's developmental history and current status; a Child Specific Treatment Summary including any changes in diagnosis, a summary of recommended therapy goals, description of how the current therapy protocol is impacting clinical progress, baseline and performance data demonstrating efficacy tied to each goal/objective, description of any service gaps (no greater than 30 days) and their impact, reasons continued therapy is needed, and justification that continued therapy cannot be managed at a lower level of care.

Generalization and progress: Include a Generalization Summary documenting progress on parent/caregiver involvement goals, progress toward educational goals with other care providers, generalization of adaptive functioning across settings, progress toward anticipated discharge including fading and consultative actions, and justification for ongoing clinician involvement and why lower level care is not appropriate.

The following services are covered through other DMAS programs and are not billed as part of EPSDT Behavioral Therapy: assistive technology devices, pharmacy items, health services, nutrition services, nursing services, targeted case management, psychological services, medical services (including neurological and psychiatric), speech-language pathology services, occupational therapy, physical therapy, audiology services, and vision services. Providers should ensure these needs are addressed through the appropriate DMAS-contracted Managed Care Organization or the DMAS fee-for-service pathway rather than billing them under EPSDT Behavioral Therapy.

Services that are not covered under EPSDT Behavioral Therapy include items that are not medically necessary, services that are solely academic in nature, and most direct supportive services in the school setting. EPSDT Behavioral Therapy may only be provided in school when it is for observation and collaboration related to behavior and skill acquisition and when services are authorized by the school, parent and provider. Other non-covered items include day treatment, vocational training, certain waiver-based therapeutic consultation, services not listed in the ISP or not approved for reimbursement by HealthKeepers, Inc., sessions for family support unrelated to the ISP (including education, recreational, custodial care, respite or child care), services provided by a legally responsible relative, services provided prior to the ISP effective date (except the clinical assessment for service planning), services provided before the child met Medicaid/FAMIS eligibility criteria, and provider travel time.

A service should be discontinued as not medically necessary when documentation shows no meaningful or measurable improvement in the child’s behavior despite services delivered according to the treatment plan. Services are also not medically necessary when there is a reasonable expectation that family or caregiver are adequately trained to manage the child’s behavior, when terminating services would not cause further deterioration, or when treatment is making symptoms worse or the child is not medically stable for behavioral therapy. Additional termination triggers include adequate stabilization such that a lower intensity of care is appropriate, inability to maintain long‑term gains, family/caregiver refusal or inability to participate meaningfully, and a lapse in services of more than 30 consecutive calendar days (which requires discharge and a new authorization/ISP if services resume).

Services determined to be not medically necessary are treated as non-covered under this guideline. Examples include those listed above (non‑medically necessary services, solely academic services, most school-based direct supports except authorized observation/collaboration, and other exclusions) as well as circumstances where clinical documentation meets the policy’s criteria for termination or discharge (for example, no measurable improvement or prolonged service lapse). Providers must not bill for services classified as non‑covered.

Service Codes, Units, and Billing Rules

EPSDT Behavioral Therapy codesHCPCSCovered

H0032	EPSDT Behavioral Therapy Initial Assessment
H2033	EPSDT Behavioral Therapy service provision and reassessments

inv-09: Assessment authorization threshold

Assessment authorization thresholdAssessments up to 5 hours (5 units) are allowed without prior authorization; any assessment exceeding 5 hours requires prior service authorization.

Applies per child and per providerThe 5-hour assessment allowance is per child, per provider.

Initial assessments exceptionInitial assessments do not require service authorization unless they exceed the 5-hour limit.

inv-10: Unit length and billing increment

Unit lengthThe unit of service for EPSDT Behavioral Therapy is 15 minutes.

Billing incrementUnits are billed in 1‑hour increments with 1 hour = 1 unit; providers may accumulate partial units but must bill only whole units.

Provider Requirements, Authorization and Documentation

Prior Authorization

Service authorization requirements

All treatment service hours require service authorization prior to beginning services. Initial assessments up to 5 hours (5 units) do not require authorization; assessments that exceed 5 hours require service authorization. Units are billed in 1 hour increments (1 hour = 1 unit). Providers may accumulate partial units throughout the week for span billing but must bill only whole units. Providers must not 'round up' partial units.

Initial assessments: allowed up to 5 hours per child, per provider without authorization
Assessments > 5 hours require prior authorization
All treatment service hours require prior authorization before starting services
Units billed in 1 hour increments; do not round up partial units

Prior Authorization

Prior authorization and ISP requirement

Services must be listed in the Individual Service Plan (ISP) and authorized by the applicable payer for reimbursement. School-based direct therapy is not covered except for observation and collaboration related to behavior and skill acquisition and only when authorized by the school, parent and provider. Services provided prior to the effective date of the ISP are not covered, with the exception of the clinical assessment for service planning.

EPSDT Program Background

EPSDT is Medicaid’s comprehensive child health entitlement for individuals younger than 21 to identify and treat health problems early. Within this context, EPSDT Behavioral Therapy is covered when medically necessary to correct or ameliorate significant impairments from developmental, behavioral, or mental disabilities. Assessments must be face‑to‑face with the child and parents/caregivers prior to starting services, and initial assessment allowances and authorization rules apply per the guideline. Providers must follow the policy’s medical necessity criteria, assessment and ISP requirements, documentation expectations, and authorization procedures to ensure services align with EPSDT entitlement obligations.

Key Definitions and Service Terms

inv-20: Service codes and units

H0032 (Modifier UA)H0032 with Modifier UA = EPSDT Behavioral Therapy Initial Assessment.

H2033H2033 = EPSDT Behavioral Therapy service provision and reassessments.

Billing ruleServices must be service-authorized and allowable activities provided by qualified providers in accordance with an approved ISP to be payable.

inv-21: Assistive technology device

DefinitionAssistive technology device: Any item, piece of equipment or product system, whether acquired commercially off the shelf, modified, or customized, used to increase, maintain, or improve functional capabilities of children with disabilities.

Reimbursement pathway

Level-of-Care and Intensity Criteria

Outpatient / Intensive outpatient ABA through EPSDT

Level-of-care criteria for outpatient/intensive outpatient ABA

Admission: Child must meet medical necessity criteria (see Coverage criteria), have a current valid psychiatric diagnosis, be medically stable to benefit, have family willing to participate, and have required assessments and ISP completed as specified prior to or shortly after initiation of services.

Continued stay: Continuation requires documentation of progress with baseline and performance data tied to goals, updated orders, treatment summaries, justification that care cannot be provided at a lower level, ongoing family participation and training, and a Generalization Summary describing progress and reason continued clinician involvement is needed.

Discharge is indicated for no measurable improvement despite compliant services, family/caregiver adequately trained to manage behaviors, treatment causes deterioration or child not medically stable, stabilization permitting lower intensity of services, inability to maintain long-term gains, family refusal/inability to participate, or a lapse in service greater than 30 consecutive days.

Provider and Supervision Requirements for ABA Services

ABA provider and supervision criteria

Requirements when providing ABA-based EPSDT Behavioral Therapy:

Provider qualifications: Providers must be either an LMHP practicing within scope of their Virginia license (or an agency that employs an LMHP) or an LBA meeting Virginia Board of Medicine requirements (18VAC85-150-10 et seq.) or an employing agency.

Direct service and supervision: Direct EPSDT Behavioral Therapy must be provided by an LMHP, an LBA, an LABA under LBA supervision, or personnel under LBA supervision per 18VAC85-150-10 et seq.; EPSDT Behavioral Therapy providers practicing ABA must meet all Virginia Board of Medicine regulatory requirements and maintain documentation of supervision activities as required.

Behavioral Therapy and ABA Treatment Modalities

Behavioral Therapy / ABA

ISP content and modality-specific requirements for Behavioral Therapy / ABA:

ISP content for treatment modalities: ISP must define target behaviors, behavioral modification strategies for each target, measurement and data collection methods, child-focused behavior modification goals with baselines and how progress will be measured, parent/caregiver education goals and measurement methods, service coordination goals including referrals and desired outcomes, and a schedule and justification for requests exceeding 20 hours/week describing therapeutic function of each session.

Assessment and Treatment Hour Limits

inv-30: EPSDT Behavioral Therapy assessments and treatment hours

Assessment hours without authorizationInitial face-to-face assessments with the child and family are allowed up to 5 hours without prior authorization.

All treatment hours require authorizationAll treatment service hours require service authorization prior to beginning services.

Requests >20 hours/weekRequests exceeding 20 hours per week require a detailed schedule of activities and justification included in the ISP (schedule must show how each session relates to treatment goals).

ISP and assessment timingPreliminary treatment plans are used to obtain authorization and the ISP must be developed within 30 days of service initiation; assessments must be face-to-face with child and caregivers prior to starting services.

OpenPayer

Virginia Medicaid EPSDT Behavioral Therapy Utilization Management Guideline