Prior authorization required before services

Obtain prior authorization approval for ABA services when required by the member's plan before rendering services.

• Prior authorization is a required documentation prerequisite when the plan mandates it.
• Do not render services expecting retrospective authorization unless the plan permits.

Verify plan prior authorization & documentation requirements

Verify whether the member's Health Plan requires prior authorization and confirm any plan-specific documentation or administrative requirements before providing services.

• Coverage decisions and benefit administration are governed by the Health Plan's coverage documents.
• Confirm state Medicaid or Medicare NCD/LCD requirements take precedence where applicable.

Complete required service activity note elements before claim submission

Complete service activity notes prior to claim submission and include the full set of required identification, timing, clinical, and administrative elements specified in the policy.

• Identification: provider organization, rendering provider/technician, member name and DOB or unique identifier.
• Exact session start and end times; date of note creation with rationale if different; pauses with times; location; service type and code; signature of qualified rendering provider/technician.
• Detailed treatment summary: clinical status, primary targets, techniques used, direct treatment, barriers and mitigation, protocol modifications or rationale when applicable, caregiver training details, telehealth compliance, progress data/graphs, response to treatment, participants and coordination.
• Addenda must reference the original note and include date, legible name, signature, and credentials.

Discharge summary requirements when ABA no longer medically necessary

When a member no longer meets medical necessity for ABA, prepare a discharge summary that documents referrals provided and the clinical rationale supported by a progress summary, and include required signatures and the date of discharge.

• Include referrals provided and rationale/reason for discharge with support in the progress summary.
• Include signature of the qualified rendering provider, caregiver signature, and date of discharge.

Adhere to referenced documentation standards and guidance

Follow the policy's referenced documentation standards and external guidance (e.g., DoD TRICARE ACD, BHCOE documentation standards, CASP telehealth practice parameters, ABA Coding Coalition model policy) when preparing clinical records for ABA services.

• Use referenced standards to ensure documentation supports coverage decisions.
• Adhere to telehealth practice parameters and HIPAA/privacy requirements when documenting telehealth-delivered services.

Denial/recoupment risk for units unsupported by documentation

Billed units that are not fully supported by the clinical documentation may be denied or recouped; documentation must substantiate the number of billed units, and audits may review all 97153/97154 units across a six-month authorization period.

• Policy note: 'Billed units not fully supported by documentation may be subject to payment denial or recoupment.'
• All 97153/97154 units billed for the entire six-month authorization period that are not supported by protocol modification requirements may be denied or recouped.

Coverage and plan limitations may trigger denial

Coverage and benefit administration are subject to the Health Plan's coverage documents, state Medicaid provisions, and applicable Medicare NCDs/LCDs; plan limitations, exclusions, or contract terms may result in denial of services or payment.

• When state Medicaid provisions conflict with this policy, state Medicaid provisions take precedence.
• Review applicable NCDs/LCDs and Medicare Coverage Articles prior to applying policy criteria for Medicare members.