CurrentBlue Cross Blue Shield - IowaPolicy N/A

Applied Behavior Analysis for the Treatment of Autism (Pre-Service Inquiry)

Prior approval form and criteria checklist for ABA services for treatment of Autism Spectrum Disorder (ASD) used by Wellmark Blue Cross and Blue Shield of Iowa/South Dakota; documents required clinical and administrative information for new and ongoing authorization requests. The form specifies eligibility questions, documentation requirements, service delivery modalities, and submission instructions but does not itself provide explicit numeric benefit limits or CPT/HCPCS codes.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyApplied Behavior Analysis for the Treatment of Autism (Pre-Service Inquiry)

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

Key ActionSubmit the completed prior approval form with diagnosis, evaluation, treatment plan/progress reports, provider credentials, CPT/HCPCS codes with units/frequency, and provider signature via fax to Wellmark Prior Approval Unit at 515-376-9104.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — this is an administrative prior-approval form and checklist used to collect information for medical necessity review.

1Form Purpose (Prior Approval)

0Explicit CPT/HCPCS codes listed in document

2Request types covered (New / Ongoing)

This is a prior-approval/pre-service inquiry form used by Wellmark Blue Cross and Blue Shield of Iowa and South Dakota for requesting Applied Behavior Analysis (ABA) therapy for individuals with Autism Spectrum Disorder (ASD). The form collects clinical eligibility, service delivery details, provider credentials, and required supporting documentation to support a medical necessity review.

The document specifies criteria and required documentation for both new (initial) and ongoing (continuation) authorization requests (including diagnosis, face-to-face 1:1 delivery, expectation of improvement, caregiver participation, assessment/treatment plan within 90 days, service frequency/duration, and provider credentials). The form itself does not list explicit numeric benefit limits or enumerate CPT/HCPCS codes within the body, though it requires that requested procedure codes and units/frequency be listed on the form.

Key facts

Form PurposePrior Approval

Request types coveredNew / Ongoing

Explicit CPT/HCPCS codes listed in document0

PayerWellmark Blue Cross and Blue Shield of Iowa / South Dakota

Policy / Form TitleApplied Behavior Analysis for the Treatment of Autism (Pre-Service Inquiry)

Operational / Submission Criteria & Provider Actions

Prior Authorization

Prior approval required

ABA services require prior approval submission using this form; prior approval does not guarantee coverage.

Documentation Required

Attach diagnostic and treatment documentation

Attach diagnosis code(s), initial evaluation, individualized treatment plan (to be completed within first 90 days for new requests), progress reports, and licensure/certification/credentials of providers as part of the support documentation for the request.

Documentation Required

Specify service units and frequency

List each CPT/HCPCS code separately with anticipated date(s) of service, total number of units per code and designate frequency using D = per day, W = per week, M = per month, and provide a description of the service for each code.

Documentation Required

Provider attestation

Provider must sign and date the form certifying accuracy and completeness; incomplete or unsigned forms may delay review.

Billing Rule

Submission route and contact

Submit completed form via fax to Wellmark Prior Approval Unit at 515-376-9104 (Mail Station 5W198).

Denial Risk

Secondary review for legal blindness/deafness

If the individual is legally blind or deaf and indicated 'Yes' on the form, the case will require secondary medical review which may delay or affect approval.

Form Documentation & Definitions

Background: This is an administrative prior-approval form used to collect the information required for a medical necessity review of ABA services for ASD. It gathers clinical eligibility (diagnosis, intellectual disability screen, prior less-intensive treatments), detailed service delivery information (face-to-face 1:1 status, days per week, hours per day, location, anticipated dates), provider licensure/certification, and supporting treatment documentation (initial evaluation, individualized treatment plan, progress reports).

Operationally the form is intended to ensure completeness for review and requires provider attestation and submission to Wellmark's Prior Approval Unit (fax provided). It also notes special handling (secondary medical review) when the individual is legally blind or deaf.

Required attachments & timing

Key definitions

D/W/MFrequency designator required on form: D = per day, W = per week, M = per month.

1:1One-to-one face-to-face therapy between provider and patient.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyApplied Behavior Analysis for the Treatment of Autism (Pre-Service Inquiry)

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Applied Behavior Analysis for the Treatment of Autism (Pre-Service Inquiry)

Coverage Summary

Medical Necessity Criteria

Operational / Submission Criteria & Provider Actions

Form Documentation & Definitions

Coding

Revision History