CurrentBlue Cross Blue Shield - LouisianaPolicy N/A

Applied Behavioral Analysis (ABA) authorization request form — submission and documentation requirements

Governs submission requirements and required documentation when requesting authorization for ABA services for members with Autism Spectrum Disorder; applies to initial and concurrent authorization requests to Louisiana Blue.

Policy Summary

PayerBlue Cross Blue Shield - Louisiana

PolicyApplied Behavioral Analysis (ABA) authorization request form — submission and documentation requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed ABA Request Form with required supporting documentation (diagnostic evaluation, signed referral, PCP wellness check, and required evaluations) for initial and concurrent authorizations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

requiredComprehensive ASD diagnostic eval (initial)

requiredLicensed referral (within 1 yr)

requiredPCP wellness check (within 1 yr)

90 daysCognitive/dev eval submission window

6 months

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Coverage Criteria for ABA Services

Authorization documentation criteria

Covered when ALL of the following submission and documentation requirements are met:

Initial and concurrent authorization submission

Initial assessment documentation: For initial assessments, include a comprehensive diagnostic evaluation (ASD-specific standardized assessment completed by a licensed clinician within the last 5 years), a referral signed by a licensed practitioner with a diagnosis of autism spectrum disorder dated within the past year, and a wellness check from a primary care physician including a review of symptoms (ROS) with a neurological component dated within the past year.
Required for initial assessment; answer checklist items on form.
Evaluations timeframe: Cognitive/developmental evaluation must be dated within the last 5 years; if not provided, it must be submitted within the first 90 days of treatment. Adaptive behavioral evaluation must be dated within the past 6 months; if not provided, it must be submitted within the first 90 days of treatment.
Checklist on form documents recency requirements.

The ABA Request Form includes an attestation acknowledging that ABA treatment is not a substitute for academic, medical, or any other behavioral health services. Providers must confirm the chosen treatment setting and intensity are appropriate for the member’s clinical needs while recognizing these limits of ABA.

Provider Submission Requirements and Actions

Prior Authorization

Authorization submission required

This form is required when requesting authorization for Applied Behavioral Analysis (ABA) services for members diagnosed with Autism Spectrum Disorder. It must be submitted to Blue Cross and Blue Shield of Louisiana (Louisiana Blue) for both initial and concurrent reviews. Complete all sections thoroughly and include specific, individualized details about the member. Electronic submissions: attach the completed form when submitting your request in iLinkBlue at www.lablue.com/ilinkblue. Fax submissions: if you do not have iLinkBlue access, fax the form and all supporting documentation to 1-800-363-9170. For assistance, contact the ABA Utilization Review Department at 1-800-821-2745.

Attach the completed Treatment for Applied Behavioral Analysis Request Form for initial and concurrent reviews.
Electronic submissions: iLinkBlue at www.lablue.com/ilinkblue — attach form to the authorization request.
Fax submissions (if no iLinkBlue access): 1-800-363-9170 — include form and supporting documentation.
Questions/help: ABA Utilization Review Department 1-800-821-2745.

Note

Provider actions

Clinical Support and Treatment Plan Criteria

ABA clinical support criteria

Clinical attestation and treatment plan details required to support ABA services:

Attestations: Provider must attest that goals and documentation focus on active core deficits of ASD (social communication, social interactions, restrictive/repetitive behaviors); that the treatment setting and intensity (comprehensive vs focused) are appropriate; that the plan accounts for skill generalization across settings, meaningful caregiver involvement, coordinated care, and transition/discharge planning; and that services follow BACB Ethics and applicable standards and laws.

Attestation checkboxes on form.

Treatment plan content: Treatment plan must state counts of new, continued, and mastered goals for the upcoming authorization period and describe observed gains and/or barriers impacting progress across communication, social, and behavior domains; if barriers are identified, describe steps currently being taken to address them.

Information is used to justify ongoing hours and frequency requested.

Definitions and Core Treatment Focus

Core ASD treatment focus

DefinitionTreatment goals and documentation should focus on active core deficits of ASD such as deficits in social communication, social interactions, and restrictive and repetitive patterns of behavior or interest.

Treatment plan elementsDocument counts of new, continued, and mastered goals for the authorization period and provide narrative descriptions of observed gains and barriers across communication, social, and behavior domains.

Barriers and interventionsIf barriers are identified, describe current steps being taken to address or resolve them to support progress toward targets.

PurposeFocus documentation on measurable, active deficits to justify individualized ABA treatment goals and intensity.

Background

Applied Behavioral Analysis (ABA) services are requested primarily for members diagnosed with Autism Spectrum Disorder (ASD). Authorization requires submission of the completed ABA Request Form with individualized documentation that justifies the treatment plan, goals, and intensity.

For initial assessments the form requires a comprehensive diagnostic evaluation that includes an ASD-specific standardized assessment completed by a licensed clinician within the last 5 years, a referral signed by a licensed practitioner with an ASD diagnosis dated within the past year, and a PCP wellness check with review of systems including a neurological component dated within the past year. If cognitive/developmental or adaptive behavioral evaluations are not already provided, the form specifies timeframes to submit them (see submission checklist).

The form asks for detailed, individualized treatment plan content: counts of new, continued, and mastered goals for the authorization period and narrative descriptions of observed gains and barriers across communication, social, and behavior domains. Providers must also complete attestations confirming focus on core ASD deficits, appropriate setting/intensity, plans for skill generalization and caregiver involvement, coordinated care and transition/discharge planning, and adherence to applicable ethics and standards.

Documentation Required

Required documentation for authorization

Submit the completed ABA Request Form with individualized member details and attach supporting documentation. For initial assessments, include the required diagnostic and referral materials listed in the submission checklist. If certain assessments are not available at time of initial authorization, note when they will be provided (some may be required within the first 90 days of treatment).

Include a comprehensive diagnostic evaluation with an ASD-specific standardized assessment completed by a licensed clinician within the last 5 years (required for initial assessment).
Include a referral signed by a licensed practitioner (e.g., MD, PSY.D, PhD) with a diagnosis of Autism Spectrum Disorder recommending ABA dated within the past year (required for initial assessment).
Include a wellness check from the PCP, including review of symptoms with neurological component dated within the past year (required for initial assessment).
Include a cognitive/developmental evaluation dated within the last 5 years — if not available, must be submitted within the first 90 days of treatment.
Include an adaptive behavioral evaluation dated within the past 6 months — if not available, must be submitted within the first 90 days of treatment.