Currentblue cross blue shield - michiganPolicy BH803ABASCC072025

Applied Behavior Analysis (ABA) Supplemental Clinical Criteria

Defines supplemental clinical criteria used by the payer to make medical necessity coverage determinations for Applied Behavior Analysis (ABA) services, including evaluation/diagnostic requirements, treatment plan content, service delivery, continued treatment, transition/discharge, documentation, coordination of care, and referenced diagnosis code(s). Prior authorization is required unless otherwise specified by contract or law.

Policy Summary

Payerblue cross blue shield - michigan

PolicyApplied Behavior Analysis (ABA) Supplemental Clinical Criteria

Policy CodePolicy BH803ABASCC072025

Change TypeInterim & Annual updates

Effective Date

Next Review DateJul 1, 202625d

Key ActionPrior authorization is required; verify member-specific benefits and regulatory mandates and submit required diagnostic, assessment, treatment plan, and progress documentation per the policy.

SourceLink

POLICY UPDATE CHANGES

03/16/2020 Version 1; Supplemental Clinical Criteria created.

03/15/2021 Annual Review

04/19/2021 Interim Update: Added New Jersey state mandates information.

06/21/2021 Interim Update: Removed AZ state mandate information.

09/21/2021 Interim Update: Added Massachusetts, New York, Washington information to the State Mandates section.

04/19/2022 Annual Review: Added Pennsylvania information, sources updated.

06/21/2022 Interim Update: Added Virginia information to the State Mandates section.

08/23/2022 Interim Update: Added California and revised Maryland in State Mandates section.

10/18/2022 Interim Update: Update to NY guidance in State Mandates section.

12/22/2022 Interim Update: Update to State Mandates section.

01/17/2023 Interim Update: Update to State Mandates section.

04/18/2023 Annual Review.

08/22/2023 Interim Review: Update to State Mandates section.

09/19/2023 Interim Review: Removal of Applicable Codes section.

10/17/2023 Interim Review: Update to State Mandates section.

12/12/2023 Interim Review: Update to State Mandates section.

05/21/2024 Annual Review: Updates to align with CASP (2024) guidelines and the Behavior Analyst Certification Board Ethics Code (2022).

09/18/2024 Interim Review: Update to Coverage Criteria.

12/17/2024 Interim Review: Update to State Mandates Section.

01/21/2025 Interim Review: Update to State Mandates Section.

02/18/2025 Interim Review: Update to State Mandates Section.

03/18/2025 Interim Review: Update to State Mandates Section.

07/22/2025 Annual Review.

1Referenced Diagnosis Codes Listed

Prior authAuthorization requirement

Documentation-heavyAdministrative burden

multipleUpdates since 2020

manyState mandates referenced/updated

alignedGuidelines alignment (CASP/BACB)

Coverage Summary

This document contains supplemental clinical criteria for Applied Behavior Analysis (ABA) for Autism Spectrum Disorder (ASD) used by the payer to make medical necessity coverage determinations. It is intended to standardize coverage decisions for behavioral health benefits managed by The Health Plan and to inform reviewers about required evaluation, treatment planning, service delivery, continuation, transition/discharge, documentation, and coordination of care. Prior authorization is required for ABA unless otherwise specified or mandated by contract or law.

The policy is documentation-heavy and requires submission of diagnostic information, validated screening tools, comprehensive assessments, a credentialed ABA provider, individualized treatment plans with defined frequency/intensity/duration and measurement methods, ongoing progress data, and coordination records. Coverage criteria have been aligned with external guidance, including the Council of Autism Service Providers (CASP) practice guidance and the Behavior Analyst Certification Board (BACB) ethics code where noted.

Policy Number: BH803ABASCC072025; Status: CURRENT; Last Review: 2025-07-01; Next Review: 2026-07-01.

Quick Facts

Policy numberBH803ABASCC072025

PayerBlue Cross Blue Shield - Michigan (The Health Plan® manages behavioral health benefits)

SubjectApplied Behavior Analysis (ABA) for Autism Spectrum Disorder

Coverage stanceCovered with criteria

Authorization requirementPrior authorization required

Documentation burdenDocumentation-heavy (comprehensive records, assessments, progress notes required)

Guidelines alignmentAligned with CASP (2024) and BACB Ethics Code (2022)

Medical Necessity Criteria

Coding

Referenced Diagnosis Codes (reference only)ICD-10

F84.0

Autistic Disorder

Provider Actions & Documentation Requirements

Prior Authorization

Prior authorization required

Prior authorization is required for ABA unless otherwise specified or mandated by contract or law; reviewers must verify member-specific benefits and applicable federal or state regulatory mandates before applying these criteria.

Documentation Required

Documentation requirements for initial evaluation

Providers must document a DSM-5-TR–based diagnosis issued by a qualified, state‑licensed clinician; ensure core team representation (medical, behavioral, and speech/language disciplines); confirm diagnosis/severity with at least one validated screening tool; complete required assessments (functional assessment/FBA when maladaptive behaviors present, caregiver interviews, direct observation, record review, baseline skills assessment, norm‑referenced and skills‑based instruments); and identify an appropriately credentialed ABA provider (BCBA master/doctoral, licensed behavioral health clinician credentialed for ABA, or BCaBA/non‑licensed individual under direct BCBA/licensed clinician supervision).

Background & Evidence

Supplemental Clinical Criteria standardize coverage determinations for behavioral health benefits managed by The Health Plan and promote evidence-based practices and consistency in medical necessity decisions.

Applied Behavior Analysis (ABA) is described by CASP as a well-developed scientific discipline and the leading evidence-based, validated treatment for ASD with hundreds of peer-reviewed studies over the past 50 years supporting its efficacy; CASP characterizes ABA as the standard of care for ASD.

The coverage criteria have been updated to align with external guidance, including CASP (2024) practice guidelines and the Behavior Analyst Certification Board (BACB) Ethics Code (2022), to ensure ethical and practice-aligned implementation.

High-level evidence notes indicate multiple supporting peer-reviewed studies and guideline sources cited in the policy references that inform these criteria and recommendations.

Evidence / Source	Notes
Guideline source: CASP (2024) Applied Behavior Analysis Treatment of Autism Spectrum Disorder
Key referenced systematic review: Holten et al., 2018 Cochrane review on diagnostic tests for ASD in preschool children
Guideline alignment: CASP (2024) and BACB Ethics Code (2022) referenced for updates aligning coverage criteria

Definitions

Transition: A coordinated set of individualized activities designed to move the patient through treatment toward discharge or other services; includes monitoring and evaluation for generalization and maintenance.

Discharge: End of services between a provider and a patient, initiated by the provider or the patient, in compliance with state laws and regulations.

Revision History

03/16/2020Initial version.

03/16/2020 Version 1; Supplemental Clinical Criteria created. (material)

03/15/2021Annual review performed.

03/15/2021 Annual Review

04/19/2021State mandates section expanded.

04/19/2021 Interim Update: Added New Jersey state mandates information. (material)

Policy Summary

Payerblue cross blue shield - michigan

PolicyApplied Behavior Analysis (ABA) Supplemental Clinical Criteria

Policy CodePolicy BH803ABASCC072025

Change TypeInterim & Annual updates

Effective Date

Next Review DateJul 1, 202625d

SourceLink

On This Page

DSM-5-TR diagnosis by state-licensed physician, psychologist, or qualified clinician (APA, 2022).
Core evaluation team: Medical (e.g., pediatrician), Behavioral (e.g., psychologist/psychiatrist), and Speech and language therapist.
Confirm diagnosis/severity with at least one validated tool (e.g., ADOS/ADOS-2, ADI, M-CHAT, CARS, ABC, DISCO, etc.).
Required assessments: Standard Functional Assessment and/or Functional Behavioral Assessment when indicated; caregiver interviews; direct observation; record review of history/prior interventions; baseline skills assessment; norm-referenced and skills-based instruments to inform goals.
Credentialing: BCBA (Master/Doctoral), licensed clinician credentialed in ABA, or BCaBA/non‑licensed under direct supervision; technicians must be supervised (RBT recommended where allowable).

Documentation Required

Treatment plan documentation

Treatment plans must be based on the comprehensive diagnostic evaluation and functional assessment and include comprehensive, clearly stated goals and outcome‑oriented interventions. Each intervention must define frequency, intensity, duration, and progress measurement methods; at least one validated measurement tool must be selected to guide intensity; caregiver participation and training must be addressed with alternate plans if caregivers cannot participate; the plan must document coordination with other professionals (school/IEP/IFSP, outpatient clinicians, medical, speech/OT, etc.); and all components must be tracked and updated regularly throughout authorization periods.

Comprehensive, clearly stated treatment goals/objectives and outcome‑oriented interventions.
Defined frequency, intensity, duration, and methods to measure progress for each intervention.
Select at least one validated measurement tool (e.g., ATEC, VB-MAPP, ABLLS/ABLLS-R, AFLS, PEAK, VABS, SRS, CFQL-2) for baseline and intensity decisions.
Document caregiver participation/training and provide reason/alternate plan if caregiver unable to participate.
Document coordination with other professionals and update components throughout authorization periods.

Documentation Required

Continued treatment documentation

For continued treatment, submit updated documentation demonstrating clinical necessity or reasonable expectation of continued improvement or maintenance of skills. Documentation must show progress for each targeted symptom/behavior using the same measurement methods as baseline (e.g., rates/percentages of mastered programs/targets, change scores on outcome measures, updated standardized adaptive measures, skills‑based assessment change scores), include parent/caregiver involvement and progress when applicable, identify barriers to participation with solutions, and describe modifications when inadequate progress (assessment of reasons and treatment changes if inadequate progress within 6 months).

Evidence of reasonable expectation of continued improvement or need to maintain skills/prevent deterioration.
Progress metrics: rate/percentage of mastered programs, mastered targets, change scores, updated standardized adaptive measures, skills-based assessment change scores.
When applicable, documentation of parent/caregiver involvement and their implementation progress.
Document barriers to participation and how they are addressed; clinical review addresses utilization shortfalls (e.g., <80% hours).
If inadequate progress within 6 months, assess causes and modify interventions (e.g., increased time/frequency, changed techniques, increased caregiver training).

Documentation Required

Recordkeeping requirements

Maintain a separate record for each individual containing the comprehensive diagnostic assessment, demographic and developmental/educational history, functional behavioral assessment (including targeted risk behaviors), behavioral/medical treatment history, the individualized treatment plan and all revisions, daily progress notes with session details, supervision documentation, and IEP/Early Intervention records when available. All documentation must be legible and include certifications/credentials of providers.

Comprehensive assessment establishing autism or other diagnosis per state mandates.
Demographics, complete developmental history, and educational assessment.
Functional Behavioral Assessment including targeted risk behaviors.
Behavioral/medical treatment history (conditions, dates/providers, current clinicians, interventions/responses).
Individualized treatment plan and revisions with objective measurable goals, caregiver training, barriers, and responses to interventions.
Daily progress notes: place of service, start/stop time, who rendered service, specific service, attendees, interventions, licensure/credentials.
Documentation of supervision of behavior technicians.
If available, copy of IEP and progress notes related to Early Intervention or allied health services.
Certification and credentials of professionals providing and supervising ABA.

Note

Coordination of care documentation

Document communications and coordination with other providers/agencies to support generalization and avoid duplication. Records should include types and number of therapies, behaviors/deficits targeted, progress related to those services, measurable discharge criteria and projected post‑discharge plan, total days/week and hours/day requested (with duration and location), dates of service requested, and licensure/certification of providers; also document parent/caregiver training and who actively participates.

Types of therapy provided and number of therapies per week.
Behaviors/deficits targeted and progress related to those services.
Measurable criteria for completing treatment and projected plan for continued care after discharge.
Total days/week and hours/day requested, duration and location of ABA therapy, and dates of service requested.
Licensure, certification and credentials of professionals providing ABA services.
Documentation that parents/caregivers have been trained, consulted, and who participated.

Documentation Required

State mandates and guideline alignment updates

The policy includes multiple interim updates that add or remove state mandate information and notes alignment of coverage criteria with external guidelines. The criteria were updated to align with CASP (2024) guidelines and reference the Behavior Analyst Certification Board Ethics Code (2022); providers should consult the policy's state mandates section and the current criteria when determining coverage obligations.

Multiple interim and annual updates to the State Mandates section are documented in the policy history.
05/21/2024 update aligns coverage criteria with CASP (2024) and the BACB Ethics Code (2022).
Providers should reference the policy's state mandates section and current criteria when determining obligations.

06/21/2021Arizona-specific mandate information removed.

06/21/2021 Interim Update: Removed AZ state mandate information. (material)

09/21/2021State mandates section expanded.

09/21/2021 Interim Update: Added Massachusetts, New York, Washington information to the State Mandates section. (material)

04/19/2022Annual review performed; sources and state mandates updated.

04/19/2022 Annual Review: Added Pennsylvania information, sources updated. (material)

06/21/2022State mandates section expanded.

06/21/2022 Interim Update: Added Virginia information to the State Mandates section. (material)

08/23/2022State mandates updated.

08/23/2022 Interim Update: Added California and revised Maryland in State Mandates section. (material)

10/18/2022New York guidance updated.

10/18/2022 Interim Update: Update to NY guidance in State Mandates section. (material)

12/22/2022State mandates consolidated/updated.

12/22/2022 Interim Update: Update to State Mandates section. (material)

01/17/2023Further state mandates updates.

01/17/2023 Interim Update: Update to State Mandates section. (material)

04/18/2023Annual review performed.

04/18/2023 Annual Review.

08/22/2023State mandates updated.

08/22/2023 Interim Review: Update to State Mandates section. (material)

09/19/2023Applicable Codes section removed from policy.

09/19/2023 Interim Review: Removal of Applicable Codes section. (material)

10/17/2023State mandates updated.

10/17/2023 Interim Review: Update to State Mandates section. (material)

12/12/2023State mandates updated.

12/12/2023 Interim Review: Update to State Mandates section. (material)

05/21/2024Coverage criteria alignment with external guidelines and ethics code.

05/21/2024 Annual Review: Updates to align with CASP (2024) guidelines and the Behavior Analyst Certification Board Ethics Code (2022). (material)

09/18/2024Coverage criteria updated.

09/18/2024 Interim Review: Update to Coverage Criteria. (material)

12/17/2024State mandates updated.

12/17/2024 Interim Review: Update to State Mandates Section. (material)

01/21/2025State mandates updated.

01/21/2025 Interim Review: Update to State Mandates Section. (material)

02/18/2025State mandates updated.

02/18/2025 Interim Review: Update to State Mandates Section. (material)

03/18/2025State mandates updated.

03/18/2025 Interim Review: Update to State Mandates Section. (material)

07/22/2025Most recent annual review recorded.Latest

07/22/2025 Annual Review.