BCBSRI Autism/ABA Coverage Update

Coverage criteria for Autism Spectrum Disorders and ABA

General ASD service coverage criteria

Covered when ALL of the following are met:

Commercial product applicability: Applies to BCBSRI commercial products; self-funded groups may elect or decline coverage per statute

See group contract/Evidence of Coverage

Diagnosis: Services are for treatment of autism spectrum disorders as defined by the most recent edition of the DSM

Provider qualifications: ABA services must be provided or supervised by a licensed behavior analyst, a Board Certified Behavior Analyst (BCBA), a Board Certified Assistant Behavior Analyst (BCaBA) under supervision, or a psychologist with equivalent ABA experience; providers must be credentialed by the insurer per RI statute

See RI statute sections on credentials

Medical necessity: Services must be medically necessary; insurer may require a treatment plan and may base continued coverage in part on evidence of continued improvement

Insurer may require treatment-plan updates no more frequently than quarterly

Location and benefit limits: Benefits apply to services delivered within Rhode Island; out-of-state coverage may be available via preauthorization when services are not available in-state; benefits continue until the covered individual reaches age 15 and are subject to member-specific terms

See RI statute and member benefit documents

Coverage tied to CPT 97535 service description

Covered when the service provided matches the described one-on-one ADL/home management training and is billed in 15-minute units under CPT 97535.

Service requirements: Service is direct one-on-one self-care/home management training (activities of daily living, compensatory meal preparation, living safety, instruction in use of assistive technology/adaptive equipment)per 15 minutes

Bill using CPT 97535

Billing/Service Description

Billing description: CPT 97535 is reported for self-care/home management training (ADL, compensatory meal preparation, procedures, and instruction in use of assistive technology devices/adaptive equipment) provided as direct one-on-one contacteach 15 minutes

Document one-on-one direct contact and service content when billing

Therapy service billing criteria

Covered when billed as described and per member benefits

Billing conditions: Service documented as direct one-on-one self-care/home management training (ADL, meal preparation, assistive device instruction) billed in 15-minute units (CPT 97535)each 15 minutes

Coverage is subject to member-specific benefits, participation agreements, and applicable credentialing or authorization requirements

For groups that do not provide Autism Services under their benefit plan, and for self‑funded or self‑insured employer groups that have not elected to adopt the Rhode Island Autism Spectrum Disorders mandate, behavioral interventions based on applied behavior analysis (ABA) principles may be a contract exclusion. Refer to the member’s subscriber agreement, evidence of coverage, or employer plan documents to confirm whether Autism Services are included for that member. Prior authorization is recommended for non‑participating ABA providers; BCBSRI’s Behavioral Health Vendor may be contacted at 800‑274‑2958 and authorizations are generally approved for a 6‑month period when granted.

Providers must not file ABA‑related services using the listed H‑codes (for example, H0032‑32, H0031‑32, H2019‑32, H2014‑32, H2012‑32). Instead, file claims using the applicable Category I CPT codes specified in this policy (for example, the ABA CPT codes and CPT 97535 when self‑care/home management training is delivered). Deleted temporary codes for dates of service prior to January 1, 2019 should be handled as noted in the policy text.

Within the provided document fragments there are no additional explicit contract exclusions beyond those already noted for plans that do not provide Autism Services or for limited/excepted benefit plans listed in the Rhode Island statute. If a specific exclusion is suspected, confirm with the member’s plan documents.

No further explicit exclusions are stated in these chunks of the source document. Coverage limitations and exclusions should be verified against the member’s subscriber agreement or employer benefit plan.

This medical policy is provided for informational purposes and is not a guarantee of payment. Final coverage and reimbursement decisions are determined by the member’s subscriber agreement, member certificate, and/or employer agreement, which supersede the provisions of this policy. Providers should verify eligibility and benefits for each member before delivering services.

Services must be established as medically necessary to be reimbursed. The insurer may require submission of a treatment plan (signed by an appropriately credentialed specialist) and may request supporting medical records to substantiate initial or continued medical necessity; failure to substantiate medical necessity may result in denial of reimbursement. The policy notes the insurer may require treatment‑plan updates no more frequently than quarterly.

Within the provided document fragments there are no explicit statements labeled as “not medically necessary.” The policy does state broadly that services not established as medically necessary or appropriate may not be reimbursed and that documentation may be requested to substantiate medical necessity.

No explicit ‘not medically necessary’ declarations are present in these chunks. The general requirement that treatment be medically necessary (and documented as such) remains in effect.

The supplied fragments do not contain explicit ‘not medically necessary’ statements. Providers should follow the medical necessity guidance in the policy and the member’s benefit documents when determining coverage and billing.

CPT / HCPCS codes, units, and coding guidance

Covered ABA codes (effective 1/1/2019)mixedCovered

0362T	Behavior identification supporting assessment; each 15 minutes of technicians' time face-to-face with patient
0373T	Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with patient
97152	Behavior identification-supporting assessment, administered by one technician under the direction of physician or other qualified health care professional, face-to-face with the patient; each 15 minutes
97153	Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes
97155	Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with one patient; each 15 minutes
97154	Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes

Covered ABA family/group guidance codes (effective 1/1/2019)CPTCovered

97156	Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes
97157	Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes
97158	Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes

Codes not to be used (use above ABA codes instead)HCPCSNot Covered

H0032-32	Mental health service plan development by non-physician (not to be used; file with applicable Category codes above)
H0031-32	Mental health assessment; by non-physician (not to be used)
H2019-32	Therapeutic behavioral services, per 15 minutes (not to be used)
H2014-32	Skills training and development, per 15 minutes (not to be used)
H2012-32	Behavioral health treatment; per hour/day (not to be used)

Speech, PT, OT codes covered when related to ASDCPTCovered

92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group
92526	Treatment of swallowing dysfunction and/or oral function for feeding
92609	Therapeutic services for the use of speech-generating device, including programming and modification
97127	Therapeutic interventions that focus on function (eg, attention, memory, reasoning, executive function, problem solving and/or pragmatic functioning)
97161	Physical therapy evaluation: low complexity
97164	Re-evaluation of physical therapy
97166	Occupational therapy (partial reference in document)

ABA and related HCPCS/H-codes (some not to be used)mixed

97156	Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes
97157	Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes
97158	Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes
H0032-32	Mental health service plan development by non-physician (listed as not to be used)
H0031-32	Mental health assessment; by non-physician (listed as not to be used)
H2019-32	Therapeutic behavioral services, per 15 minutes (listed as not to be used)
H2014-32	Skills training and development, per 15 minutes (listed as not to be used)
H2012-32	Behavioral health treatment; per hour/day (listed as not to be used)

Speech, PT/OT, therapeutic and rehabilitative CPT codesCPTCovered

92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, two or more individuals
92526	Treatment of swallowing dysfunction and/or oral function for feeding
92609	Therapeutic services for the use of speech-generating device, including programming and modification
97127	Therapeutic interventions that focus on function (eg, attention, memory, reasoning, executive function, problem solving and/or pragmatic functioning) and compensatory strategies; per document context
97161	Physical therapy evaluation: low complexity
97164	Re-evaluation of physical therapy (not separately reimbursed per text)
97166	Occupational therapy evaluation, moderate complexity (partial text present)
97167	Occupational therapy evaluation, high complexity
97168	Re-evaluation of occupational therapy (not separately reimbursed per text)

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Deleted/legacy temporary CPT/Category II codesCPT

039T-0361T, 0363T-0372T, 0374T

Deleted/previous codes (for claims with dates of service to 1/1/2019 providers should file with deleted codes prior to that date)

Covered CPT CodesCPTCovered

97535

Self-care/home management training (e.g., activities of daily living (ADL) and compensatory meal preparation, procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact; each 15 minutes

Covered CPT CodesCPTCovered

97535

Covered CPT Codes (15-minute units referenced)CPTCovered

97535

Self-care/home management training (activities of daily living and compensatory training); direct one-on-one contact; each 15 minutes

Age limit — Benefits continue until age 15

Age limitBenefits continue until the covered individual reaches age 15.

ScopeApplies to services delivered within Rhode Island; out-of-state coverage possible via preauthorization if in‑state providers unavailable.

Product lineCommercial products subject to RI Autism mandate.

Billing unit — Each 15 minutes

Billing unit

Prior authorization, documentation, and billing actions required of providers

Prior Authorization

Authorization / Notification — Prior authorization recommended

Prior authorization is recommended for non-participating providers. Participating providers must notify the BCBSRI behavioral health vendor of the start of services as required by member-specific participation agreements.

Non-participating providers: prior authorization recommended; contact BCBSRI Behavioral Health Vendor at 800-274-2958.
Participating providers: notify behavioral health vendor of treatment start per participation agreement and member-specific requirements.
Authorizations are generally approved for a 6-month period and are based on medical necessity.

Note

Certain therapy and evaluation codes excluded from authorization

The following therapy and evaluation CPT codes are covered but are excluded from service limits and prior authorization requirements under this policy for commercially insured members.

92507, 92508, 92526, 92609

Background on ABA and ASD

Applied behavior analysis (ABA) is described in the policy context as a systematic process used to design, implement, and evaluate behavioral interventions intended to produce socially significant improvements. ABA interventions are typically structured, often delivered one‑to‑one, and target development of adaptive skills (for example, social communication, daily living skills) and reduction of interfering or safety‑risk behaviors. Providers delivering ABA must meet credential requirements described in the Rhode Island statute (for example, BCBA, BCaBA under supervision, or licensed clinicians with equivalent ABA experience) and services must be medically necessary and documented appropriately.

Key definitions used in this policy

Applied behavior analysis (ABA) — definition

DefinitionApplied behavior analysis (ABA) means the design, implementation, and evaluation of environmental modifications, behavioral stimuli, and consequences to produce socially significant improvements, including direct observation and measurement.

PurposeUsed to design, implement, and evaluate behavioral interventions to improve socially important behaviors and demonstrate intervention effect.

Typical useOften used to treat children with autism spectrum disorders and includes highly structured, one‑to‑one intensive behavioral interventions.

Autism spectrum disorders (ASD) — definition per DSM

DefinitionAutism spectrum disorders (ASD) means any of the pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Outpatient and home-based ABA level-of-care criteria

Outpatient / Home-based ABA (intensive behavioral intervention)

Admission: Not specified; providers must follow medical necessity and authorization processes (prior authorization recommended for non‑participating providers and participating providers must notify the behavioral health vendor).

Authorizations are generally approved for about 6 months and are based on medical necessity; contact BCBSRI Behavioral Health Vendor at 800-274-2958

Continued stay: Continued coverage may be contingent on evidence of continued improvement and insurer may request supporting documentation to substantiate ongoing medical necessity

Insurer may require a treatment plan and may request updates no more frequently than quarterly

Applied Behavior Analysis clinical and coding criteria

ABA clinical goals and targets

Clinical targets and intent of ABA

Goals: Increase selected behaviors, teach new skills, maintain and generalize behaviors, reduce interfering behaviors, and improve adaptive, social, communication, and functional skills (eg, ADLs, meal preparation, toileting, dressing, domestic and community skills)

Target behaviors: May include challenging behaviors such as aggression, destructiveness, self-injury, and deficits in social communication or adaptive functioning that may place the individual or others at risk

ABA references

References list includes ABA-related guidance but no explicit ABA coverage criteria in these chunks.

ABA citation: Behavior Analyst Certification Board guideline and ABA research cited in references

Modalities referenced by the policy

Applied Behavior Analysis (ABA)

ABA modalities: Individual technician-delivered ABA, clinician/qualified professional-directed ABA with technician(s), family adaptive behavior treatment guidance, multiple-family group guidance, and group adaptive behavior treatment (with or without protocol modification)

Covered codes include 0362T/0373T and CPT 97152–97158 (effective 1/1/2019) when rendered by certified ABA providers and medically necessary

Occupational/functional training (97535)

Modality billing: Self-care/home management training delivered as direct one-on-one sessions and billed per 15 minutes (CPT 97535)each 15 minutes

Used for ADL and functional training in the ASD/behavioral health context

Service limits and visit/unit guidance

ABA, Speech, PT, OT — none specified for ABA when covered under mandate; benefits continue until age 15

ABA coverageNo visit limits specified for ABA when covered under the Rhode Island mandate; benefits continue until the covered individual reaches age 15.

Related therapiesSpeech, physical therapy, and occupational therapy are covered for ASD when they are a covered benefit for other conditions and are not subject to additional limits when provided for ASD treatment per statute.

Provider notificationNon‑participating ABA providers are recommended to contact BCBSRI Behavioral Health Vendor for authorization; authorizations typically approved for a 6‑month period.

Self-care/home management training (97535) billed in 15-minute units

Billing frequencyCPT 97535 is billed in 15‑minute units.

Service delivery

Policy revision history

2019-01-01effective_dateLatest

Policy became effective for Commercial Products, including coding guidance effective January 1, 2019 (notably coverage and CPT code listings for ABA and CPT 97535 billing in 15‑minute units).

OpenPayer

Payment Policy — Autism Spectrum Disorders Mandate (including ABA)

Coverage criteria for Autism Spectrum Disorders and ABA

CPT / HCPCS codes, units, and coding guidance

Prior authorization, documentation, and billing actions required of providers

Background on ABA and ASD

Key definitions used in this policy

Outpatient and home-based ABA level-of-care criteria

Applied Behavior Analysis clinical and coding criteria

Modalities referenced by the policy

Service limits and visit/unit guidance

Policy revision history

Payment Policy — Autism Spectrum Disorders Mandate (including ABA)

Coverage criteria for Autism Spectrum Disorders and ABA

CPT / HCPCS codes, units, and coding guidance

Prior authorization, documentation, and billing actions required of providers

Background on ABA and ASD

Key definitions used in this policy

Outpatient and home-based ABA level-of-care criteria

Applied Behavior Analysis clinical and coding criteria

Modalities referenced by the policy

Service limits and visit/unit guidance

References and related policies

Policy revision history