CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy Autism Spectrum Disorders Mandate

Defines coverage for Autism Services for commercial products in Rhode Island including applied behavior analysis (ABA), pharmaceuticals, psychology, psychiatry, physical therapy (PT), occupational therapy (OT), and speech therapy, consistent with RI statutory mandate (R.I. Gen. Law 27-20.11). Specifies provider credentials, authorization/notification practices, service limits exemptions, and CPT/HCPCS codes covered when billed with autism diagnoses.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy Autism Spectrum Disorders Mandate

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 8, 2018

Next Review DateN/A

Key ActionNon-participating ABA providers should obtain prior authorization from BCBSRI Behavioral Health Vendor at 800-274-2958 prior to services; authorizations are generally approved for a 6-month period and based on medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes identified in this brief.

0359T–0373TCategory III ABA codes listed

Multiple CPTsPT/OT/Speech codes listed

Commercial productsApplies to

Until age 15Statutory age limit

Coverage Summary

BCBSRI covers Autism Services for commercial products in Rhode Island pursuant to the Rhode Island statutory mandate (R.I. Gen. Law 27-20.11) effective January 1, 2012. Covered services include Applied Behavior Analysis (ABA), pharmaceuticals, psychology/psychiatry, and rehabilitation therapies (physical therapy, occupational therapy, and speech therapy) when medically necessary for the treatment of an Autism Spectrum Disorder as defined in the DSM.

ABA services must be provided by credentialed/licensed providers consistent with state requirements and insurer credentialing (e.g., Board Certified Behavior Analysts (BCBA), Board Certified Assistant Behavior Analysts (BCaBA) under supervision, or licensed psychologists/social workers/therapists with equivalent experience).

When PT/OT/Speech services are provided for ASD (excluding ABA), they are excluded from usual service limits and prior authorization requirements that would otherwise apply, and must be billed using the appropriate PT/OT/Speech CPT codes with an autism diagnosis when applicable.

Services are generally required to be delivered within Rhode Island unless preauthorization documents that the required services are not available in-state. Statutorily, benefits under the chapter continue until the covered individual reaches age 15.

Key facts

ScopeApplies to commercial products

Age Limit (statutory)Coverage continues until age 15 per statute

ABA CPT Codes ProvidedCategory III ABA codes listed (e.g., 0359T–0373T) — covered when rendered by a certified ABA provider and medically necessary

Rehab Codes ProvidedPT/OT/Speech codes listed (examples: 92508, 92526, 92609, 97127, 97161/63/65/66/67, 97012–97036, 97110, 97112, 97530, 97535, etc.) — excluded from service limits/authorization when primary diagnosis is Autism

Effective Date2018-01-08

Medical Necessity / Coverage Conditions

General Medical Necessity / Coverage Conditions

Coverage is provided when ALL of the following are met:

Commercial product coverage: Member is covered under a BCBSRI commercial product (policy applies to commercial products only).
Autism Spectrum Disorder diagnosis: Diagnosis is an Autism Spectrum Disorder as defined in the most recent edition of the DSM (e.g., primary diagnoses F84.0, F84.5, F84.8, F84.9 referenced for coding).
Medical necessity and treatment plan: Services are medically necessary for the treatment of ASD and meet medical necessity criteria, which may include evidence of continued improvement when relevant. The insurer may require submission of a treatment plan signed by an appropriate specialist (child psychiatrist, behavioral developmental pediatrician, child neurologist, or licensed psychologist trained in child psychology); updates may be required no more frequently than quarterly.
Providers must furnish medical records upon request to substantiate initial or continued medical necessity.
Provider credentials for ABA: Applied Behavior Analysis (ABA) services must be provided and/or supervised by credentialed providers per Rhode Island law and insurer credentialing (e.g., Board Certified Behavior Analyst (BCBA), Board Certified Assistant Behavior Analyst (BCaBA) supervised by a BCBA, or a licensed psychologist/social worker/therapist with equivalent applied behavior analyst experience).
Credentialing and licensure per RI statute apply; insurer credentialing is required.
In-state service delivery (unless preauthorized): Services must be delivered within the State of Rhode Island, unless preauthorization documents that the required services are not available in-state in the carrier's network.
Preauthorization allows out-of-state coverage only when in-state providers are unavailable.

Authorization, Notification & Provider Participation

Authorization / Notification / Provider Participation

Provider actions differ by participation status:

Provider type

Non-Participating Providers: Prior authorization is recommended: Non-participating ABA providers are recommended to request prior authorization from the BCBSRI Behavioral Health Vendor at 800-274-2958 prior to services.
Authorizations are generally approved for a 6-month period and are based on medical necessity.
Participating Providers: Participating providers must notify BCBSRI Behavioral Health Vendor of the start and end dates of services to ensure correct claims processing by calling 800-274-2958.

Prior Authorization

Prior authorization recommendation for non-participating ABA providers

Non-participating ABA providers are recommended to obtain prior authorization from BCBSRI Behavioral Health Vendor by calling 800-274-2958 prior to providing services. Authorizations are generally approved for a six-month period and are granted based on medical necessity.

Note

Notification for participating providers

Participating providers must notify BCBSRI Behavioral Health Vendor of the start and end dates of services to ensure correct claims processing. Call 800-274-2958 to provide this notification.

Documentation Required

Treatment plan and medical necessity documentation

Insurer may require submission of a treatment plan signed by a child psychiatrist, behavioral developmental pediatrician, child neurologist, or a licensed psychologist with training in child psychology. Updated treatment plans may be required no more frequently than quarterly. Providers must furnish medical records or other necessary data upon request to substantiate initial or continued medical necessity.

Billing Rule

Use of ABA-specific Category III codes

Certified ABA providers must bill using the specified Category III ABA codes and must not use the listed H-codes for certified ABA services. File ABA services with the Category III codes instead of the H-codes.

0359T
0360T
0361T
0362T
0363T
0364T
0365T
0366T
0367T
0368T
0369T
0370T
0371T
0372T
0373T
H0031
H0032
H2019
H2014

PT / OT / Speech Therapy Specifics

PT/OT/Speech Therapy Specifics

For groups that offer Autism Services:

Coverage and limits exemption: Physical therapy (PT), occupational therapy (OT), and speech therapy services for ASD (when the primary diagnosis is Autism) are covered and are excluded from any service limits or preauthorization requirements that would otherwise apply to these therapies.
This exemption applies when submitted with a primary diagnosis of Autism (e.g., F84.0, F84.5, F84.8, F84.9).
Billing when delivering ABA: If a speech-language therapist, physical therapist, or occupational therapist who is certified as an ABA provider renders ABA services, they must bill using the ABA Category III codes listed in the coding section rather than the standard PT/OT/Speech codes for those ABA services.
School services not covered under carrier benefits: Benefits are not provided for services furnished by school personnel under an IEP/IFSP; the carrier's obligations do not replace school district or government obligations to provide educational services.

Exclusions / Non-applicability

Services NOT covered under the RI mandate (statutory exclusions):

Excluded insurance products: The chapter does not apply to certain insurance products, including those subject to the Small Employer Health Insurance Availability chapter, the Individual Health Insurance Coverage Act, hospital confinement indemnity, disability income, accident only, long-term care, Medicare supplement, limited benefit health, specified disease indemnity, and other limited benefit policies.
Self-funded group contract exclusions: Self-funded or self-insured groups that have not elected to adopt the Rhode Island Autism Spectrum Disorders mandate may exclude behavioral interventions (ABA and related programs) from member contracts; benefits may vary by member agreement, so refer to the Evidence of Coverage or subscriber agreement.

Coding (CPT / HCPCS)

Covered PT/OT/Speech and related CPT codes excluded from service limits/authorization when primary diagnosis is AutismCPTCovered

92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder
92526	Treatment of swallowing dysfunction and/or oral function for feeding rehabilitation
92609	Therapeutic services for use of speech-generating device; programming/modification
97127	Therapeutic interventions that focus on cognitive function (new code effective 1/1/2018)
97161	Physical therapy evaluation: low complexity
97163	Physical therapy evaluation: high complexity
97165	Occupational therapy evaluation, low complexity
97166	Occupational therapy evaluation, moderate complexity
97167	Occupational therapy evaluation, high complexity
97164	Re-evaluation of physical therapy (not separately reimbursed in some contexts as noted in source)

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Background & Definitions

Rhode Island law (R.I. Gen. Law 27-20.11) mandated coverage of Autism Services effective January 1, 2012 for applicable group health contracts. BCBSRI implemented coverage consistent with that mandate and its definitions/scope.

The statute defines Applied Behavior Analysis (ABA) and requires that individuals providing ABA be appropriately credentialed: nationally certified (BCBA or BCaBA supervised by a licensed BCBA) and licensed by the state as a health care provider/clinician, and credentialed by the insurer. BCBSRI’s policy echoes these credentialing expectations and recommends prior authorization for non-participating ABA providers.

Physical therapy, occupational therapy, and speech therapy provided for the treatment of ASD are covered but are excluded from customary visit limits and preauthorization requirements that apply for other conditions. Parity provisions and the statute affirm that PT/OT/Speech benefits for ASD must be at least as available as for other medical/surgical conditions.

Coverage under the mandate does not replace or duplicate services provided by school districts under an IEP or IFSP; services furnished by school personnel under those educational plans are not benefits under the carrier’s obligations.

Applied Behavior Analysis (ABA): the design, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvements in human behavior, including direct observation, measurement, and functional analysis of the relationship between environment and behavior.

Autism Spectrum Disorders (ASD): includes pervasive developmental disorders as defined by the most recent edition of the DSM (used as the diagnostic standard for coverage).

Credentialed ABA Provider: an individual who is nationally certified (BCBA or BCaBA under supervision) and licensed by the state as a health care provider/clinician and credentialed by the insurer, consistent with R.I. Gen. Law 27-20.11.