CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy Autism Spectrum Disorders Mandate

Defines BCBSRI coverage for Autism Spectrum Disorder (ASD) services for Commercial Products, including Applied Behavior Analysis (ABA) and related PT/OT/Speech services, consistent with Rhode Island statute. Specifies provider credentialing, notification requirements, covered CPT/HCPCS codes, exclusions for certain group types, and limits/administrative requirements.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy Autism Spectrum Disorders Mandate

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2022

Next Review Date

Key ActionNotify BCBSRI Behavioral Health Utilization Management of start and end dates for ABA services (call 800-274-2958).

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes identified (has_material_change=false).

CommercialPlan applicability

6 monthsTypical authorization period

NoneAge limit

RI 27-20.11State mandate

Coverage Summary

BCBSRI covers Autism Services for Commercial Products only, consistent with Rhode Island statute (RIGL 27-20.11). Covered services include Applied Behavior Analysis (ABA) and related therapies — including physical therapy (PT), occupational therapy (OT), and speech therapy — when medically necessary. The policy affirms provider credentialing and documentation/medical necessity requirements, notification of ABA service start and end dates to BCBSRI Behavioral Health Utilization Management, and parity provisions that exempt PT/OT/Speech for ASD from the usual visit limits or preauthorization requirements that apply for other conditions. Self-funded (self-insured) groups may opt out of the state mandate and exclude behavioral interventions based on ABA principles per their contracts.

Key statistics: Plan applicability: Commercial Products only; Typical authorization period: 6 months; Age limit: no age restriction (BCBSRI notes no age restrictions for Autism services); State mandate: RI General Law 27-20.11.

Key statistics

Plan applicabilityCommercial Products only (self-funded groups may opt out)

Typical authorization period6 months (services generally approved for a 6-month period based on medical necessity)

Age limitNo age restriction (BCBSRI does not have age restrictions for Autism services)

State mandateRhode Island General Law 27-20.11 (mandatory coverage statute)

Coding

Covered ABA and related CPT/Category III codes (when rendered by a certified ABA provider and medically necessary)CPT|HCPCS|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 a patient
97151	Behavior identification assessment; administered by a physician or other qualified health care professional, each 15 minutes
97152	Behavior identification-supporting assessment; administered by one technician under the direction of physician or other qualified health care professional, 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
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
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
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

Covered PT/OT/Speech and related therapy CPT codes (when ASD is primary diagnosis)CPT|mixedCovered

92507	Treatment of speech; language; voice; communication, and/or auditory processing disorder; individual
92508	Treatment of speech; language; voice; communication; 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 cognitive function; each 15 minutes (initial mentioned)
97129	Therapeutic interventions that focus on cognitive function; each 15 minutes
97161	Physical therapy evaluation: low complexity
97162	Physical therapy evaluation: moderate complexity
97163	Physical therapy evaluation: high complexity
97164	Re-evaluation of physical therapy (not separately reimbursed per policy text)

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Codes not to be used (report Category I/III CPT codes instead)HCPCS|CPTNot Covered

H0032-32	Mental health service plan development by non-physician (not to be used for ABA)
H0031-32	Mental health assessment; by non-physician for certified ABA professional (not to be used)
H2019-32	Therapeutic behavioral services, per 15 minutes (not to be used for ABA)
H2014-32	Skills training and development, per 15 minutes (not to be used for ABA)
H2012-32	Behavioral health day treatment; per hour (not to be used for ABA)

Provider Actions & Billing Requirements

Documentation Required

Notification of ABA service start/end dates

Participating and non-participating providers must notify BCBSRI Behavioral Health Utilization Management of the start and end dates of ABA services to ensure correct claims processing. For assistance or to submit notification, contact 800-274-2958.

Contact BCBSRI Behavioral Health Utilization Management at 800-274-2958 to notify start/end dates of ABA services

Prior Authorization

Authorization period and medical necessity

Services are generally approved for a 6-month period and are authorized based on medical necessity. Providers may need to submit a treatment plan and evidence of continued improvement to support both initial and continued authorization.

Typical authorization period: 6 months
Authorization requires demonstration of medical necessity and may require treatment plan and evidence of improvement

Documentation Required

Treatment plan signature and update frequency

An insurer may require a treatment plan signed by a child psychiatrist, behavioral developmental pediatrician, child neurologist, or a licensed psychologist with training in child psychology. The insurer may require an updated treatment plan no more frequently than quarterly.

Accepted signers: child psychiatrist; behavioral developmental pediatrician; child neurologist; licensed psychologist with child training
Treatment plan updates: no more frequently than quarterly

Billing Rule

Use of ABA-specific CPT/Category III codes

Providers certified in ABA must bill using the listed Category I and Category III CPT codes for ABA services: 0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158. The HCPCS H-codes listed in the policy (e.g., H0032-32, H0031-32, H2019-32, H2014-32, H2012-32) are not to be used for ABA and should be replaced with the specified CPT/Category III codes.

Use CPT/Category III codes: 0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158
Do not use H-codes (H0032-32, H0031-32, H2019-32, H2014-32, H2012-32) for ABA

Documentation Required

Medical record submission upon request

Upon request by the reimbursing carrier, providers must furnish medical records or other necessary data that substantiate that initial or continued treatment is medically necessary and appropriate.

Provide medical records or necessary data upon request to substantiate medical necessity

Background, Definitions & Evidence

Statutory basis: BCBSRI coverage is provided in compliance with Rhode Island General Law 27-20.11, which mandates coverage for Autism Spectrum Disorders (ASD) and defines ASD and Applied Behavior Analysis (ABA). The RI statute specifies the scope of covered services to include behavior analysis and PT/OT/Speech for the treatment of ASD and allows coverage to continue beyond childhood per carrier practice (BCBSRI states it has no age restriction).

Scope and requirements: Services must be medically necessary and may require a treatment plan (signed by a child psychiatrist, behavioral developmental pediatrician, child neurologist, or licensed psychologist with child training) with updates no more frequently than quarterly; carriers may require evidence of continued improvement to establish medical necessity and can request medical records to substantiate necessity.

Credentialing and documentation: Providers delivering behavior analysis must be appropriately credentialed (e.g., licensed applied behavior analyst, BCBA, BCaBA supervised by a BCBA, or psychologist with equivalent experience) and be credentialed by the insurer as required by the statute. The policy requires notification of ABA service start and end dates to BCBSRI Behavioral Health Utilization Management.

Parity and exclusions: The statutory and policy provisions incorporate parity requirements (MHPAEA) so that visit limits and other treatment limitations for PT/OT/Speech when provided for ASD do not apply as they would for other conditions. Self-funded groups that have not adopted the RI mandate may exclude behavioral interventions based on ABA principles per their member agreements.

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

Autism Spectrum Disorders (ASD): Defined as any of the pervasive developmental disorders as described in the most recent edition of the DSM (Diagnostic and Statistical Manual of Mental Disorders).

Evidence and references cited include guidelines and literature supporting ABA and ASD care: Behavior Analyst Certification Board guidelines, the DSM-5 (American Psychiatric Association), peer-reviewed ABA outcome studies (for example, meta-analyses and long-term outcome studies cited in the policy), and Rhode Island statute references (RIGL 27-20.11).

OpenPayer

Payment Policy Autism Spectrum Disorders Mandate

Coverage Summary

Medical Necessity Criteria

Coding

Provider Actions & Billing Requirements

Background, Definitions & Evidence

Revision History