Blue Cross Blue Shield RI Autism Services Coverage

Coverage and Medical Necessity

General Coverage and Medical Necessity Criteria

Covered when ALL of the following are met

Covered Services: ABA services, pharmaceuticals, physical therapy, psychology, psychiatric, and occupational therapy services are covered for treatment of Autism Spectrum Disorders (ASD) when medically necessary.

Provider Qualifications: ABA services are supervised by an individual licensed by the state in which the service is rendered (e.g., licensed behavior analyst, psychologist with equivalent experience, or licensed assistant under supervision).

Notification/Authorization: Notification of start and end date of ABA services is recommended for correct claims processing; services are generally approved for a 6-month period and are based on medical necessity.

Medical Necessity Documentation: Provider must establish medical necessity and appropriateness; insurer may require a treatment plan signed by a child psychiatrist, behavioral developmental pediatrician, child neurologist, or licensed psychologist with training in child psychology; insurer may request medical records to substantiate necessity; continued improvement may be used in medical necessity determinations.

Geographic and Age Scope: Mandated benefits apply to services delivered within Rhode Island; benefits under the statute continue until the covered individual reaches age 15 (note: BCBSRI states it does not have any age restrictions for Autism services in policy text).

Covered ABA services

Covered when billed as specified and medically necessary:

ABA code coverage: The listed ABA Category I and III CPT/HCPCS codes (0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158) are covered when rendered by a certified ABA provider and when medically necessary.

Provider credentialing and rendering: ABA codes are covered only when rendered by a certified ABA provider (or appropriately supervised technician) and in accordance with insurer credentialing and state licensing requirements.

Improper code usage: The listed H‑codes (H0032-32, H0031-32, H2019-32, H2014-32, H2012-32) are not to be used for these ABA services; providers should file with the applicable Category I and III CPT/HCPCS codes above.

Therapies exempt from limits/authorization for Autism

Covered exempt therapy services for Autism:

PT/OT/SLP exemption: The enumerated physical therapy, occupational therapy, and speech therapy CPT codes (see coding tables) are covered and excluded from service limits or authorization requirements when submitted with a PRIMARY diagnosis of Autism (F84.0, F84.5, F84.8, F84.9).

Behavioral interventions based on the principles of Applied Behavior Analysis (ABA) are excluded by contract for some members — specifically certain self‑insured / self‑funded groups that have not adopted the Rhode Island Autism Spectrum Disorders mandate. Providers should confirm coverage with the member's specific benefit contract and refer to the member or employer agreement for applicability.

Services delivered under the statutory Rhode Island mandate and to members whose plans include Autism Services remain subject to the policy's coverage criteria and credentialing requirements, including that ABA services be supervised by an appropriately licensed or nationally certified provider (e.g., licensed behavior analyst, BCBA/BCaBA as applicable).

Do not submit the listed H‑codes for ABA services; these codes are not to be used. Specifically, providers should not file H0032‑32, H0031‑32, H2019‑32, H2014‑32, or H2012‑32 for ABA. Instead, bill the appropriate Category I or Category III CPT/HCPCS ABA codes (e.g., 0362T, 0373T, 97151–97158, 97153–97155) as specified elsewhere in this policy.

Using the H‑codes in place of the designated Category I/III codes may result in claim denial; file claims with the applicable Category I and III procedure codes for ABA services.

Periods or types of care for which the provider cannot establish medical necessity and appropriateness are not reimbursable. If medical necessity for a given period or modality of treatment is not documented to the insurer's satisfaction, neither the carrier nor the patient is obligated to reimburse for that care unless the patient has been informed and provides written agreement to continue treatment at their own expense.

Upon request, providers must furnish medical records or other necessary documentation to substantiate that initial or continued treatment is medically necessary and appropriate; failure to provide requested documentation may affect reimbursement.

This policy is provided for informational purposes and does not guarantee payment. Benefits and eligibility are determined by the member's subscriber agreement, member certificate, or employer agreement, which supersede this medical policy.

If services are determined to be not medically necessary (or are non‑covered under the member's benefit plan), providers may not charge the member for those services unless the member has been informed in advance and has agreed in writing to accept financial responsibility.

Codes and Billing Guidance

Covered ABA CPT/Category III CodesmixedCovered

0362T	Behavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with patient; requiring the following components: administration by the physician Or other qualified health care professional who is on site; with the assistance of two Or more technicians; for a who exhibits destructive behavior; completion in an environment that is customized to the patients behavior: patient
0373T	Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time faceto-face with a patient; requiring the following components: administration by the physician r other patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior:
97151	Behavior identification assessment, administered by a physician Or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s) / caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/ treatment plan
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
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, which may include simultaneous direction of technician, 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 ABA CPT/HCPCS CodesmixedCovered

0362T	Behavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with patient; requiring the following components: administration by the physician Or other qualified health care professional who is on site; with the assistance of two Or more technicians; for a who exhibits destructive behavior; completion in an environment that is customized to the patients behavior: patient
0373T	Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time faceto-face with a patient; requiring the following components: administration by the physician r other patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior:
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
97151	Behavior identification assessment, administered by a physician Or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s) / caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/ treatment plan
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, which may include simultaneous direction of technician, 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

Codes not to be used (file with applicable Category I and III codes above)HCPCSNot Covered

H0032-32	Mental health service plan development by non-physician (not to be used)
H0031-32	Mental health assessment; by non-physician for the certified ABA professional to create a treatment plan: (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 day treatment; per hour (not to be used)

Codes not to be used — file with Category I/III codes aboveHCPCSNot Covered

H0032-32	Mental health service plan development by non-physician (not to be used)
H0031-32	Mental health assessment; by non-physician for the certified ABA professional to create a treatment plan: (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 day treatment; per hour (not to be used)

Physical, Occupational, Speech Therapy Codes (covered when primary dx = Autism)CPTCovered

92507	Aural rehabilitation; individual
92508	Treatment of speech, language, voice; group
92526	Treatment of swallowing dysfunction
92609	Therapeutic services for use of speech-generating device
97127	Therapeutic interventions focusing on cognitive function; each 15 minutes
97129	Therapeutic interventions focusing on cognitive function; each 15 minutes (subsequent)
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 in some cases)

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Authorization review frequency

Authorization review frequencyServices generally approved for a 6-month period

Basis for approvalApprovals are based on documented medical necessity and appropriate treatment planning

Notification expectationNotification of start and end date of ABA services is recommended for correct claims processing

Primary diagnosis requirement

Required primary diagnosisAutism (ICD-10: F84.0, F84.5, F84.8, F84.9)

Effect of primary diagnosis

Provider Notifications, Documentation, and Billing Risks

Prior Authorization

Notification and authorization period for ABA services — Notification of start and end date recommended/needed; approval generally for a 6-month period

Notification of start and end dates for ABA services is recommended. Services are generally approved for a 6-month period and are authorized based on medical necessity. Providers should submit notification of ABA services to facilitate preauthorization and network determination.

Services generally approved for a 6-month authorization period
Notify payer at start and end of ABA episodes when possible

Billing Rule

Autism-related therapy codes exempt from prior authorization/limits — Listed PT/OT/ST CPT codes covered and excluded when submitted with primary autism diagnosis

Background and Rationale

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

ABA uses evidence‑based behavioral learning principles and structured intervention techniques — often delivered in intensive, one‑to‑one formats with supervision by licensed or certified professionals — with the goal of improving social communication, adaptive living skills, and reducing challenging behaviors.

Key Definitions

Applied Behavior Analysis (ABA)

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

ScopeIncludes behavior identification assessments, adaptive behavior treatment (individual, technician-delivered, group), family guidance, and protocol-modified interventions delivered typically in 15-minute units (see covered ABA codes).

Delivery expectationsIntensive behavioral intervention is often highly structured and delivered one-to-one by trained therapists; services must be provided or supervised by credentialed ABA professionals (e.g., BCBA, BCaBA as required).

Autism Spectrum Disorders (ASD)

DefinitionAutism Spectrum Disorders (ASD): 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 Therapy Service Levels

Clinical Characteristics and Coding Requirements for ABA

ABA clinical characteristics

Clinical intent and delivery expectations for ABA

Treatment Goals: Improve social communication, social interaction, play, flexibility of behavior, and reduce challenging behaviors (e.g., aggression, self-injury); teach adaptive living skills and functional abilities.

Intensity and Delivery: Intensive behavioral intervention typically involves highly structured, often one-to-one techniques delivered by a therapist or trained technician; family guidance and group formats (family adaptive behavior treatment guidance, multiple-family groups, group adaptive behavior treatment) are part of expected delivery formats.

Measurement and Treatment Planning: ABA involves design, implementation, and evaluation of behavior-modification plans with direct observation and measurement; treatment plans should document frequency, duration, measurable goals, and evidence of progress; insurer may require updated plans no more frequently than quarterly.

Approved Treatment Modalities

ABA

Modalities: ABA individual therapy, group therapy, family guidance, multiple-family groups, behavior identification assessment, adaptive behavior treatment with or without protocol modification are recognized modalities.

ABA (adaptive behavior treatment, assessment, family guidance)

Adaptive behavior treatment details: Codes describe technician-delivered treatment by protocol (15-minute units), practitioner-delivered protocol modification, group modalities, and family guidance; billing is per 15-minute unit as specified by each CPT/HCPCS code.15-minute units

Visit Limits and Exemptions

Physical Therapy, Occupational Therapy, Speech Therapy

Policy stancePT, OT, and Speech Therapy services for ASD are covered and excluded from service limits or preauthorization when the group offers Autism Services.

ABA provider noteIf a PT/OT/SLP is certified as an ABA provider and renders ABA services, the ABA codes in this policy must be used to report those services.

Scope limitationCoverage does not affect obligations of school districts or government to provide services under an IFSP or IEP; services furnished by school personnel are not covered benefits under this policy.

Listed PT/OT/ST codes when primary dx = Autism

Actionable exemptionThe enumerated PT/OT/SLP CPT codes are covered and excluded from service limits and prior authorization requirements when submitted with a primary diagnosis of Autism (F84.0, F84.5, F84.8, F84.9).

OpenPayer

Autism Services (including Applied Behavior Analysis) Coverage Criteria