Applied Behavior Analysis (ABA) for the Assessment of Autism Spectrum Disorder
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Policy governs submission and authorization requirements for ABA assessment and related treatment authorization for members with Autism Spectrum Disorder, including required documentation and 6-month certification periods; applies to providers submitting to Blue Cross Blue Shield - Tennessee.
No material clinical or coverage changes in this revision.
Coverage Criteria
Authorization criteria
Covered when ALL of the following are met
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The hours per week authorized for Applied Behavior Analysis (ABA) are not inclusive of other concurrent therapeutic services. Specifically, authorized ABA weekly hours should be considered separate from time spent in services such as occupational therapy or physical therapy. When submitting requests, document any concurrent services and clearly identify the hours authorized and used for ABA versus other therapies to avoid double-counting.
Provider Submission & Documentation Requirements
Submission and authorization period
Submit request online through Availity.com or fax to: 1-800-496-9600. Requests for continuation of ABA services must be submitted at least once every 6 months. Provide the following provider and member information: Provider of ABA Services Name, Address, City, ZIP Code, Phone Number, Fax Number, Provider ID / NPI Number / Tax ID, Member Name, Date of Birth, Member Identification Number, Parent/Guardian Name, and Member Current Telephone Number. Ensure diagnostic confirmation is included (e.g., diagnostic report, doctor's order) and clearly indicate the Diagnosis and Severity Level. Note: The hours per week authorized are not inclusive of other services (e.g., occupational therapy, physical therapy).
- Submit via Availity.com or fax: 1-800-496-9600
- Continuation requests: at least every 6 months
- Include full provider and member demographics and identifiers
- Diagnostic confirmation required (diagnostic report, doctor's order)
Prior service history requirements
Document a complete ABA treatment history and prior service intensity. Provide initial ASD diagnosis date; whether member had ABA with another provider; first ABA treatment start date if applicable; intensity of prior services (Focused or Comprehensive); average number of hours per week; whether services have been continuous since start; if there was a break in services, state when and why; list accomplishments from prior ABA services; existing goals with documented progress; new proposed goals; and description of parent/caregiver involvement. For continuation requests, describe current symptoms/behaviors, safety risk status, impact on participation in age-appropriate activities, whether measurable progress has been made toward goals with documentation in the ABA treatment plan, and whether progress can be maintained if ABA is reduced or discontinued (with explanation if no).
- Initial/First Date ASD Diagnosed
- Has member had ABA with another provider? If yes, provide first ABA treatment start date
- Intensity of prior services: Focused or Comprehensive
- Average number of hours/week
- Continuous ABA services since start? If no, explain breaks (when and why)
- List accomplishments from prior ABA services
- Provide existing goals with progress and measurable new proposed goals
- Describe parent/caregiver involvement
- For continuation requests: document current symptoms/behaviors, safety risk status, impact on function, measurable progress toward goals, and whether progress can be maintained if services reduced or discontinued
Required documentation for authorization
Required documentation for authorization includes: diagnostic confirmation (diagnostic report or doctor's order), the ABA treatment plan with measurable goals and progress notes, full member demographics and identifiers, provider identifiers (Provider name, address, NPI/Tax ID), ABA treatment history details (see prior service history), and answers to continuation-specific questions (safety risk, functional impact, measurable progress, ability to maintain progress if reduced). Incomplete or missing diagnostic confirmation or required documentation may result in denial of the request.
- Diagnostic confirmation: diagnostic report or doctor's order (required)
- ABA treatment plan with measurable goals and documented progress
- Provider identifiers: name, address, phone, fax, Provider ID/NPI/Tax ID
- Member identifiers: name, DOB, member ID, parent/guardian name, contact number
- ABA treatment history as detailed above
- Continuation-specific documentation: safety risk, functional impact, progress documentation, plan for maintenance if reduced
Diagnostic confirmation required
Diagnostic confirmation is required. Missing or incomplete diagnostics, treatment plans, or prior service history may lead to denial or delayed authorization. Ensure all requested fields and supporting documentation are provided at time of submission.
- Provide diagnostic confirmation with request
- Incomplete submissions may be denied or delayed
Background
Applied Behavior Analysis (ABA) services in this policy apply to members with Autism Spectrum Disorder (ASD) and focus on assessment, treatment planning, and measurable goals. Authorization requires diagnostic confirmation (for example, a diagnostic report or doctor’s order) and documentation of the ASD diagnosis and severity level (Level 1, 2, or 3).
Providers must include an ABA treatment history when requesting authorization: the initial/first date of ASD diagnosis, prior ABA service history including whether prior care was Focused or Comprehensive, average hours per week, continuity of services, and any breaks in service. For continuation requests, the policy emphasizes documentation of safety/functional impact, caregiver involvement, and measurable progress toward documented goals.
Authorization requests must be submitted via Availity.com or fax, and continuation requests must be submitted at least every 6 months. Certification periods are structured as 6 months (26 weeks), and requests lacking required diagnostic confirmation or complete documentation may be denied.
Definitions
Level of Care Criteria
ABA-specific Criteria
ABA-specific criteria
Criteria to support ABA assessment and authorization
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Applied Behavior Analysis (ABA)
Applied Behavior Analysis (ABA)
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